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Treating Afghanistan

Hood River doctor learns that helping the war-torn country means treating it as a "delicate piece of crystal."

If you were to bore a hole from Hood River through the Earth to the other side, staying at about the 45th parallel, you'd end up roughly in Rustaq, Afghanistan.

Dr. Mike Pendleton's journey there was nearly as arduous and, arguably, more nerve-wracking.

In November, Pendleton flew halfway around the globe -- the last leg of which was a white-knuckle ride on a Tajik Air flight filled with reporters from the BBC and CNN -- to Dushanbe, Tajikistan, as leader of a three-member medical response team from Portland-based Northwest Medical Teams. Theirs was the first American physician group to enter the war-torn country after the U.S.-led bombing campaign began in October.

From Dushanbe, it was 280 km in a "Russian jeep" as Pendleton and the others called it (among more colorful names) to the Afghanistan border, through multiple checkpoints where armed men "arbitrarily administered arbitrary rules arbitrarily" and another five hours over a mountain range to Rustaq.

"Picture the worst logging road you've ever seen," Pendleton said of the overland travel. "Make it worse than that, then make it worse than that, then add six inches of dust."

Pendleton's month-long stint in Afghanistan was his fourth with Northwest Medical Teams to a global trouble spot. In the last few years he's volunteered for similar duty in Vietnam, Albania and Turkey.

Pendleton, a family practice doctor with Columbia Gorge Family Medicine, was joined on his team by Dr. Henry Reitzug, a physician from Seattle, and Erda Fuller, a nurse from Fairbanks, Alaska.

The team went in with six duffle bags of medical supplies expecting to face "classic" disaster relief conditions -- primarily people displaced because of the war.

Instead, they found something quite different.

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When Pendleton and his team arrived in Rustaq, he felt a sense of "overstimulation." The town is about the size of Hood River -- but that, he said, is where the similarities end.

"It was an experience of time standing still -- of being completely in the moment," he said of driving into the town. "Everything was so totally new that I didn't have any frame of reference."

Rustaq was part of the last 10 percent of the country that the Taliban did not control (prior to the bombing campaign) and was "relatively unscathed," Pendleton said. General Ahmed Shah Massoud -- the Northern Alliance leader that was killed in a suicide attack Sept. 9 in a prelude to the terrorist attacks on the U.S. -- had been popular and his image, even three months after his death, was still prevalent.

"There were trucks driving around with his picture on the side," he said -- and also with machine guns mounted in the back. Nearly everyone walking around the streets was armed with AK-47s or RPG's (rocket propelled grenades).

Pendleton and his team stuck out because they were Caucasian and obviously Western but also because of Fuller.

"We would stand in the bazaar and there would be 100 kids just staring at Erda," Pendleton said. There were no women on the streets -- only men and children.

Pendleton and his team were put up in a mud-brick "compound" where they had two translators, a cook and a "man-Friday." They settled in and prepared to begin treating the sick.

But "within 24 hours, it became clear that the Western take on what was going on was superficial," Pendleton said. The events of Sept. 11 had put Afghanistan on the map and "brought it to the surface of our consciousness," he said. "But this was a disaster that had been generations in the making." They had gone in with the "Western notion" that people were dying in the streets, he said.

"Instead what was going on was that people were quietly desperate."

The team began working with two already-established medical clinics in town, and were immediately introduced to the "Afghan system." When word spread that there were American doctors in town, the first people who flooded the clinics were the local commanders -- even though most had no urgent medical problems.

"The way the Afghan system works is, first come the people in power, then their families, then the people who need it most," Pendleton said. Still, it wasn't long before a very sick patient came in -- a 2-year-old boy who was suffering from cerebral malaria.

Pendleton's instinct was to immediately start treating the boy. But he held back and deferred to the Afghan doctor, determined to provide help and Western medical expertise but not to take over. He wanted the local people to trust their own doctors -- and for the doctors to trust themselves -- knowing that he and his team would be there only a short time.

"It's the classic dilemma," he said. "Do you teach someone to fish or do you give him a fish?"

They treated the child with antibiotics and tried to rehydrate him, but he showed no improvement. Over the course of a few days, Pendleton watched the interaction of family members as the boy grew sicker. The mother, covered head to toe in a burqa, was nearly always present but would retreat to a corner of the room whenever Pendleton entered -- where she crouched and "became very small, trying to disappear." The boy's grandfather was also ever-present. One of Pendleton's most vivid memories is of the grandfather sitting in a corner of the dingy, candlelit room with tears streaming down his face, quietly weeping.

As they tried to save the boy's life, Pendleton found himself learning from the clinic's Afghan doctor and staff about a disease he had little experience with.

"It was very moving," he said. "They were like professors teaching me about malaria." Despite their efforts, the boy eventually died.

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Within a few days of their arrival, Pendleton and his team shifted gears from rescue to rehabilitation. They continued to administer medical help, but also worked to come up with a more effective aid program.

"Our job was to come up with a (new) program and sell it to Northwest Medical Teams," he said. After realizing that the need was long-term, the team came up with an idea that differed from Northwest's usual model of sending teams like Pendleton's to disaster spots for 3-4 weeks at a time.

"This is a situation that really demands (a team) to be there for six months," Pendleton said. "It requires someone with a memory of what's been going on." The model they proposed was a three-pronged aid program that would distribute medical help via Northwest Medical Services along with food and non-food supplies via other non-governmental organizations (NGO's) -- "out of the back of the same truck," said Pendleton.

The "piggy-backed" aid package could be taken to rural communities, which would be offered the aid in return for doing some work that would help themselves in the long run -- like building a road, a latrine or a well. (Pendleton presented the proposal to Northwest Medical Teams upon his return. The organization is currently reviewing it and expects to decide whether to go forward with it or not in the next few weeks.)

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Pendleton stayed in Rustaq most of the time, with one side trip to nearby Taloqan, a larger city to the south that had recently been liberated from Taliban control. There, too, he was surprised at how what he saw differed from his expectations.

"I kept on looking for any evidence of anything," Pendleton said. "Like hospitals suffering or the power grid destroyed." He expected the city to be pock-marked by bullets and people to be wandering around depressed or in shock.

"But people didn't seem to be, per se, worse off for having had the Taliban there, or better off for not having them there," he said. "There wasn't a firebreathing hatred of the Taliban." While there might have been more obvious machinations of war and the effects of the Taliban regime in larger cities like Kabul and Kandahar, Pendleton got the impression that the "pace of the day" in rural Afghanistan was pretty much the same as it had been for centuries.

In Rustaq, just as the Taliban's regime seemed far away, so too did the war on terrorism -- and even the U.S.-led bombing of the country.

One night American planes dropped hundreds of yellow food packets nearby. "When they found out it came from an airplane," said Pendleton, "the kids asked if they'd been bombed." He accompanied some locals as they went to retrieve the packets, which contained pasta and tomato sauce, dates, a pop tart, and peanut butter and jam.

The Afghans were unfamiliar with everything but the dates.

"They'd never seen peanut butter before," he said. "They thought it was like glue."

Pendleton was in Rustaq for the the last part of Ramadan -- the Muslim month of fasting -- and for the celebration at the month's end called Eid. For three days he was swept up in the celebration -- invited inside home after home for tea and joining in the festival atmosphere. It was the only time that women were seen much outside.

"It was like looking at fields of Easter lilies," he said of the pastel-colored burqas.

Pendleton left Afghanistan not only with his team's proposal for immediate aid to the Afghans, but with a distinct impression of long-term changes that need to happen for Afghanistan to become a functioning country. The number one priority, said Pendleton, is to give women status as citizens.

"Give the women the opportunity to do what women do well worldwide," he said. As soon as women are empowered, he said, there will follow a higher level of education and of health care. "Women won't take no for an answer" when it comes to their children, he said.

Another necessary fundamental change is to "get rid of the warlord class" by taking away their power and making them irrelevant.

Pendleton would like to return to Afghanistan -- especially if Northwest Medical Teams decides to implement his team's aid model. He feels that, along with helping people in need, such work makes him a better doctor here at home.

"Here, we rely so much on tests and labs," Pendleton said. "When you get away from that, your intuition takes over and you learn to trust your instincts."

Pendleton, who now has a map of Afghanistan on his office wall, said he also feels a "sense of ownership" of the problem.

"I feel like we could make difference, but it doesn't lend itself to a quick fix," he said. While others talk of "modernising" the country, Pendleton views it differently.

"We need to bring them very, very carefully not into the 21st century, but out of the 15th century and into the 20th.

"I look at it as a delicate piece of crystal," he added. "We only have one chance to do this right."

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