food distribution

In early June, four guys from my home town came to Afghanistan to make a documentary.  One of the first things that we did was a food distribution in Balkh city (about 45 minutes from Mazar).  My friend, F. who runs a kindergarten heard that there were many extremely poor people there.  One of her teachers, S. had come to her to ask if we could help.

After the horrible winter that we had, food prices soared (though this was not just in Afghanistan, it was a global price increase).  Some children in the States raised $2000 so that we could do a larger distribution.  We reckoned that with that amount of money, we could buy enough food to feed 30 families for a week.  

food for a family for a week

 

We had heard many horror stories about food distributions.  People are so desperate to feed their families, that they become violent and people who are not part of the distribution begin to crawl over walls and  riots start. So, a friend who had done this before gave us a very detailed plan to keep things organized, but we also had an escape plan if things got crazy.

S. had met with the kalontar (like an elder) of the village and made a list of families with the biggest needs.  We then made a date and headed out.

Well, the plan went flawlessly.  It went so quietly and smoothly, it was almost boring (though the joy of helping these families was very exciting)

My film guys and some local Afghan men lined up all of the food on a raised porch-like area.  Each family was to receive a big bag of flour, a bag of rice, a bottle of oil, and  a "goody" bag with beans, salt, soap, and matches. The women were all lined up against a wall, and their men were on the other side of the courtyard.  We organized it so that when we called a name, the family had to come and get their food, and they had to be totally gone before we called another name.  It worked really well.

While we were handing out the food, S. whispered the families' stories to me.  Some were incredibly sad.  Widows, men that are too weak to work, men that want to work, but nothing can be found because of the economic conditions.  Older sons who would usually work for their family died in accidents or of illnesses.  One of the most common though, was that the old (I mean like 70 year old) men were still producing babies, though they were too old to work, so these poor younger women (sometimes teenagers) are married off (actually sold) as second or third wives, have no way to feed their children.

This is a huge problem in Afghanistan. The society itself has social rules about helping widows, but if the husband is still alive, they won't help, no matter how old, weak, or sick.  So many of the younger women pray every day that their husbands will die so they can get on the dole.  This is the plight of women in Afghanistan. 

When we were finished, we had enough money left over, so F. went with A. two weeks later and gave out food to 10 more families.  That was the day before I went into the hospital.

Last day of clinicals

You never know what life will bring you tomorrow.  When I went to work at the hospital on June 24th, I had no idea it would be my last day.  

We went back to the neuro/psych ward so we could follow up on the patients we had the day before.  We were surprised to see the patients smile at us.  Though their problems are far from over, I think that just showing a bit of kindness to them lifted their hearts a bit.  We spent that day much the same as the day before, doing PT with the stroke patients and holding hands with the depressed patients.  

At the end of the day, I took my students into a room to have a post conference with them and talk about what they had learned.  After the conference, as my students were walking out the door, I said something that made one of them laugh out loud.  About 30 seconds later, and armed guard came running into the room looking for the woman who had laughed out loud.  Apparently that is still illegal to some.  I couldn't believe it.  Thankfully the woman had already slipped out of the room, and I could honestly say I didn't know where she was.  It turns out that the governor of our province was touring the hospital and heard the woman laugh and sent his guard to arrest her.  I still sit shaking my head when I think of it.

After I extricated myself from that situation, I went into the nursing lounge to change my head-covering so I could leave, and I was accosted by the head nurse.  SHe started yelling at me about the behavior of two of my students.   She said that it was completely inappropriate for the one to have laughed and the hospital had lost face, because the governor was there.  Then she said that two of them had been in the hall flirting with male med students the whole time we were there.  She said that they even winked and made kissing faces and sounds toward them.  

She said that she knew things were different in my country, but that these students just can't act like that and I need to control them.  After about 10 minutes of her yelling at me, I finally got a word in edgewise.  I said, that this sort of behavior was also not appropriate in my country (not the laughing, but flirting in the hall during clinicals is not acceptable).  I also said that I have 10 students, and when I am working with them on a patient, I can't see all of the others, and that they were old enough to govern themselves, and that I would talk to the head of the nursing school about them.  She finally calmed down. 

I went to the head of the nursing school that afternoon (who I must say dresses like Elvis Costello).  I told him that I was having trouble with a couple of my girls flirting with boys and before I even said their names, he knew who they were, and said that he would take care of it.  That made me feel better.  Apparently I am not the only one who has had trouble with them.  

As I said, you never know what the next day will bring.  If I had known it was the last day I would spend with my students, I would have said goodbye or given them all hugs, etc...As it was, I just left them hanging.  

the psych ward

The week before I got sick, our clinical rotated through the neuro/psych ward.  They don't have enough rooms to separate the two, so they are all in one big room.  One one side of the room are older women who have had strokes.  They are pretty sad, most are poor, and one in particular touched my heart.  It was just she and her husband subsistence farming.  She was so worried about what was going to happen to her and her husband now that she couldn't work.  I worked extra hard with her teaching her some physical therapy exercises.  My heart broke for her, but it was all I could do.

On the other side of the room, there were four women who were as the Afghan doctor said "psychotically depressed".  That means they were so depressed that they were having breaks with reality.  I didn't really see that.  I think that the doctors were just tired of hearing them cry and they made up that diagnosis as an excuse to give them antipsychotic medication to put them to sleep.

The first girl was about 16-17 years old.  Her mother was with her and obviously cared deeply for her, as a mother should.  I sat on the bed with her, and accepted a warm, sweet cup of milk that her mother offered me and asked what was going on.  The mom told me most of the story.  She said that a year before, the girl had gone to a wedding and some men had come to the wedding and threatened to kidnap the girls.  Since then, this young woman had not stopped crying.  

Afghans are notoriously emotional, but this seemed way over the top, to be frightened, and then to cry for a whole year.  I had a sense that there was more to it.  In Afghanistan, if a woman is raped, it is considered her fault.  As I watched this young woman and her interactions with people, and the fact that we couldn't get her to tell her story, but just let her mom speak for her, I felt that she had probably been raped at that wedding, and perhaps even gang raped.  My heart burned for her.  I knew that if she told her parents, it may mean death for her.  I took the nursing student assigned to her (this is the same student that I took out to help me with Roqia [the little girl with abdominal TB]) out into the hall and told her my thoughts.  I asked her to just sit with the girl all day, hold her hand, and listen to her.  I told her to make sure that this girl knew that no matter what happened that day, it wasn't her fault.  I also sat with her off and on all day that day, and told her over and over that if anything else had happened to her, that it wasn't her fault, but it was shame on the men who did it.  

Another lady, near the end of the row was so depressed that she was starving herself.  She was literally just skin and bones, and she was completely catatonic from the antipsychotic medication that she had received.  She had several small children one of which would come and sit with her every day.  It broke my heart to watch these little children watching their mother starving herself to death.  I sat and held her hand as well, and cried with her (as I did with every patient that day).  I also snuck her a little money before I left that day to help her buy her medicines.

While I was sitting with her, another lady was brought in and put in the bed beside her.  She then began screaming a blood curdling scream and shouting that she will pour gasoline all over herself and light herself on fire.  

At the end of the row, in a bed beside the window, there was another young married woman.  I don't think she could have been more than 19, but already had several children.  She was also labeled "psychotically depressed".  As I was holding her hand, she looked at me with tears streaming down her face and said, "God has left me.  God has left Afghanistan."

That was one of the most difficult days for me in Afghanistan.  But my students learned a lot about caring for more than just a body part.  They learned to care for people.  The next day, when we walked through the door for clinicals, all of the patients that we had cared for the day before smiled.  Their problems are far from over, but a little kindness went a long way.

A few more notable things happened this day.  A man in the ward next to ours died.  He had a heart attack.  His family began wailing, which if you have never heard you are fortunate.  Then armed guards came running down the hall with their kalashnikovs at the ready.  When a patient dies, guards always come to make sure that the family members do not kill the doctors or nursing staff.

Did you ever see the movie "Blood Diamond?", They keep shrugging their shoulders and saying TIA (meaning "this is Africa").  The Afghans have the same phrase.  WHen you ask why something is the way it is, they shrug their shoulders and say, "Afghanistan as dega" (This is Afghanistan).

A terrible burn

Sometime near the end of April, my driver showed up with his little nine month old boy, who had been severely burned three days before, because he pulled over a pot of boiling water onto himself.  I was pretty upset with him for several reasons.  First of all, he had taken my first aid class, and had been taught how to prevent this, and  to immediately put cold water on a burn, and to never spread mud on it.  Well, he had ignored all of those things, and when I saw the baby, he was covered in mud.  The second thing was that he had waited three days to come to me.  I asked him why, and here was his answer...

About 2 years ago, he came running to me, like there was a dire emergency, and asked me to come see his mother, because she was sick.  I asked what was wrong with her, and he said she has diabetes.  I said, well when did she find out (as he was so excited, I thought it must have been a new diagnosis, and the family was scared).  Turns out she had it for 20 years.  I asked if she was having any new problems with it and he said no.  From previous blogs, it is clear that I am over busy, and usually, when people have problems, I will drop everything to help them.  But at that time I was extremely busy, and it put me over the edge that he would try to manipulate me like that (he did this quite often.  When I did get to go see his mom, he tricked me into coming on a day when every woman in his family was there and I ended up having over 30 women clamoring for me to examine them).  So I reacted rather badly and told him to never do that to me again.

The second reason that he waited so long was because of an incident that happened about 2 weeks before his baby was burned.  He showed up at my front gate on a day when I was running late and did not have a guard working, and he rang my bells for over 10 minutes.  I finally went out, and talked with him through our tiny little window that we have cut out of our gate.  He said that his mother needed eye surgery at the eye hospital and since I know the administrator there, would I ple

ase call and ask how much it would cost. I said yes.

So, I made the call and of course there are different prices for all different surgeries and I had no idea which surgery she needed.  Later on, when I got to the office, I told him there were different prices and that she needed to go there and be examined to find out how much it would be.  He said that she had gone and they said it would be about $100.  I asked, "then why did you show up at my house and ask me to call?"  He laughed and said he thought I could get a lower price.  I talked with his boss that day, and told him that it was inappropriate for a man to show up at my house asking to talk to me, and to tell him to never do it again.  If he has a problem, he can call or see me at the office.

So, he didn't bring his son to me until he was dying.  At first I felt bad, but I know that I had made it clear that if there was a real need I would be there for him, so I gave up the guilt.

Back to the story.  He, his wife and their son showed up in front of K.'s house (she is the nurse that I work with) and another foreign woman happened to see them there and called me.  K. and I exam

ined him, and at first, because of all the mud, I thought that he was covered in third degree burns.  It was really bad.  He also had a fever.

We took him into the bathroom and began to scrub his wounds.  It was horrific to hear his screams, but very necessary.  WE finally got the mud cleaned off,and the dead skin.  His whole left arm and leg were burned, along with a spot on his scalp and small spots on his right hand and foot.  We covered the wounds in silvadene cream, Vaseline gauze and wrapped him all up.  We then made a plan to debride (scrub) the wound and change the dressing every three days. We also gave him some antibiotics and tylenol for infection and pain.  Thankfully, I had some narcotics with me,

and we began to give him some pain medicine about 30 minutes before we started.  After a couple of weeks though, he equated the me

dicine with what was to come, and he began to throw up the medicine as soon as we gave it.  So, we had to do with Tylenol suppositories.

The going was slow, as a matter of fact, I never got to see him completely well, because I got sick.  But I did get to see his leg heal, and his arm was healing well, though we feel that part of his arm was indeed a third degree burn.  It took 3 months to heal.

This picture was taken after about two months, when his leg was already better, but his arm still had a long way to go!

TB

Sometime back in late March/early April, we used our blessing fund to send a 12 year old girl, Roqia, to Kabul to have abdominal surgery. 

This little girl was born with multiple birth defects.  She had a cleft palate, and her face was malformed, making her eyes protrude.  She is also very small for her age, but that is pretty common among the poor in Afghanistan.  She had originally gone to the doctor to be examined for cleft palate surgery, but something else showed up.

 She had a very swollen stomach, which was either going to be diagnosed as liver cancer (this would have been a death sentence for her), or tuberculosis.  It turns out that she had abdominal tuberculosis.  They did surgery to clean out the abdomen and to do a biopsy.   She was then sent back to Mazar with her family.  

That's when I came in.  They had left her abdomen open so that the TB drainage could drain out of it.  But, apparently during the surgery, they put a small hole in her bowel, so it wasn't just TB drainage coming out, but bowel contents as well.  In Kabul, they had placed a colostomy bag over the wound to catch the drainage, but since she didn't have a protruding colostomy, the bag wouldn't catch the drainage.  

I went to her house (they are very poor, so their house isn't the nicest or the cleanest on the block).  She was in a great deal of pain, and the drainage was unbelievable.  It was (if you have a weak stomach, please don't read this part) part white cheesy TB drainage mixed with bowel contents (diarrhea).  I washed my hands, and put on gloves and took off the bag.  She had a big X shaped hole in her belly, and gunk (the official medical term) was pouring out of it.  I cleaned her up, and tried to put a new bag on, but so much stuff was oozing out, that I couldn't get the bag to stay.  It was a different sort of bag than we have in the states.  There wasn't any adhesive on it.  Instead, there was a strap that wrapped around your body to hold it in place.  It was also very heavy, so that no matter how tight I wrapped it, if she sat or stood up, it would slide down and the edge would sit on top of her wound giving her excruciating pain.  

Speaking of pain, in the midst of all this, she was recovering from surgery, and pain medicine is not usually prescribed after surgery in Afghanistan.  I examined her,and found that her stomach was very distended (swollen with air), so I called a pediatrician friend in Kabul, who had been following her case (Dr. J), and he felt that she should have an enema.  He said that after her surgery, the swelling was down, the drainage was minimal, and her pain was under control.  So, it was a bit disconcerting that she was doing so badly.

I didn't have access to an enema that day, so I taught her mother how to keep the wound clean, then went home.  That night, my roommate gave me a great idea.  She told me to get a nursing student to come help me with Roqia.  She said it would be a great way to mentor a student in nursing care.  

I went out the next day and bought an enema, then went to the nursing school to find a student.  The head of the department thought it was a great idea as well, and went to a classroom with me to find someone.  There, he gave a long speech about how whoever went with me would need to behave and they couldn't look at the drainage and faint or throw up or react in any way what-so-ever.  This speech had to be made, as they needed to know this wasn't about prestige and getting in good with the foreigner.  It was about taking care of a sick child.

I was hoping to get a student of the same ethnic group, as this family's ethnic group is the most persecuted ethnic group in Afghanistan.  Well, the girl that volunteered was not just of the same ethnic group, she had also spent most of her life as a refugee in Iran (as had this family).  So, she could relate to them very well, and would treat them with respect.

I was very impressed with this girl.  She washed her hands before and after and wore gloves.  She also was very patient and did a lot of teaching with the family.  Later on, I was to have this girl in my clinical group, just before I got sick, and she indeed will be a good nurse.

Back to Roqia.  She felt much better after the enema and the drainage slowed down considerably.  I visited her several days later, though and all of her symptoms had returned.  I talked with Dr. J again and he said to give her another enema then start her on some medicine that should keep things moving along better.  When I gave the enema this time, (warning, again, don't read this part if you are squeamish) I looked in the pan afterwards, and a long white worm had come out.  So I added some worm medication to her treatment.

Thankfully, after that she began to make steady progress to get better.  She was due to have her cleft palate repaired in September, but since I got sick and had to come home, someone else is following up on her care.

An aside about the family.  They love this child.  They are however, a typical Afghan family and don't know much about hygiene.  Roqia's mom did her best to keep the wound clean, but in the process, not much else stayed clean.  She had a box where she kept the rags that she was cleaning Roqia's wound with (both clean and dirty were in the same box, along with her TB medication).  One day, she served me tea.  When an Afghan serves tea, they must serve some sort of candy (sweets they call it).  After she served me the tea, I saw her reach into the box and dig around finding all of the candy that had spilled out into the bottom of it, then she served it to me.  Though I am usually not very careful with what I eat at Afghan's houses, I had to draw the line there.  As a matter of fact, it almost made me retch when I saw her do that.  I had to finagle around to find an excuse to not eat the candy, but I managed to get out of it.

Trip to theouterlands part 3

When we left for the mountains, we decided as a group, that I would be anonymous, meaning that we would not tell anyone that I was a nurse, for fear of me being overwhelmed with work.  I did not bring any of my diagnosis books or assessment tools (not even a stethoscope).  But, the woman who runs the CP clinic did not get that memo, and she mentioned to all of the patients families that a nurse was coming. Oh dear...

One day while we were on our trip, an employee at the CP clinic asked me to go look at his daughter who had been sick for a while.  So, we went out to his village and it turns out that his daughter has malaria.  She had already been diagnosed, and was taking medicine, but I didn't have my drug book with me, so I called a friend back in Mazar to get the right dosages.  She was not taking enough, so I corrected the dose for her.  About a month later, I found out that all Afghan malaria was drug resistant, and that what the doctors prescribe is useless there.  Ugh...well it is a lesson learned.  During our surveys on this trip, we found out that in the mountains, most people get malaria every summer.  So, they desperately need some prevention measures, like mosquito nets, and getting rid of standing water etc...

After we finished with the little girl, one of the women in the house said that she was suffering severely with gall stones.  She had lost so much weight, that she was a stick and her shoulder blades were sticking out.  She said that the doctor told her she needed surgery,  she couldn't afford it...again the public hospital is supposed to be free, but the docs and nurses want bribes to treat you.  Thankfully there is  a Turkish run wing of the hospital and we had made some contacts there, so we got her into see someone.  It is s frustrating to deal with the apathy of the medical community there!

As we left the house, people started coming out of houses and streets all over the village, asking for me to come and examine their sick loved ones.  This is my biggest struggle in Afghanistan.  The need is so incredibly great, and the resources are so few.  I long to help everyone in need, but I am only one person, and sometimes I work until I have nothing left and I get so sick that I can't go on for a while. (more about that in a later blog)  I did something that day that I don't do very often, but for my sanity I am having to learn.  I walked away.  

The next day, at the clinic, a baby was brought to me who had pneumonia.  Since I didn't have anything with me, I couldn't treat him, and once again, I had to walk away (though I did tell the mom to get the baby to the hospital).  I really struggled that night with what I should do, and I finally came to the conclusion that I wouldn't travel without my medical things again.  The basic things do not take up much space, and it will be worth it.  Second, though I can't go into a village and treat every single person I see, when individuals come to me (like the baby with pneumonia), I need to be ready to treat them.  

Trip to the outerlands part 2

It has been a REALLY long time since I blogged, and tons has happened.  I'll try to write in order.  At the last blog, I was traveling in the outer lands.  I will pick up from where I left off.

While F. and I were working in the CP clinic, A girl of about 12 was brought in.  She didn't have use of her legs, and they were stiff with contractures. Her mom said that she had CP.  The problem was, that she had an open sore on her foot, and the clinic cannot treat children until they are otherwise healthy.  I asked the mom to take the bandage off of her foot so I could examine it.  It was completely gangrenous.  All of her toes, through the middle of her foot was black.  Then there was a diagonal split that was entirely open flesh.  It was one of the worst wounds I have ever seen.  

I asked her mom if she had been to the hospital, and she said they had, but the doctors wouldn't treat her, because she was handicapped.  F. and I bundled her up and took her back to the hospital.  We went into the ER with her, and the ER doc recognized her.  He said it didn't matter, because she didn't understand what was going on.  He said that she had polio and shrugged.  We told him that she was a little girl in pain and that she needed treatment.  He said that they had treated her, but that the parent's had taken her out before treatment was finished.

Honestly, I didn't know who to believe.  It was quite possible that they didn't do anything for her, because of her mental and physical state, or that they were expecting bribes to treat her, even though it is a free hospital.  But, it could be that they were treating her, and the illiterate parents took her out, because they didn't understand the length of the treatment.  

One thing was for sure, the doctor didn't think her worthy of treatment.  We dug our heels in, so the doctor came and cleaned the wound and started and IV.  Then, F. and I stayed with her until she was admitted to a ward.  We made sure she was scheduled for surgery (for amputation of her foot above the ankle), and that she was getting antibiotics.  

We then sat and talked with her and her mom, and though there were some obvious problems, it was clear that the little girl had a good intelligence level, and that she understood what we were saying to her.  

We went back two days later to make sure everything was going well, and she was scheduled for surgery the next morning.  We loved on her and her mom and then had to leave.  They wept hard, as we were probably the only people who had ever shown compassion to them.  

trip to the outerlands

Back at the beginning of March, four of us ladies made a trip to a more rural province. Each one of us has a goal of getting to a more isolated area to work, so we went on this survey trip to see how it may be. We had several goals. One was to see if that particular place was where we wanted to go. Two was to see what type of work was going on in that area. Three was to see..well, can we hack it?

All of us came away changed, but I will just tell my story. It was a more difficult place. We had an outdoor toilet, which would be fine except for the frequent diarrhea that is so common in Afghanistan. Trips out there at 4:30 in the morning aren't the best fun.

In Mazar, we are used to walking around anywhere and wearing a head covering that leaves our face bare (or naked as they say here). But, there we wore a hijab. (a veil that covers everything but your eyes). In this area, most of the foreign women have chosen to never walk alone, so we were somewhat of a disturbance to our guards. Every time we left, they would say, are you sure? I'll go with you. We finally convinced them that we would be ok.

So, F. and I went a walking one day, and as we came to an intersection, we saw a little Toyota truck full of police. We thought nothing of it, as it is such a common site. but suddenly we saw a riot of men following the police. Neither of us said a word, but both of us at the exact same time flipped around and started walking the other direction. We had no idea what was going on, but we knew it was something we didn't want to walk into. We found out later it was a demonstration in protest of Denmark, which had decided to republish some offensive cartoons regarding the prophet Mohammad. Glad we got the heck out of Dodge!

F.'s mother has cerebral palsy (CP), so her heart is drawn to children who have physical challenges. There is a CP clinic in the town we were in, so she and I worked in it for a few days. She had a lot of ideas, and had sent some toys and materials ahead that we could work with. The children were amazing, and the work that the clinic was doing was equally amazing. A physical therapist had come out and taught some local Afghan women how to stretch and exercise the children, and they had learned well. One little boy had even learned how to walk.

We have all seen some pretty horrific things here regarding how parents treat their children, and because of this, we were really worried about how they would treat a child who was less than physically perfect. We were very surprised. The mothers doted on these children. One mother even said that her husband was so good to their little girl with CP, that their other children didn't think he liked them at all!

I learned a lot about CP that week. I had thought it just happened at birth, but it can occur up to 2 years after as well. It can happen as a result of severe dehydration after a bought of diarrhea (which is a common cause of death here as well). It can happen after a high fever. (Also common here, because as soon as they see a runny nose, they start piling clothes and blankets onto a baby even in the severe summer heat thinking that they will prevent pneumonia. Instead, they cook their babies). I can't tell you the number of mothers who told me that their baby was fine until a bought of diarrhea, and suddenly they were limp or stiff. The same with the fever.

The saddest, though is that it can also be caused by shaken baby syndrome. Most kids here are severely abused. It is a part of life that they grow up with. The problem is that some of it is not meant at all as abuse. Kids are just thrown around like they are rag dolls when they are little. They have multiple siblings who pick them up and carry them, toss them around, and drop them (I have seen two year olds carrying around their 6 month old sibling who is almost the same size as they are). When a mom wants to put a baby to sleep, she puts it on her legs and rocks hard, it until it is completely rattled. They have no idea. Also, they shake them when they are choking. My heart freezes every time I visit friends with children, because I see danger at every turn!

While we were there, I evaluated a child new to the program, and I am fairly certain that she has shaken baby syndrome. Her head was huge indicating hydrocephalus (water on the brain), and she had gone blind. She also screamed a hideous scream, the kind you hear from crack babies. It was blood curdling and made you want to run away. It was so sad. She is scheduled soon to go to Kabul to have surgery to receive a shunt that will remove the water. So sad.

That was just the beginning of the trip...more to come...

beggars

What do you do with beggars in a country where it is a profession? According to the laws of Islam, you have to give to beggars to get to heaven. If that is true, then you have to have beggars to give to. I struggled for a long time about what to do with them. Some are truly poor and desperate, some are not. Some of the children aren't beggars at all, but see a foreign woman with a nice face, and act like a beggar to see if they can get anything from me.

In the past, I sort of picked and chose according to the moment. There are times in the bazaar that if I give to a beggar, tons of them will crowd around me, and it becomes a mob scene with women and children pulling my clothes off. I hate that.

Lately though, because of the wretched winter they had here and now the drought we are in, prices have doubled for staples like flour, oil, and rice, so I give to nearly everyone I see. When I shop, I ask for small change so I have something to give.

I have been looking for other ways to give as well though. My roommate loads little draw string bags to give out. She packs it full of sample bottles of shampoos and soaps or first aid supplies and a 50 afghani note (one dollar...a lot for a beggar). I used to buy cookies when I went in to a shop to give to the children, but being the nurse that I am, I have wanted to do something a bit more nutritious. So, today, I walked home from "du sad bestar" (the hospital I am working in). It is about a three mile journey, so I usually run into a lot of beggars. Last week, I ran into about 5 in a 5 minute period, so I thought this week that I would be more prepared. So, I stopped at a little store and bought 4 little boxes of Mango juice, thinking it would add some vitamin C and beta carotenes to their diet. So I walked and walked, and no beggars. I couldn't believe it. There just weren't any out today! Perhaps they were hanging out at wedding halls, as it is wedding season. Or, perhaps the police came through and cleared them all out. That is possible. I saw a big truck full of Kalashnikov armed men drive by as I was leaving the hospital...who really knows?

I was a bit disappointed, as I was very tired from the day at the hospital, and I had loaded myself down with all these juices. But, as I got to the back side of the bazaar, where all of the used clothing is, I saw a little old woman bent completely in half shuffling along with her little bag of bread looking into a shop to see if the man would give her a bit of change. I looked to make sure she was a beggar (though I really didn't have a doubt). Then, I turned around and bent over to talk with her and gave her the juice and told her it would be good for her. At this point, usually the beggar will say "God bless you", because to give to beggars gains favor with God. I don't believe this. I give, because I know that God loves these poor distressed people. I said, "God bless you khAlla (auntie)". Then she grabbed me and hugged me around the waist because she couldn't stand strait, and burst into tears. I bent down to hug her back and cried with her.

What else could I do?

du sad bestar

Du Sad Bestar That is the name of the hospital that I am assigned to. It means 200 beds. I take that to mean that they can have two hundred patients. If you haven't been in Afghanistan for a long period of time, the first thing you may notice as you walk in the door is a guard with a Kalashnikov (old Russian type automatic machine gun) at his side. Not your every day occurrence in the USA. Though, I think we do have armed guards in most ERs nowadays. I have actually gotten used to seeing Kalashnikovs. I actually don't really notice them anymore unless I am trying to remember what it was like to be new here. I noticed this time, because I was wondering what in the world I would blog about. Life has gotten so "normal" for me here, that I forget what things are really NOT normal in the west.

I actually haven't blogged in a while, because I was over a half a month without electricity, and my computer battery is so bad now, that by the time I used it for a 45 minute exercise routine, it was finished. I guess our frequent, long lasting power outages are also not "normal".

There are two of us "foreign" nurses who are to be supervising the clinical instructors. Clinicals are on Monday and Tuesday, though the original schedule had them on Tuesday and Wednesdays...ok, how can I begin to explain why we had to completely change the 18 week schedule that had been set for months....March 21 was the Afghan New Year. It is celebrated by people from all over Afghanistan making a pilgrimage to Mazar (my town) to the blue mosque/shrine of Ali (you can Google that one...it may be under Shi'ite traditions). Then, every Wednesday, for 40 days (which equals like 5 Wednesdays or so), the women of the city gather at the shrine for a picnic lunch. Police guard the perimeter so that men can't get in, and women dress up in their finest shiny dresses and it becomes the social event of the year. We had to change our schedule that had been set for months, so that the female instructors could go on a picnic.

We also have a short meeting on Sunday to go over what the instructors are to be teaching during the clinicals. The plan was that we would rotate around all of the clinical sites to see how the teachers were doing. Unfortunately, the teacher at du sad bester has a habit of not showing up for clinicals. So, I am there on a permanent basis. All of the other instructors go to the school to sign in that they are present, then they go to the clinical site, then back to the school at the end of the day to sign out. This particular teacher was told to not even go to the school, but just show up at the clinical site, because otherwise, he would sign in, then disappear and reappear to sign out at the end of the day, having never stepped foot in the hospital. Sigh...

Our first week was technically last week. We started at the nursing school on Monday with a meeting for the students to explain the rules to them. Mostly "normal" stuff... you must have a uniform, your ID badge, a watch with a second hand, stethoscope...Boy did they ever balk at that! One guy got up and said, "you can't lay your American rules on us. We are poor Afghans!" We actually didn't make any rules. We just read to them the rules that the nursing school has always had, and told them that they would be enforced.

So, the next day was practice day. They were to show up at their clinical site, in uniform, on time. That was all. we had 7 of 10 show up. All were late. One didn't have his uniform, several, a couple didn't have ID cards, a couple didn't have a pen or paper. None had stethoscopes. On the bright side, the instructor showed up on time.

We finally got started this week. Only three students showed up the first day. My coworker, K, made this great plan to build up their knowledge every week. So, this week they were to take a history and get vital signs. Next week, they will do the same, but also do a head to toe assessment, the next week, we add procedures like IV starts, etc... We let them go into a ward to choose their patients, get their history and take the vital signs. Here I must put in another aside. A ward is not like a ward in the States. It is a room full of beds. Also, in the States behind hospital beds is equipment, like oxygen, suction, ambu bags (the bags used in respiratory resuscitation) . There is no such thing here. Just beds.

About 15 minutes later we went to check on them, and take the vital signs ourselves, so that we could see if the students were right or not. It turns out they hadn't really done anything. So I observed. It was obvious that they had never done that before. So, I gathered them together and took them to an empty room and taught them how to take a temperature, blood pressure, pulse and respirations, and then made them practice on each other until I knew that they could at least put the cuff on right side up.

Another thing we did was buy bags of supplies for each of the clinical sites. We included things like a BP cuff, alcohol swabs, thermometers (you would be hard pressed to find a thermometer in a hospital here. the nurses just touch your forehead and make a guess as to what the temperature is.) My big contribution was a bottle of alcohol so that the students can wash their hands between patients. They thought I was obsessed, as I followed them around with this bottle. Everytime I got near one of them, I was pouring alcohol on them! Yet another aside. They don't have isopropyl alcohol here. That is the rubbing alcohol that we use in the States. They have ethanol. It smells like a bottle of rum, and I have to confess, the past two days of clinicals have tempted me to upend that bottle into my mouth!

So this particular clinical group, which I will have for several weeks is all boys, so all of the patients are male. As this is Afghanistan, before I can touch a patient who is a man, I must ask his permission. So far, I haven't had anyone refuse, though I have had some very smiley men, who really creeped me out.

I will continue this blog tomorrow, as I am now exhausted just recalling the past two days!

nursing seminar

I teamed up with two other nurses this week, "K" and "M" to hold a 3 day seminar to teach nursing instructors what they need for their nursing students in their clinicals. It was quite the eye opener! "K" started by giving an introduction to the expectations. They have to show up for their clinicals, or they will be out of a job. Period. Sounds silly to have to say? Well, several of the instructors never show up, so the students drink a bit of tea, then leave. They then graduate and start working in the hospital with no clue of what to do. We would like to stop this practice, so she also gave some expectations for the students. If they don't meet those expectations, they don't graduate!

I then gave a lesson on "Comfort measures". These range from fluffing pillows (yes, some nurses still do that) to getting the patient to do deep breathing , coughing, and leg exercises to prevent pneumonia and blood clots. They had no idea that patients on bedrest were at risk for these things. I also said that a patient should get up and walk ASAP after surgery, and they thought I was crazy (they still think you need to wait 24 hours...a practice that is not long ago in our past). So they couldn't believe that I had surgery this summer, and walked out of the hospital less than two hours later!

The next day, I gave a lesson on assessment (many new things there!), and "M" gave a lesson on medication math. The assessment went well, and I had found this great program on "lung sounds" on the internet, and because I am an aid worker, they gave me a 30% discount! So we got to hear a lot of crazy sounds. They were upset that I didn't have any heart sounds to listen to. I told them, that they had enough new and important stuff to learn, and that if they heard anything different than lub-dub, they should tell the doctor.

Here is where it went crazy. "M" introduced them to medication math. What the doctor orders is not necessarily how the drug is supplied, so you have to do some calculations to figure out the correct dose. For example, the doctor may order 15 mg of something, but it comes in a bottle labeled 30mg/ml. So, you have to give 1/2 ml. That is an easy one. They aren't always that easy. These nursing instructors are the creme of the crop, some with 20 years experience, and they had never calculated a dose! They draw medicine up into a syringe and just give it without knowing how much of the drug is actually in it! Oh dear.

Then, we went on to drip rates for IVs. That was even worse. They just eyeball it and give a little or a lot (no kidding). That is dangerous for an adult, it is lethal for children. In the States, though we learn how to do a drip rate, we have machines now that do it for you. here they have nothing mechanical at all, so it is up to the nurse. When a patient gets up to go to the bathroom, they shut their own IV, then open it back up when they get back to bed, and usually, they open it all the way up and get flooded with fluid! So crazy.

So, we have decided to have another "mini" seminar just for medication math for these poor instructors.

The instructors were eager to learn though, and that was very heartening. The students come back to school jsut after New Year (which is March 21 here!) So, we will have our work cut out for us!

a light at the end of the tunnel

Well, I can still see my breath in my house, but it is no longer painful! Spring looks like it may come early this year, but you never know what is around the corner. The BBC is still calling for snow. We shall see. In the meantime, over 1000 people have died as a result of the coldest winter on record in Afghanistan, and over 300,000 livestock have died, with as of yet unknown repercussions. Here are a couple of links to download video of this Afghan winter.

http://edition.cnn.com/video/#/video/world/2008/02/16/guillermo.afghanistan.weather.cnn?iref=videosearch

http://edition.cnn.com/video/#/video/weather/2008/02/10/vo.afghanistan.deadly.cold.ap?iref=videosearch

Last week, a friend, "F", who runs a kindergarten here called and asked me to see a couple of siblings of one of her students (ages 3 and 1.5). She said that their hands and feet were black and swollen from frostbite and one had a blister that was open. My heart froze, and the chill ran through my entire body as I thought of having to take small children to the hospital to have their fingers and toes cut off. I gathered all I thought I would need to try to thaw them out, along with some ibuprofen and codeine for the pain. As soon as I walked into the room, I could tell it was an extremely poor family. They had next to nothing. And there is a certain smell that a room picks up with the family is poor. I can't describe it. I call it the smell of poverty. It is the same smell that was in the orphanage I worked in in China. It is a smell that I am becoming more and more familiar with.

F brought them some cushions to sleep on and a blanket and some coal for heat. I brought a thermos of warm water to thaw out the children (it takes fuel to heat water and I was afraid that they wouldn't even have that.)

I looked at their little hands and feet. They were black, and they were icy, but they didn't seem as bad as they had been described. F said that they weren't as bad as when she had seen them earlier. So, I gave them both some medicine, and placed their hands and feet int he warm water. I also took out a bar of soap to wash them (some of the black was simply dirt). As we waited for them to thaw, I passed out gummy bears to all of the children (lost count when the whole family was in the room), and we sang children's songs to them in both English and Dari, and told stories. When the two that I was treating started to cry, I went to plan B and brought out the beanie babies I had brought them. They really enjoyed that too.

It takes a long time to thaw frozen body parts, so as we continued to wait, I went around the room to feel everyone else's toes and fingers...There were at least 6 children and 4 adults in the room (the size of an American bathroom!), and not a single one of them had a pair of socks...need i remind you that the average temperature during the day in the month of January did not get above the teens? It was too late to address that issue, but the next day, we sent them all socks and gloves. We also reinforced that once the children's fingers and toes were thawed, they had to keep them warm, or it would be even worse, and they would lose them.

In the Afghan culture you are not supposed to say anything bad may or will happen. They think it will cause it to happen, and if they do say it, they preface it with KhudA nakuna (God forbid!) But I have found that they simply will not follow my instructions unless I scare them into it. So, I told them that if their hands froze again, they could get infected and would lose them and if they weren't cut off in time, they could die. Harsh, but true. I can only hope they listened. When we left, the little fingers and toes were warm and pink. God was smiling on those children that night. I have no other explanation.

Today, as I was walking to the office, I GOT HOT! I couldn't believe it! The sun was shining and I got hot! There is hope.

Winter part three-the never ending story

Yesterday, I was sitting on cushions, with two heaters on, and I could still see my breath. There was no electricity, and our water had finally frozen. I hit rock bottom. I can't imagine how it must be for the Afghans who can never get warm. Our guard came in with a blow torch and heated our pipes for about 30 minutes, seemingly to no avail, but a couple of hours later, we suddenly had water again! Today we had running water and electricity the whole day! A blessing without precedent!

How do you walk with the poor when you are not one of them? This is the question I have been asking myself the past week, as things have gone from bad to worse. The Afghan people have made great strides in trying to move forward after generations of wars and tribal conflict. But, they hang by a precarious thread. They have a little now for basic survival, but there is still nothing in reserve. Any disaster can take them down, and that is what we are seeing now.

What does poor mean in this society? My friend and I went looking for the poor the other day. We have a fund set up in America to use to buy food, medical care, blankets and heating fuel for the poorest of the poor. There are many poor here, but there are some who are simply desperate. We asked local Afghans to introduce us to the people that they think are poor.

My friend's house helper picked out two families. We went to the first and saw a weird scene. It was almost like it had been set up. (Yes, there are people here who would scam a foreigner to get whatever they can). It was a concrete house (you really want to live in a mud house here, warmer in the winter and cooler in the summer). There was no heat what-so-ever. It was absolutely frigid! It was a widow, with nine other people in her house, including two healthy working age sons. Now, at the moment, it is difficult to get a job, but if you are desperate to eat, there are some things you can do. We asked what they needed, and they said everything, and the quantities that they asked for were huge. We looked around though, and there were two chickens in the yard, two bicycles, and a small generator. That doesn't sound like much from a western standpoint, but there are people now who are tearing up every scrap of wood they can find to heat their house, and their children are starving. This family was not that desperate. If they were, they could sell the generator, the bicycles, and they could eat the chickens.

We went to the next house. This family was different. There were two families living in two rooms of a house. In one room, there was a woman, her husband, who was disabled from kidney problems, and two children. The other room housed a widow, her daughter and several children. This is the room in which we sat. Two of the children sat in the coldest corner. One slept while the other looked at us with big haunted eyes. As we spoke with the woman, she said that she peels chickpeas for 20 afghanis a bag (40 cents). This will buy bread for her family, but not much else. Suddenly, a metallic cough rang out from the little girl, which went right through my bones, then the tell tale whoop during the intake of air, which indicates whooping cough. Yes, this family was hard up. We made a list of things to bring them, including antibiotics for the children.

The third family we visited was recommended to us by my house helper. There was an older woman, her son, his wife and their 1 1/2 year old daughter. The man was out, presumably looking for work. They lived in the basement of their landlord. It was about 14 feet by 7 feet. They owned nothing but a teapot and the clothes on their back. Their neighbors had loaned them a little gas bottle to cook on, and a carpet to keep the cold from seeping in through the dirt floor. They had just moved here from Bamian (the city with the ancient Buddha statues that the Taliban destroyed in 2001). We asked why they moved away from their qaom (relatives...all Afghans live in a neighborhood surrounded by family). They said they heard that it would be better in the city. I don't know what drove them to think this, but it was so strong, that they hitched a ride on a potato truck and sat on bags of frozen potatoes for probably two days of driving. They were desperately poor. We also made a list of things to bring them, including cushions for the floor, so they are not sleeping on the bare cold floor, one more blanket (two had already been donated), and some basic food necessities to get them through a few weeks. (Usually this includes flour, rice, kidney beans, and oil). We also ask neighbors to pitch in with what they can, a cooked meal, a bag of potatoes, an extra floor cushion... We cannot save Afghanistan, but if we work with the Afghans and show them that they can help their own country, it is a step forward. Hopefully in the process, we are alleviating some of the suffering.

Nursing clinicals

When I took this new job helping the nursing students with their clinicals, I knew it would be a challenge...yesterday, I got a reality check.

Definition: clinicals are when a nursing student goes into the hospital and puts the theories they have learned in the classroom and the lab into practice. The instruction that the students receive here is pretty equivalent to what they receive in the states, and they have a good lab in which to practice...but clinicals. I hardly know where to begin.

First, we are supposed to be supervising the instructors who are teaching clinicals. This is difficult to do when the instructor never shows up. So the poor students are unleashed into the hospital setting with no goals, and no supervision. So, mostly they just stand around for a while, then drink a cup of tea and leave. These students are in their last year of school. In a few weeks they will graduate and get a job as a nurse, having never once even touched a patient!

So, we are teaching the clinicals. We arrived at 8 am and I got a tour of the hospital...please lay aside your expectations of what a hospital in the west looks like, and step back several hundred years. Now, the students who were meant to show up at 8:30 started trickling in about 9:15. Oh dear. I assigned one patient to every two nursing students, instructed them to go over their chart, examine the patient, and see what medications they were on, and I would come and see what they had done. (we were in the "ICU" where there were about 5 patients in the room). I stood back and watched for about 10 minutes as they looked at the charts, then they just stood there staring. So, I went to the first pair and asked what they had found out. They said that she was there for Nafas tangi. (literally tight breath). That is a generic diagnosis given to anyone having trouble breathing. Could be asthma, emphysema, bronchitis, anxiety, heart failure, etc... I looked at the chart though, and she was on all sorts of heart medications. The problem is, that the drug names are all written in English...the nursing students don't know English. Sigh...

So, I asked if they had done a physical assessment (examination). No. Ok, first take the vital signs. No blood pressure cuff or stethoscope to be found. Well, you can at least take pulse and respirations. Those are important if the patient is having trouble breathing and has heart problems and is on heart medications. So, one student put her hand on the patient's wrist to count the pulse. I asked her if she had a watch. Oh, no...well, how do you know how many beats per minute? Oh, I have a cell phone she said. Does it have seconds? no. Ok, here is my watch. So, she counted on one wrist, while I counted on the other. she got 60. I got 144. Granted it was an extraordinarily weak pulse that was very difficult to count but the extreme difference told me she had no idea what she was feeling for. So, we worked on that for a while. In the meantime, all 7 of the students had crowded around me and the patient and were leaning on me trying to see and here everything. I think they were nervous and just didn't know what else to do!

After we got the pulse down, I told them it was important to look at the whole body, especially the feet. The woman was 70, and had been in the hospital for 9 days. She was at an extreme risk for a blood clot. there are no PTs here to come and walk with the patient. So, we went to check her feet, and they had 2+ pitting edema (very swollen). Even so, her little legs were about the size of my wrist!

When we finally got through with that patient, I wanted to make sure that I set a good example, so we set out to wash our hands. We finally found THE ONE sink in the hospital...I though I might be sick in it. It was so gross, that I felt it may be better to not wash after all. Turns out that we couldn't anyway, because the pipes are all frozen, and there was no soap to be had. We finally found a pitcher with warm water and we poured it over our hands and rubbed hard. (hopefully the friction removed a few germs...sigh again).

We went on to the next patient, and it went much as before. The chart was nearly unreadable, it was half English and half Dari, and the students hadn't done any kind of exam.

At the end of the day, I had a post conference with them. You know, for what they had available to them, they had actually done ok. Here are the instructions that I gave them.

1. Your patient is a person, not a thing or a body part. When you go up to them, talk to them. They are sick and scared. They don't know who or what you are (doctor, nurse, student, weirdo off the street), and they don't know what you are doing to them. Tell them who you are and what you are going to do. Treat them like a person.

2. You must take vital signs. This is important. Who has a watch? All raised their hand. Bring it to the hospital every time you come! If you don't have a BP cuff, at least get the pulse and respirations, and we will come up with a stethoscope so that you can listen to lungs.

3. To examine a patient, you must touch them. You cannot do a physical exam without touching the patient. (this is a public hospital which means that the patients are very poor. Though you don't have to pay to go to nursing school, you do have to have some sort of money to pay for food and lodging while you go to school, so typically the students are of a higher class than the patients, so they disdain them, and don't want to touch them).

4. Wash your hands. I know that sometimes there simply is no way, as there is no soap or water, but try your best to find some and when you can, wash.

5. Many of these patients have been here for days/weeks. They are at high risk for pneumonia and blood clots, as they just sit and lay around all day. Go to them every hour and have them pedal their feet and take deep breaths and cough. Even that may save a life.


I came to a quick realization that this hospital will never be UAMS or Good Sam, and we will not be able to get the nursing students up to the level of a Western trained nurse. But if I can just get one to wash her hands, we will have saved a life. If I can get one to treat a patient like a human, we will have given someone dignity. If we can make one step forward, lives will be changed, and then we can prepare to take the next step.

A few more notes about the hospital. It is a big, cold concrete building with concrete floors that are caked with mud. When we arrived, someone was mopping, and it was so slick that I thought if I can just keep from falling down today, I will have accomplished something big. The wards are full of flat beds, and patients just sit in them all day. There are no food trays to be passed. Families must provide sustenance for the patients. The patients are dirty, with no place to wash. They must go to a bathroom down the hall, that I would go into kidney failure to avoid.

The doctors come in, treat the patient as an inconvenience, and never touch them (I say again, how can you examine a patient without touching them?) The charts are just a bunch of papers stapled together, with instructions written in English, and no orders are ever discontinued, so when it says Dopamine (an IV medication used to treat extremely low blood pressure), but your patient doesn't have an IV, you wonder what is going on. On the next line, you see Enalapril (used to treat high blood pressure), and you realized that someone lost their mind. But, everything is extreme here. Someone has low pressure, so they give dopamine is such a large quantity that the pressure spikes and they give a medication to bring it back down.

On several of the charts the blood pressures on admission were written as 65/0 or close to it. Then, though they were on dopamine their pressures were not monitored. Now, in the States, with that kind of blood pressure you probably won't survive, though you may. Here, there is no way... NO WAY! I think the pressures are made up by people who cannot here on the low grade stethoscopes they have here. Sigh...

One of our patients had been admitted because she had not urinated in several days. She had been in the hospital for a number of days, but there was no clear diagnoses to be found on her chart. As we started our exam, the doctor came in with her son (you must quickly get out of the way when a doc comes in, as they view themselves as gods, and nurses as roaches). The son had a handful of x-rays with him, showing that his mother had TB and had been treated for only one month, then quit treatment. Treatment for TB is 6-9 months, and antibiotic resistant TB is so rampant here, that if you miss one dose, there is nearly no hope. This woman had been laying in a crowded room for days coughing and exposing every other patient, doctor, nurse, student and visitor to resistant TB. Big Sigh... At least the students recognized that she needed to be wearing a mask.

While we were there, a lady was admitted and the women with her sat beside her and sobbed. I put my arm around her and said, Auntie (a proper form of address for an older woman whom you do not know), is this your mother? She said yes. I asked what was wrong. She said, her blood pressure is 0. I looked at the woman MOVING AROUND IN THE BED AND OBVIOUSLY BREATHING, and sighed yet again.

Winter part two

I cannot describe the pain that winter has caused here. Last week, a building in our bazaar caught fire, it spread, consuming two of the biggest retail buildings in our city, and damaging 7 others. ISAF (the international security assistance force) came to help put out the blaze, but it was too far gone to save the two buildings. As a result, 500 people were directly put out of business, and tons of others were affected (for example the people who make the clothing that is sold in those stores, and the people who sell the fabric to make the clothing, etc...on down the line). If you would like to see pictures and hear news of this fire, paste this link into your browser: http://the-rumi.blogspot.com/2008/01/balkh-city-on-fire.html It has really devastated the city. When you drive or walk past, it looks like two burned skeletons and the shattered dreams of people who are just trying to make life better here.

There are all sorts of rumors that go around here when something like this happens. Some say it is the wrath and judgment of God against materialism. Others say it is certainly Al Qaeda or the Taliban. I think someone just got careless with their open flame gas heaters and poof the building went up in flames. There are no building or fire codes here, so of course there were no sprinklers or fire hydrants.

It sounds terrible that the laws haven't caught up here yet, but less than 100 years ago, The US was in the same boat. It took tragedies of children dying in factories to get child labor laws passed. Many people died in clothing factories and tenement fires before building and fire codes were passed into laws. These are Afghanistan's growing pains. Hopefully this suffering will not be in vain.

In the meantime, the cold seems to be unrelenting. We have managed to get a bit of a handle on it. Last night we hung parachute fabric on the inside of our door. You can still see your breath in our hall, but now, there isn't such and arctic blast coming in.

The cold managed to get me first though, and I am down with bronchitis and a sinus infection. So, since I can't smell, I didn't notice the gas leak in my room until my guard came in to change the gas bottle. He said, dear, I am very worried about you. The smell is bad. So, I called my two friends in and sure enough, it was bad. So I had to open up my room to the arctic and air it out. We didn't have electricity, but a dear friend had given me a battery operated fan for the summer, and it happened to be charged up and working! So, my room is now filled with fresh air, albeit cold.

They say that 14,000 sheep have died in the mountains. Simply froze. Also 200 people have died. In the States the sheep wouldn't be that big of a problem, because the government would come in and subsidize. But here, that means the shepherds are out of business, and thousands of people will not have meat to eat in the spring.

As you go through your day, let me encourage you to count your blessings. Toilets that flush. Water that comes out of the faucet, furnaces that come on with the touch of a button, buildings with fire codes and sprinkler systems, and smoke detectors. Fire hydrants that actually have water and firemen who show up and sacrifice themselves to save others. Electricity that is powerful enough to run your refrigerator, hot water heater, electric blankets, computers, stoves, ovens and microwaves. Police who are upright and enforce the laws, instead of breaking them, the freedom of women to get into a car and drive anywhere at will. Grocery stores that are full of food, and jobs that provide enough to eat with. We truly are blessed.

Winter

This is the coldest winter in Afghanistan in at least 10 years. It has even snowed in Herat and Kandahar, where there is usually no snow at all int he winter. They say that 60 people have died in Herat due to their roofs falling in from the heavy snow.

There is no such thing as central heat in Afghanistan. Most Afghans use something called a 'sandalee" to keep warm.

There are various forms of the sandalee. Traditionally, there is a small hole dug into the middle of the floor (easy to do when your floor is dirt). Hot coals are placed into the hole, then a table is placed over the hole and thick heavy blankets are placed over the table and overlap the cushions the people sit on. You sit on the cushions and put your body under the heavy blankets. It is a very quick way to get warm, but you can imagine the dangers. Almost every family has a story of a child rolling down into the coals and burning to death. Other children have suffocated under the heavy blankets, others have been the victim of CO poisoning.

Nowadays in the city, there are more sophisticated forms of the sandalee. The heat source may be put into a big metal bowl, so that children don't roll into the hole. Others use electric heat sources (though electricity is often scarce here). The problem is, that you cook and clean in an unheated room. Imagine washing dishes in water that is straight snow runoff and the temperature in the room is 25 F.

There are other forms of heat. There are old-timey type wood burning stoves like your great grandmother used, but for the most part, there is no wood in Afghanistan. There are diesel drip heaters. Basically diesel is in a can on the side, with a spigot. You turn the spigot on, diesel drips down a tube into a small barrel type container and you drop a match into it, and it slowly burns. I know many people who have had fires in their houses due to this type of heater. And, diesel in expensive. In the two weeks since I arrived, my roommate and I have spent over $60 in diesel. I have a German made diesel heater. It is basically the same principle, but a bit safer and more controlled. I also have a gas heater in my room. I have had fun dancing with the two heaters trying to make my room bearable. I get it to where I can function as long as I am wearing a lot of layers.

A few people have sawdust heaters. They tend to keep the room comfortable as long as they are burning properly.

All this to say. Winter is hard on the Afghans. Their hands and feet are always bright red and swollen with the cold. They spend most of their time being cold and only get warm when they have time to get under the sandalee.

I wonder if there is ever a time when Afghans are not suffering...

Ashura

Today is the tenth day of Muharram. This is the day that Shii'ite Muslims mourn the passing of Hussein Ali. You can get more of its history at Wikipedia. My goal is to give you a picture of how they mourn.
Again, for Afghanistan, I need to go back a bit and explain ethnicity here. There are many ethnic groups in Afghanistan. This is part of the reason it is so difficult to unite them. There are Pashtuns (the Taliban was made up of Pashtuns), Tajiks, Hazaras, Uzbeks, and a myriad of other groups.
Most people in Afghanistan are Sunni Muslims. The Hazara people, who are the people that I happen to have a lot of contact with are Shi'ite (also known as Shia). They look more Mongolian that typical Afghan, and because they are Shias, they tend to be persecuted, especially by the Pashtu.
In the city that I live in, there was a massacre of Hazaras during the Taliban. I have a friend who literally ran with her husband and two small children to the mountains when the Taliban invaded this area. She was still hemorrhaging from the birth of her second child.
So, today is the day for the Hazaras to mourn their hero. They do this by flagellating themselves with chains into a bloody mess. It is one of the most difficult holidays here. The calls to prayer from the local Shia mosque are mournful to begin with, but the singing that lasts all night for Ashura is dark and frightening. It reminds me of the phrase from Lord of The Rings that says, "there is a fell (deadly) voice in the wind." I have to sleep with ear plugs to block out the heartbreaking pain of the voice.
When they work themselves up into such a frenzy, there is no telling what will happen, so needless to say we expats don't leave our house on Ashura for safety sake.

In addition to the sadness of people beating themselves to the point of sometimes having to be hospitalized, this is the coldest winter that many can remember. It gets down to 8-11 F every night, and there is no central heat here.