Housefly

May 2009     Afghanistan

The path to the truth is not a straight line in Afghanistan, whether asking directions,  learning tribal customs, or just trying to gather patient history.  Today I asked one question, got five different answers, and came to an ugly conclusion.  (Names changed, as usual.)

I returned from a transport to Hong Kong last night and went straight out early this morning to pick up a previous patient and return her to her village.  This one was unusual:  a three-year-old Afghan girl recovering from severe burns, referred  by the US embassy last month.  I was up north at that time, and my boss had flown down to a US Army Forward Operating Base (FOB) to pick her up for the specialty treatment she needed.   That was all I knew about her case, so I wanted to read the medical reports and see how she was able to get this treatment.

I met the Afghan burns doctor at the hospital, and he led me inside to meet a small brown girl with wild hair and big eyes.  Her father stood quietly off to the side.  The doctor peeled back the blanket and sheets, apologizing for not having any patient history available for us to take along, but that he would email it later.  Ruby had a massive bright pink splotch spread across her lower back, butt, upper thighs and all points between, and on her right foot, or what was left of it. The outer half was gone, just a skinny foot with two toes and a most of an ankle. On her left side, rectangular bright pink patches, where the skin had been harvested for grafting.  Maybe 30% of her body, apparently third and fourth degree burns, which go right down into the bone.

There was a routine US State Department helicopter flight at the airport, and we were going to be late.  As we loaded her into the ambulance, the Doctor quickly answered in very limited English, “Taliban, in the village.  Night.  The family they run out to the field, but this one, she fell into the bread cooking oven in the ground.”   A simple story, unfortunate but believable at first.  Fourth degree?  She must have been stuck in there.  How did she not burn her hands?

Funny that the State Department uses old Soviet aircraft, but they are cheap, reliable and more importantly, do not attract much attention.  On this corner of the airfield, there were a lot of conspicuously unmarked men and aircraft, and no shortage of weapons.  They had held the flight for us and had a photographer waiting – I got the sense that all of these people were relieved to see and do some tangible, positive relief work.  Ruby represented actual hope in this land, as long as people chose not to think too closely about her circumstances, or ask questions that might bring unsettling answers.

We strapped the gurney inside the Mi-8 cargo helicopter, spun up and headed south, towards the badlands.  At the first FOB, we dropped off some guys and gear, and picked up others.  Lots of interesting equipment and preparations going on, big white guys with huge beards, contractors and troops, initials and acronyms, Nepalese security, no locals.  One of the pilots asked about the girl;  he remembered bringing her to Kabul last month.   I asked him what had caused her injuries. “A cooking accident,” he answered.  A flight security guy cocked an eyebrow and said, “Oh, that again? Right.  No, that’s what they do to the girls here.” He went on, “Yeah, take note:  it is always a little girl, never a boy, and always the back, butt and legs burned.”  I asked “So this is local discipline?  For what? Wait, that’s her dad.  He did this?”

The dad had been right next to me on board.  He was about 25 going on 40, dressed like a conservative Muslim from down south, and yeah, maybe Taliban. Definitely he smelled so bad that one of the guys opened a window in the helicopter, preferring the shrieking turbine engines and jet fuel to the goatherder’s overwhelming rancidity.  But he pushed this girl into the fire?  I said “Why don’t we throw him out the fucking door once we get up there?”  A contractor shrugged and said “Mate, we don’t know for sure if he is that one that did it.  That’s just…it’s how things are done around here.  It prevents them from getting married.”

Up again and now headed to our destination, a small field hospital in a FOB near the Pakistan border, where this patient first appeared.  There is a huge gray area when it comes to treating non-military patients, a conflict of resources and priorities vs. medical duty to treat.  Circumstances determine who gets what, and this is an eight-bed facility in a very hot area, so locals and even Western civilian contractors are usually sent elsewhere.  The base is setting up a clinic for locals, subject to staff availability; the first priority is keeping their scarce resources available for combat casualties.  Still, when family members walked right up to an American unit out patrolling in March, they made some radio calls and got her medevac’d to try to get proper treatment and maybe save her infected foot.

While moving her from the landing pad to the hospital, one of the nurses came out, smiled at Ruby and said “Oh, yeah, here she is  – I remember her.”  I asked what had happened to her.  The nurse said “Well, who knows.  But that is the thirteenth little girl I’ve treated for burns, always to the same area.”  I pressed her on it,  though she dodged and avoided making a judgement call, as if expressing a rational opinion was the root of the problem here.  She said “They don’t always seem to want the girls.  They always say it was a cooking accident, hot water maybe. Sometimes we end up with them.”  I pointed out that cooking accidents burn the front of kids, not the back.  She said “Yeah, this one was probably ‘dipped.'” She shrugged, because really, what to do about this?

I recognized the burn patterns because child abuse is universal, but the difference is that in this culture I am not even sure if it is legal offense.  It is culturally accepted, to some extent. There are no child protective services or even police in her province, and most issues are judged and enforced by a council of old fundamentalist men.  Assuming Ruby survives, she will now have a reduced market value, and maybe stick around to take care of her aging parents, if they have no sons to capture a daughter-in-law for this task. So we were sending her right back to where she came from:  back to her short, brutal life.

Next I met with the senior medical officer.  I cut to the chase and asked her directly.  She explained “Yeah, this is too much damage for a water burn.  Maybe cooking oil or fire, but hard to say because we did not see her until infection had set in.”   I said “What would you do about this in the first world?”  Finally I got an answer:  “I would have to call it in as child abuse, either neglect or trauma.”   With that, we signed her over and they prepared to discharge her and her charming dad, who thanked nobody. That’s when it got complicated.  It turned out that they lived southwest of Kandahar, nine hours by rough road, not a good choice for her condition.  Now what?  Mick and James, the ex-special forces guys running my security for this delivery, are used to nasty places and lots of “activity.”  Like everyone else, they were donating their services free of charge on this one.

Mick stepped out to make a few calls, seeing about borrowing a helicopter or an armored vehicle convoy.  He came back, shaking his head.  “No way.  It is really hot down there. The military will not even go on the roads, and they won’t fly to the FOB there without Apache gunships and Predators.  Forget it.  We have to get them a public taxi.”  James protested this, insisting that he would drive them there himself tomorrow.  He operates on the low-profile idea,  blend in rather than armor up and stand out, and he could pass for a local with his dark skin and beard.  Hiding in plain sight is what he does when out on activities, often completely solo.

I grilled him about his intention to drive the girl south himself, suggesting that he does not need to take that level of risk – this was not friendly fire, he did not throw her into the bread oven,  and “You do not owe them anything.  We already saved her life, step away now.”   James said “Yeah, I know, but I would like to do something positive here now and then, contribute something more than all this killing.”  I said “I don’t love this place or these people enough to drive that road and neither do you. We are done here.” He went on,  “I don’t want to send her anywhere with that guy.  He is Pashtun. They are fucking animals.  Did you see him comfort her even once?  He does not give a shit.  The fucking door-gunner kept her calm.”

Mick came back and finalized it. He said “We’re fucked either way with this one.  We can’t fly it, and we can’t drive it.  They can’t even drive it.  When the Talib stop the taxi and get one look at the obvious western medical treatment and bandages, these people are finished.”

When I left, there were more Afghan Army casualties coming in on two Black Hawks, from a roadside bomb nearby. They would need the few available beds. The medical staff planned to pass the hat to pay the nine-hour cab fare for Ruby and her dad.

35 photos, none graphic: http://www1.snapfish.com/share/p=674111263265801607/l=4391335017/g=6193089/otsc=SYE/otsi=SALB

Tags: Afghanistan, Islamic fundamentalism, military, paramedic work, Taliban

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