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Teleconferencing Medicine

Feb 3, 2011   //   by peretz   //   culture, hospital, long, photos  //  2 Comments

Tues­day was one of my most reward­ing days in Afghanistan.  I wit­nessed some­thing unde­ni­ably and irre­versibly positive.

In the morn­ing an ambu­lance came to pick Dr. Pete and me up from the Taj.  We crammed along with the dri­ver in front, while 5 female OBGYN doc­tors and a male ward direc­tor sat in the back, occu­py­ing one bench and the patient cot.  I’ve rid­den in the back of this ambu­lance before and know that the cot slides around and the whole setup can’t really accom­mo­date more than 3 com­fort­ably. But the back also con­tained a bunch of endoscopy equip­ment, which I had taken out of the hos­pi­tal (where it had pre­vi­ously sat for 7 years unused, after USAID proudly donated it but for­got to teach any­one how to use it, or even bother to fig­ure out whether sen­si­tive expen­sive equip­ment from Amer­ica can be plugged into the unpre­dictable cur­rent com­ing out of their wall sockets.)

Afghan Ambulance

Then again, I have also rid­den on the lap of an older bearded Afghan stranger in a Toy­ota Corolla sta­tion wagon taxi where we were 11 all together and 3 women sat in the trunk. Hameed, who was my com­pan­ion on this adven­ture, tried to pass me off for an Uzbek who didn’t know the local lan­guage. That cover lasted for about 3 sec­onds until one of the geezers started talk­ing to me in Uzbek, and then laughed that I didn’t know my own lan­guage. Then Hameed claimed I was mute, for lack of any­thing else to say. That excuse lasted for as long as I didn’t speak (3 sec­onds) since he had failed to warn me of his inten­tions. They all laughed and the guy told me ‘kine kana’ for sit dude and guided me onto his lap.

Ambu­lances are not used in the same way in Afghanistan.  They may some­times trans­port a patient from a rural clinic to the main hos­pi­tal, but mostly they are for off-label uses. The dri­ver is crazy even by Afghan stan­dards. Usu­ally he blares his siren, verves in traf­fic, as if he were born to be a race cum bumper car dri­ver, play­ing per­pet­ual chicken on the drag. Today he man­aged to keep him­self mostly in check, prob­a­bly because of the female doctors.

Today, we were head­ing to the ILC (the Inter­net Learn­ing Cen­ter) at Nan­ga­har Uni­ver­sity for the first ever tele­con­fer­ence between the doc­tors of Afghanistan and Pak­istan, and I was a lit­tle bit anxious.

Nangahar University Main Quad

Cul­tur­ally, we men are not allowed to speak to the female doc­tors (or females in gen­eral, other than the ones we brought along with us).  We can­not look them in the eyes.  We fol­low this pro­to­col because we have been told that doing oth­er­wise would make them feel uncom­fort­able. Instead, our con­ver­sa­tion flows through a respected Afghan inter­me­di­ary. That was the role of the male doc­tor who is their ward director.

But, you see, some­times, and in our sit­u­a­tion in par­tic­u­lar, it is use­ful to talk, such as, when you need to assess their needs for a par­tic­u­lar type of train­ing.  Do they speak Eng­lish?  How well?  Would an Eng­lish speak­ing spe­cial­ist suf­fice?  Should the trainer speak Pashto?  Is trans­la­tion only nec­es­sary for the finer points?

We got off to a bad start. We were hav­ing inter­net qual­ity of ser­vice prob­lems. The con­fer­ence qual­ity was jit­tery to the point of annoy­ing. We finally hacked together a solu­tion, using the video feed from the poly­com tele­con­fer­enc­ing unit while rout­ing the audio through Skype. At last it was working.

Tele­con­fer­enc­ing is a visual medium. When we first fired up the equip­ment and their faces popped up on the screen, I saw the doc­tors play out their instinct to bring their veil to their faces and hide from pub­lic view. We dis­abled the window-inside-the-window on the pro­jected screen that showed us what the doc­tors in Pak­istan were see­ing.   You can hide behind the voice, but not behind a cam­era; but you can think that you are hid­den when the cam­era isn’t reveal­ing what it sees.

When select­ing a loca­tion for the con­fer­ence, we con­sid­ered sev­eral places with pass­able inter­net.  In the past a con­fer­ence had been sched­uled at the Taj, but the women did not show up because of cul­tural issues stem­ming from the fact that it is known as a West­erner enclave. So now we were on neu­tral turf at Nan­ga­har Uni­ver­sity, (hav­ing trans­ported them 10 miles to an inter­net cen­ter that was built by the Rotary Club and to inter­net that was pro­vided by NATO.)

The female doc­tors sat in the front row and the men sat behind them.

Teleconference of Afghan Female Doctors

Dr. Pete’s main gig is run­ning a com­pany that sets up telemed­i­cine capa­bil­i­ties in var­i­ous hos­pi­tals and field clin­ics around the world.  Though his work­ing rela­tion­ship with Holy Fam­ily Hos­pi­tal in Pak­istan, Pete got a female OBGYN doc­tor ultra­sound spe­cial­ist and a female Pashto trans­la­tor to teach a class on the proper use of an ultrasound.

I was play­ing gen­eral inter­net and audio­vi­sual tech in the equation.

It started out as a bor­ing lec­ture. The lec­turer spoke, the slides advanced. For me the mate­r­ial was new and there­fore inter­est­ing. I also had the sec­ond occu­pa­tion of observ­ing the entirety of what was going on. But the intended audi­ence sat silent and seemed bored.

Were female doc­tors reluc­tant to ask ques­tions? If so, why? Were they shy? Was it old hat and bor­ing? Were we the con­de­scend­ing for­eign­ers that assumed they were merely play­ing doc­tor until they met us and wanted to teach them a thing or two?

Pete was doing a good job break­ing the ice, ask­ing “dumb ques­tions”, and man­ag­ing the flow.

And then, about an hour into the lec­ture, a new voice piped up. She spoke qui­etly and was fur­ther away from the micro­phone so it was harder to hear. I climbed around a maze of wires (from the poly­com, the pro­jec­tor, the speaker sys­tem, the lap­top and attached micro­phone) and brought the micro­phone nearer. The female doc­tors laughed at my park­our moves to maneu­ver the lap­top and not snag any wires. We were begin­ning to win them over.

They asked two or three ques­tions in all. We ran around behind the scenes, print­ing new hand­outs that the Pak­istani doc­tors sent over in response to the questions.

Two hours after it started, the class was over. By way of effec­tive classes, this was a fail­ure.  Very lit­tle new infor­ma­tion was trans­fered per unit time.

I posi­tioned myself at the back of the class­room next to the male ward direc­tor who has been typ­ing away smartly at this lap­top and chat­ting on his cell­phone dur­ing the lec­ture.  He had a long white beard, designer glasses, and a tra­di­tional white cap. I told him that we under­stand that the class wasn’t per­fect, but that we con­sid­ered this a first test. We would also like to become bet­ter and improve the classes and to do this we needed open crit­i­cism from the doc­tors them­selves. He walked to the front of the room and trans­lated what I said to the doctors.

And then some­thing unex­pected hap­pened.  They turned and started to speak to us directly.  Or, under these cir­cum­stances, I can be for­given for erring on the side of call­ing it directly.  They expressed their needs.  They expressed sat­is­fac­tion at today’s meeting.

At first their remarks were ven­tured in the void, not addressed to any­one in par­tic­u­lar. But then we (also) started to feel com­fort­able to engage the indi­vid­u­als, respond­ing to indi­vid­ual com­ments and weav­ing a com­mon con­ver­sa­tional thread. It was a true dia­log.  We took notes: they wanted large, high res­o­lu­tion actual ultra­sound images, case stud­ies, exam­ples of nor­mal and abnor­mal cases. (They said that they didn’t know what nor­mal was sup­posed to be!) They wanted to be doc­tors play­ing diagnose-this-patient while star­ing at the same raw image.  They didn’t need a basic the­o­ret­i­cal review. They had the books and stud­ied them. They wanted the doc­tors in Pak­istan to show their images, and they wanted to bring their own trou­bled cases to discuss.

(Please Please for­give the poor audio qual­ity and lack of edit­ing, but you can hear the banal­i­ties of the moment for your­self. for­give the poor audio qual­ity and lack of edit­ing, but you can hear the banal­i­ties of the moment for yourself.)

The women ranged in age from the 30s to their 50s and in this con­ver­sa­tion I saw within them artic­u­late doc­tors who cared about their patients and wanted to become bet­ter stew­ards of their health, but also I saw (for­give me Allah for say­ing this) youth­ful excited chat­ter­ing girls.

Pete pointed out that doc­tors from devel­oped coun­tries have a lot to learn from Afghanistan.   Since it takes so long for peo­ple to get them­selves to a hos­pi­tal, patients present advanced stage patholo­gies. Abnor­mal­i­ties are so com­mon that you almost have to rede­fine nor­mal. He told me that when he spent a day at another ultra­sound clinic in Jalal­abad, he was blown away at the pre­sen­ta­tion of unusual in every case. Each would be a case study in Amer­ica. You just don’t see that kind of stuff as a doc­tor. More cases in one day than he has seen in all his clin­i­cal rotations.

We learned a lot from this ses­sion, sim­ple banal things.

We learned not to ask, but to just give. You end­lessly wal­low in self-censoring cul­tural sen­si­tiv­ity orbits ask­ing whether you can com­mu­ni­cate with the doc­tors directly, but then again, you can just do it. Don’t ask can we have your emails. Just give a hand out with your own, with the Pak­istani doc­tors emails, the coor­di­na­tors, etc. Add a note describ­ing what role each per­son plays and put the ball in their court.

At the end Qahar, a friend with whom we col­lab­o­rate with on var­i­ous inter­net projects, walked into the room. On their way out, the female doc­tors sur­rounded him. They told me that he is their com­puter teacher and their Eng­lish teacher too. It was clear that they appre­ci­ated him.

And that appre­ci­a­tion also cau­tiously reflected on us. They started to trust us that we actu­ally cared and weren’t there to merely wave an illu­sory magic wand in the form of high-minded advice and grandiose con­sul­ta­tion based on “The way we do it in America …

***

Of course, it is dis­hon­est to end on such a pos­i­tive note. A cou­ple days later, we went for a sec­ond vic­tory. The head doc­tor of the hos­pi­tal where the women worked was sup­posed to have a one on one plan­ning meet­ing with the chief doc­tor from Pak­istan, to plan future train­ing ses­sion for doc­tors from other depart­ments. It was the third attempt to sched­ule such a meeting.

The time was set on both sides, the venue pre­pared, var­i­ous par­ties were involved. And then, he didn’t show up.

I was sad and it showed when I talked to our friend at the ILC. And he tried to con­sole my by say­ing, “We are used to this. We plan, we talk, and then when it comes time, it doesn’t work out. That’s normal.”

It’s a big chal­lenge to stop being used to fail­ure. It’s a big chal­lenge to rede­fine normal.

So like no shit, there we were…

Jan 31, 2011   //   by peretz   //   long, photos, terms  //  No Comments

Today we went on the PRT (provin­cial recon­struc­tion team) base in Jalal­abad. Lou had arranged the meet­ing. A New Yorker was run­ning it. He spoke fast (refresh­ingly so, as one’s mind atro­phies from a pre­dom­i­nance of inter­ac­tion with non-native speakers.)

He was excited about a par­tic­u­lar new fund­ing stream from USAID that was meant for off­beat projects that are not being addressed by other large funds. Lou had con­nected a few dots and sug­gested cricket fields and now the ball is rolling.

Dur­ing the meet­ing I was drown­ing in acronyms. At some point, I requested a time out to deacronymify. I think it was around the point that we were told that the pro­posal should, of course, address COIN (counter insur­gency) objectives.

Here are some notes from that time-out:  Feel free not to read them!

  • PDC (Provin­cial Devel­op­ment Coun­cil) staffed by PC (Provin­cial Coun­cil) who are the vot­ing mem­bers, 19 of which 5 are female.
  • ASOP — Afghan Social Out­reach Pro­gram, sub­set of IDLG
  • DDA — Dis­trict Devel­op­ment Association
  • These are all Shura’s of appointed peo­ples. But the best guys are the rung bel­low them, the CDC — com­mu­nity devel­op­ment coun­cils — “They are like the small town PTA (Par­ent Teacher Asso­ci­a­tions) in Amer­ica that know what the local issues are, and they are elected!”
  • TWG — tech­ni­cal work­ing group, usu­ally the TWG of some sub­ject under some other acronym.
  • IDLG — Inde­pen­dent Direc­torate Local Gov­ern­ments (a USAID gov­ern­ment part­ner). They appoint local gov­er­nors, and DDBs (Dis­trict Devel­op­ment Boards)
  • ANDS — Afghan National Devel­op­ment Strategies
  • StIKA — Sta­bil­ity in Key Areas. It’s the new LGCD (Local Gov­ern­ment Com­mer­cial Development).
  • NSP (National Sol­i­dar­ity Pro­gram) is under the NMRD? WTF?

They did not have a shop at the PRT, but we were able to get some hygienic prod­ucts at the MWR (Morale Wel­fare and Recre­ation) bunk.We had lunch at the DFAC. Over lunch, it was men­tioned that USAID is under­staffed in the region. I asked where the bot­tle­neck lies. It turns out that there are more USAID employ­ees hang­ing in Kabul/Bagram ~1200 than are active in the field. And the rea­son is quite an Amer­i­can one. In prac­tice, USAID employ­ees that are part of the PRT have to be phys­i­cally fit to ride with full Army gear in MRAPS. (And that is the only way they are allowed to get around to get their work done.) It’s hot and heavy.

As an Amer­i­can com­pany, USAID has to fol­low the Amer­i­can with Dis­abil­i­ties Act for Hir­ing, which means that they can­not exclude peo­ple based on their level of fit­ness (some­times age or dis­abil­ity) for the task at hand. USAID has prob­lems recruit­ing peo­ple that are younger and can get clear­ance. So their pay­roll is full of old guys.

The net result is all the phys­i­cally fit peo­ple (600 of them) are active in the field while Kabul is a “geri­atric ward” (1200).

This is your government.”

***

When you live “out­side the wire”, going the DFAC (Din­ing Facil­ity) at the base is kind of like raid­ing your parent’s pantry when you are a poor stu­dent. You fill your pock­ets with gum, soda, cook­ies, cliff bars, etc. Here was our score today:

IMG_2075

We focused on gum.  Thanks Uncle Ben!

***

Dave was telling me that when he hung out with the Spe­cial Force guys, all of their sto­ries started with, “So like no shit, there we were…”

Basketball court in a pool FOB Finley-Shields

So like no shit, there we were on an Amer­i­can base play­ing bas­ket­ball and trash talk­ing in Russ­ian with our Afghan driver/translator Najib, inside an empty swim­ming pool, which was ini­tially built by the Rus­sians when this was their Army base and then used by the Tal­iban as an exe­cu­tion ground. You could see the bul­let scars on ground, and the US sol­diers would cir­cle around us, doing their busi­ness, occa­sion­ally recov­er­ing our balls which had bounced out of the pool.

IMG_2057

***

And to round out today’s ram­ble is a good one, but you have to click some links. It’s a TAL (This Amer­i­can Life) episode. In the first act you will meet JD (Japan­ese Dude) — aka Mohammed Jawed. He’s the one that took the photo of the sheep and boy on the bike (ear­lier post). Well any­ways, lis­ten to this act, which is like the first 5 min­utes: http://www.thisamericanlife.org/radio-archives/episode/369/poultry-slam-2008

Measure Ma’an

Jan 29, 2011   //   by peretz   //   photos, videos  //  2 Comments

Each be ruled by his own.

Here in Jalal­abad, wood is ruled by a ma’an (my spelling, try­ing to capu­ture the pro­nun­ci­a­tion. Else­where it is spelled mann.)

Most of the heat­ing and cook­ing energy needs in Afghanistan are sup­plied by wood. Along the road you see plenty of shacks of the wood deal­ers.  Today we stopped by.  Typ­i­cally kids are chop­ping wood while an older bearded pro­pri­a­tor (father/uncle) is sip­ping tea and wait­ing for customers.

Chopping Wood

I noticed our wood was being weighed on a scale, but instead of weights, it was coun­ter­bal­anced by cal­i­brated rocks. The unit of mea­sure is a ma’an, which varies locally but approx­i­mates 7 kilos.

Chopping Wood

A ma’an is the pref­ered unit of mea­sure for wood, and is part of a com­pre­hen­sive unit scale:

.

.

.

ma’an SI Typ­i­cal Items

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1 khar­war 80 560 kg wheat chaff, scrap metal

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nim khar­war 40 280 kg

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1 ma’an - 7 kg wood, rice

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nimma’an 1/2 ma’an 3.5 kg

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charak 1/4 ma’an 1.25 kg car­rots, onions

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nim charak 1/8 ma’an 625 g

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1 pau 1/16 ma’an 322 g lemons, peanuts, sugar, meat

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nim pau 1/32 219 g

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khord 1/64 109 g henna, chai

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nim khord 1/128 55 g

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pookhtabar 1/256 27 g herbal med­i­cine

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nim pookhtabar 1/512 14 g

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chi­takai 1/1024 7 g spices, surma

Accord­ing to wikipedia the ety­mol­ogy can be traced to the Hebrew word mana, as in mana from the desert. Every day the wan­der­ing tribe that exited Egypt was allowed to col­lect one Omer of mana. On Fri­day, the col­lec­tion was dou­bled, to pro­vi­sion for Sat­ur­day, the Sab­bath day of rest. An omer is a dry weight of mea­sure, approx­i­mately the vol­ume of 3.5 liters of water. On Fri­day there­fore, the col­lec­tion was 7 vol­u­met­ric liters, which would weigh 7 kg (if water).

To con­tinue reach­ing for more con­nec­tions, the ma’an weights were made of stone. An impe­r­ial stone is 6.35kg, not that far off?!

None of this should be con­fused with a ma’an in Pak­istan. A Pakima’an is appar­ently 7 times an Afghan ma’an.

Not every­thing is mea­sured using this scale. If for exam­ple you were buy­ing opium, then the stan­dard mea­sure is a “kar­tus” defined as the weight of a AK47 bul­let cas­ing, a sen­si­ble stan­dard from those at hand.

Shoes

Jan 21, 2011   //   by peretz   //   Uncategorized  //  1 Comment

Behold a typ­i­cal Afghan shoe.

Typical Pair of Shoes

It’s a dress shoe, because that’s the pre­ferred style. And it’s bent in the back because they wear them like slip ons. This is con­ve­nient. Afghans take them on and off so many times a day. They take them off to pray 5 times a day. They take them off when­ever they enter some­ones house for tea, etc. etc. And this is prob­a­bly true across most of Cen­tral Asia and many other coun­tries in the “rug belt”.

What I don’t under­stand, is why no one has seized on this huge mar­ket oppor­tu­nity of mak­ing a fancy dress shoe, with­out a back, a dress shoe nat­ural slip on? (Maybe some­one has, and this is your oppor­tu­nity to mar­ket their wares in the comments.)

Another inter­est­ing con­se­quence of this, is that there is so much more work for shoe shin­ers. When you take off your shoes in the restau­rant, they walk up and make their offers.

Shoe Shine

This is a much more nat­ural way to do this than what I have seen in the West. I just couldn’t ever imag­ine myself sit­ting down to have some­one kneel in front of me to shine my shoes, while I made myself look busy with a news­pa­per. To bad, I have noth­ing to shine here. Can you guess why?

Guess which ones are mine?

I got some army boots from the Bush Mar­ket the other day, and while I smelled weed when we walked into the shop, I didn’t expect the shop­keeper to take a mini break to toke on a apple core bong in the process:

Shoe dealer hitting an apple bong

Coming to Terms

Jan 14, 2011   //   by peretz   //   terms  //  No Comments

And there’s more where these came from…

  • FOB — for­ward oper­at­ing base, as in FOB Fenti, a US Army base at Jalal­abad Air­field (JAF)
  • FOB — free open bar, as in FOB TAJ ;)
  • COMMS — com­mu­ni­ca­tions, cell phone con­nec­tion, inter­net, radio.  Gotta keep it running.
  • Prime — Main per­son on task, who has to keep COMMS flow­ing. “You’re prime, I need you to have COMMS.  None of that cell­phone stolen in the mar­ket business.”
  • COP — com­bat out­post, COPs are sup­ported by FOBs.
  • Reach­back — sup­ply line, ver­sus front­line, for­ward lean­ing and stretched per­son­nel.  They need you, the reachback.
  • Secu­rity Indus­trial Com­plex — Dave’s term for the incen­tive struc­ture for pri­vate secu­rity com­pa­nies to tell you how dan­ger­ous it is if you travel with­out them.
  • Sky Cover — in case of attack, run to the high­est point.  We con­trol the skies.  The birds will pro­tect you.
  • Bush Mar­ket - this is what locals call the mar­ket for Amer­i­can goods that either leaked from (or fell off the truck on the way to).  Such mar­kets exists in Kabul and in Jalal­abad, and prob­a­bly around the coun­try.  (I’ve seen one in Kyr­gyzs­tan too.)  You can get Army boots, MREs and even cook­ies that Amer­i­can moms shipped to their sons in Afghanistan.  Some­times they eat the cook­ies.  Some­times, they barter them for Afghan goods. Relat­edly, Amer­i­can poul­try dona­tions to Rus­sia in the early 90s (dur­ing George H Bush’s admin­is­tra­tion) were called Bush’s Legs, “legs” more  clearly denot­ing drum­sticks in Russian.
  • Lover’s SIM card — The cell phone provider Eti­salat has really good in net­work rates and you can talk for hours with your loved one.  The advent of cell­phones has cre­ated an oppor­tu­nity to trans­gress the taboo of min­gling gen­ders.  “As they say, if he’s got a cell­phone, he’s got to have a girl­friend,” says our Afghan friend.  The out of net­work rates cre­ate bar­ri­ers between peo­ple who have phones on dif­fer­ent net­works, such as MTN, Eti­salat, Roshan and Afghan Wire­less.  Of course, you could get cell­phones with sev­eral sim cards, and then you could really be a playa for realz!
  • Two SIM cards?

  • OPM — other people’s money, that which the con­trac­tors don’t care about spend­ing.  “What do we care? It’s OPM.” This, in response to Dave’s remark that it’s cheaper to pro­vide inter­net to 50,000 kids than to hire 1 Xe (a rebrand­ing of Black­wa­ter) guard.
  • Night Let­ters - is what you don’t want to find on your door in the morn­ing. Var­i­ous fac­ul­ties in Nan­ga­har Uni­ver­sity some­times get Night Let­ters.  Then it’s fre­quently traced back to stu­dents from their very own Shariya (Islamic Law) Fac­ulty.  How oddly convenient?
  • TCN — third coun­try national — for exam­ple a Nepali/Ghorka secu­rity con­trac­tor work­ing in Afghanistan.  Cheaper to hire.
  • Mak­ing Money, as in, “my tow gun­ner has been mak­ing a lot of money.  For 80 shots, he’s got over 100 con­firmed casu­al­ties.” To be super clear — no money is actu­ally exchanged.
  • XO - exec­u­tive offi­cer, as in: Who’s the XO of this COP?
  • DFAC — Din­ing Facil­ity, as in, How’s the DFAC in this FOB?
  • Fri­day — is the new week­end.  Roads are free of cars.  Peo­ple are home with their fam­i­lies. At 1pm all the Mosques are over­flow­ing for the weekly pod­cast.  Ter­ror acts are less frequent.
  • This one blew only half way.

    Kabul to Jalalabad

    Jan 12, 2011   //   by peretz   //   long, photos, taj  //  4 Comments

    The ride from Kabul to Jalal­abad was long and adventurous.

    I saw a dog being killed in Kabul. They are con­sid­ered pests here.

    A dead dog

    Most of our drive time was spent sit­ting in traf­fic on the windy seg­ment of the Kabul River Gorge (also called Tangi Gharu).

    Part of the rea­son for the bad traf­fic is that peo­ple tend to drive on both sides of the road in both direc­tions. At first it seems like a good idea, you get a lit­tle bit ahead of your neigh­bor. But local opti­miza­tion can some­times lead to global cat­a­stro­phes. Such deci­sions cre­ated grid­locked jenga puz­zles on nar­row roads with pre­car­i­ous drop offs and small mar­gins for error. Each one took hours to resolve.

    Gridlock on the Kabul Jalalabad Highway

    Had we left much ear­lier in the morn­ing (say 6am) we wouldn’t have expe­ri­enced this traf­fic. And so we sat in the car, or got our to stretch our legs, or to take pho­tographs of war debris from var­i­ous wars, such as this Russ­ian tank:

    Soviet Tank Lays in the Valley beside the Kabul River

    When­ever we’d show our faces, a crowd would appear. The younger ones talked to us. Some­times they asked for “energy” = soft drinks.

    Law Students, Future Bureaucrats

    I met a boy named Pamir who is studing law, on the right. He’s gonna be a bureau­crat some day. On his stu­dent card, you could see his blood type.

    Student Card has Blood type A+

    Jin­gle Trucks from Park­istan con­sti­tute a large frac­tion of the traffic:

    Jingle Truck

    Todd Jingles

    Out of the gorge we were out in broad open val­ley swept by opaque dust storms, bend­ing trees horizontally.

    The road had warn away in parts, and you have to be ready to stop abruptly when you spot a pot hole. This caused our acci­dent. A truck in front of us stopped. We stopped right behind it, and many cars stopped on our bumper behind us… So far so good. But the truck in front started back­ing up. We honked. It didn’t care. It ate half our hood before it finally stopped.

    Accident Post-Mortem

    Thank­fully, its clear­ance was high enough that the dam­age was only cos­metic. Since there is no insur­ance and no pro­to­col for how to resolve acci­dents other than by talk­ing. Our dri­ver (on the right) got out and started a long nego­ti­a­tion directly on the high­way. (Truck dri­ver is on the left.)

    Post Accident Negotiations

    This is one of the main rea­sons why for­eign­ers are dis­cour­aged from dri­ving. All of the NGOs and even the secu­rity com­pa­nies now hire local dri­vers. This is the kind of advice we get: if you hit some­one, get the hell out of there. If you stick around, you will get clubbed. (And if you see some­one dead/wounded, look out for booby traps. This one applies not only while driving.)

    One amaz­ing thing about Afghanistan is the jusx­ta­po­si­tion of the past and the future, and how one causes the other.  There is no postal ser­vice, for exam­ple.  You have to rely on email.

    Solar Power

    There will prob­a­bly never be a wired tele­phone net­work here, but every­one has a cell­phone. Cell­phone tow­ers (when not pow­ered by gen­er­a­tors) are pow­ered by solar.

    We did see con­struc­tion crews lay­ing fiber optics cable along the high­way. Sadly, I missed the photo op. Maybe Lou or Todd got it?

    Much of the country’s hydro­elec­tric facil­i­ties are located along this stretch of river, so the fact that the Kabul river is but a stream, presents a problem.

    Approach­ing Jalal­abad, we pass the Darunta Dam and afte­wards is Nan­ga­har Uni­ver­sity whose ini­tial build­ings were used to house the Soviet engi­neers that built and oper­ated the Darunta Dam.

    Right before you breach the perim­iter of Jalal­abad city proper, take a left down Awe­some Todd’s road (see Open Street Maps).

    Wel­come to the Taj. This has become our home (Lang­ton Annex ;) More about the Taj and its occu­pants in another post.

    For now, a teaser:


    This is part of the longer nar­ra­tive blog series, that started with What is Nor­mal any­way? I will try to have this sub-series fol­low a liner nar­ra­tive, while the gen­eral post stream will jump around.

    Nangahar Public Hospital

    Jan 4, 2011   //   by peretz   //   hospital, long, photos  //  6 Comments

    The first time we came to the hos­pi­tal, the staff apol­o­gized pro­fusely for not being able to host us. They were deal­ing with the wounded of a sui­cide bomb­ing inci­dent in the dis­trict. There was one casu­alty. Five peo­ple were in the OR. And they were embar­rassed in front of us, that such things hap­pen in their coun­try. We left, and came back yesterday.

    Nan­ga­har Pub­lic Hos­pi­tal (NPH) is a Regional Post-Graduate Teach­ing Hos­pi­tal for the East­ern Region of Afghanistan. The East­ern Region cov­ers the provices of Kunar, Nan­ga­har, and Lagh­man. But in prac­tice it also cov­ers the provinces of Logar and Kapisa, and the dis­trict of Sirobi (which tech­ni­cally belongs to Kabul Region).

    22 clin­ics from the East­ern Region trans­fer patients to NPH by ambu­lance. The hos­pi­tal does not have an Emer­gency Response Ambu­lance team. Three dis­trict hos­pi­tals of Kama, Ghaniki and Khugiani also refer patients to the NPH.

    Patient Numbers

    Patient Numbers

    Loca­tion. The hos­pi­tal is located in the city of Jalal­abad, halfway between Peshawar and Kabul, on the main high­way link­ing the two. This high­way is the main transport/supply line between Pak­istan and Afghanistan. The bor­der check­point, called Torkam Gate, is a half hour to the East and is the entrance to the Khy­ber Pass. The stretch of high­way west to Kabul is con­sid­ered the most dan­ger­ous road in the world by the NYT. It is dan­ger­ous because of acci­dents. And often, because of acci­dents, traf­fic on the nar­row road comes to a com­plete stop. NPH sees 600 patients from car acci­dents each month. Some patients pre­fer to be referred to NPH rather than hos­pi­tals in Kabul because, if the issue is suf­fi­ciently crit­i­cal, it is a much closer drive to Peshawar, Pak­istan where there are hos­pi­tals bet­ter than any­thing in Afghanistan.

    Organgram

    The hos­pi­tal has 10 depart­ments, which all train post-graduate spe­cial­ists: Inter­nal Med­i­cine (Med­ical Ward), TB, Infec­tious Dis­ease, Pedi­atric, Gen­eral Surgery, Ortho­pe­dic, OBGYN, ENT (Ear, Nose and Throat), Opthamol­ogy, Neu­ropsy­chi­atric (opened this year.)

    A post grad­u­ate med­ical spe­cial­ist is some­one who has grad­u­ated a seven year med­ical pro­gram, CONQUER EXAMINATION, like SAT that deter­mines which Fac­ulty at which Uni­ver­sity you can attend: The order of RANK based admis­sion by fac­ulty fol­lows: Med­ical, Engi­neer­ing, Eco­nom­ics, Law, Agri­cul­ture, Com­puter Sci­ence, Lit­er­a­ture, etc. So to get to med­ical school in the first place, they needed top marks. — Accord­ing to Ahmed “Zia” Ahmedi Here Afghan stu­dents vent about higher edu­ca­tion on Face­book.served a 2 year prac­ti­cal at a regional clinic, and received high marks at a cen­tral exam­i­na­tion in Kabul. Based on their grades and spe­cialty of inter­est, they are sent to post-graduate train­ing hos­pi­tals around the coun­try. Most spe­cial­ists train for 3 years, OBGYN is 4 years, and surgery is 5 years.

    Chief of Medical Department

    Accord­ing to Alhaj, Alhaj means that he has per­formed sev­eral pil­grim­ages to Mecca.  If it were just one, he would be merely Haji. Prof. Moham­mad Ismail “Alam”, Chief of Med­ical Ward, there are 30 spe­cial­ists being trained in the inter­nal med­i­cine depart­ment now, and 15 fac­ulty. (By con­trast, there are 3 trainees in the neu­ropsy­chi­atric depart­ment, hav­ing started just this year.) The Med­ical Ward has 15 beds in the ICU/CCU. 8 for women and 7 for men. There are 12 nurses, 6 female and 6 male, and 1 head nurse. In the ICU and CCU both men and women take care of patients of both gen­ers. There are also spe­cial wards where female nurses take care of female patients.

    Internal Medicine Hierarchy

    It's Different Around Here

    Prof. Alam first stud­ied to be a doc­tor in the 1970s from an Amer­i­can NGO called CARE/Medico. CARE/Medico in Afghanistan — I can­not under­stand how a writer of Carl Edgar Law’s cal­i­bre could have pos­si­bly researched health care in Afghanistan and, more par­tic­u­larly, med­ical teach­ing there over the past two decades (Can Med Assoc J 1983; 128: 186–190) with­out dis­cov­er­ing the work of the med­ical ser­vice arm of CARE known as CARE/Medico.From 1963 to its dis­so­lu­tion in 1979 CARE/Medico car­ried out a 3-year res­i­dency pro­gram for recently grad­u­ated Afghan doc­tors from the Uni­ver­sity of Kabul. This program’s nucleus was a per­ma­nent team — includ­ing a Cana­di­anstaffed lab­o­ra­tory in Avi­cenna Hos­pi­tal, Kabul — sup­ple­mented monthly by vol­un­teer spe­cial­ists from the West, mainly Canada and the United States. It was Afghanistan’s only con­tin­u­ous med­ical teach­ing link with the West­ern World.Dur­ing its 15-year exis­tence (ter­mi­nated by the Russ­ian occu­pa­tion of the coun­try, like the Man­age­ment Sci­ences for Health pro­gram) this teach­ing course was, in effect, a high-grade res­i­dency pro­gram in med­i­cine, surgery and gyne­col­ogy.Prob­a­bly more than 100 young Afghan doc­tors became pro­fi­cient in West­ern med­ical and sur­gi­cal teach­ing and tech­niques. There was also a nurse’s train­ing pro­gram. So thor­ough was it that shortly after my return from Kabul in 1968 (hav­ing served in the CARE/Medico pro­gram there as a teacher) I met one of my stu­dents, who had just qual­i­fied as a second-year res­i­dent at St. Paul’s Hos­pi­tal, Saska­toon.This may not seem remark­able unless you remem­ber (as men­tioned in the CMAJ arti­cle) that the Uni­ver­sity of Kabul’s med­ical school taught “archaic” med­i­cine in French that was simul­ta­ne­ously trans­lated into a Farsi dialect, which is pretty well devoid of med­ical equiv­a­lents.I feel that Mr. Law’s arti­cle was infor­ma­tive — but only on a small seg­ment of the sub­ject. Canada’s con­tri­bu­tion in exper­tise and man­power (doc­tors, nurses and lab­o­ra­tory tech­ni­cians) to this Afghanistan pro­gram was out­stand­ing and should be duly recorded.FRANK MACINNIS, MD, FRCP©, FACP; Clin­i­cal direc­tor; Depart­ment of Psy­chogeri­atrics; Alberta Hos­pi­tal; Edmon­ton, Alta. (source: PubMed) He fondly remem­bers Dr. Mobri (first name and not sure about spelling) who taught him, and won­ders if he can get in touch with him now. The Amer­i­can staff left the CARE/MEDICO inter­nal med­i­cine train­ing clinic when the Rus­sians came, and Prof. Alam stayed there for 13 years (whole time of the Russ­ian occu­pa­tion) lead­ing the clinic. He said that the Rus­sians kicked out the Amer­i­cans and treated the CARE/MEDICO trainees with scep­ti­cism, accus­ing “Alam” of being a CIA agent. “When the Rus­sians left and Mujuhadeen came to power and there was unrest in Kabul (early 90s) I left on a fel­low­ship to India. And when I returned a few years later to the Tal­iban, I trans­fered to Nan­ga­har Pub­lic Hos­pi­tal and have been here ever since.”

    HealthNET TPO

    Most hos­pi­tal build­ings were ini­tially built by Rus­sians. For a while, the Red Cross of New Zeland sup­ported the surgery depart­ments. Now the whole hos­pi­tal is man­aged by Health­NET TPO, an NGO based in Hol­land, and funded by the Euro­pean Com­mis­sion. The hos­pi­tal is owned by the Gov­ern­ment, but Health­NET man­ages it and pays for all patient ser­vices as well as all 545 staff of the hos­pi­tal from Secu­rity Guards (whose pay starts at 5000 Afs = 100$ per month) to Nurses (7.5-10k Afs=150–200$/month) to Doc­tors (12-20k Afs=220–400$/month) to Admin­is­tra­tors (~15k Afs = ~300$/month).

    Zia

    Ahmed “Zia” Ahmedi is the hos­pi­tal admin­is­tra­tor employed by Health­NET TPO. He is 28, ener­getic, and speaks almost per­fect Eng­lish, which he learnt in Pak­istan, where he spent the first 22 years of his life. He sports an iPhone 3GS which rings non-stop. He jokes, “I am like the tele­phone switch board.” He moved to Kabul six years ago to work for the UN, then switched to work for a US State Depart­ment Jus­tice Sup­port Ini­tia­tive, and then as an admin­is­tra­tor for the Inter­na­tional Med­ical Corps. But he likes his cur­rent job at the hos­pi­tal most, because he sees the peo­ple he helps.

    No Weapons in Hospital

    Zia says that the biggest prob­lems with hos­pi­tal are social. Patients fight with doc­tors, neglect health codes, and barge into Oper­at­ing rooms dur­ing surgery. “They are unfa­mil­iar with hos­pi­tal conduct.”


    *** READ ON FOR THE GRITTY DETAILS ***

    Please for­give the cur­rent look, I have to clean up this formatting.

    Nan­ga­har Pub­lic Hos­pi­tal Visit (01/04/11  — 10AM — 3:30PM)
    Lou and Peretz vis­ited the hos­pi­tal to inspect equip­ment, meet staff, and assess needs.

    Met:

    • Ahmed Zia Ahmedi, Hos­pi­tal Administrator
    • Dr. Baz Moham­mad, Hos­pi­tal Director
    • Alhaj, Prof. Moham­mad Ismail “Alam”, Chief of Med­ical Ward
    • Nurse of Med­ical Ward
    • Doc­tor from Sur­gi­cal Ward
    • Almas (stayed for first hour)
    • Qahar, Inter­net Facil­i­ta­tor of Med­ical Fac­ulty, accom­pa­nied us until lunch.

    Places:

    • Admin Offices
    • Med­ical Ward — ICU/CCU
    • Surgery Ward — Post Op Recov­ery Men/Women
    • Equipm­nent Storage

    Equip­ment Inspected:

    • Bed Side Patient Mon­i­tors — Philips Sure­Signs VM8
      • 1 in Stor­age — miss­ing cables — appar­ently Rotary and AI crew already know about this and are bring­ing the needed cables.  Is this correct?
        • Ed Myers — 1 unit in stor­age should not be a Philips Patient Mon­i­tor email indi­cates the loca­tions — Maybe it shouldn’t, but it is: http://www.flickr.com/photos/49543096@N03/5327332655/ From the loca­tions email vs what we have seen, this is prob­a­bly the free stand­ing one from the Oper­at­ing The­ater.  We will make a point to track down cables.  Then again, in the photo all of the cables appear to be there.  We’ll fig­ure out what to do with it and report back!
      • 9 in Med­ical Ward (All work­ing. Sticky elec­trodes — appar­ently HELBIG doesn’t work, but PLIA-CELL DIAGNOSTIC ones do work.)
        • Ed Myers-Some of the ekg stickys are for the 12 lead EKG machine so this is true
          • Is the 12 lead EKG in stor­age?  We saw two GE ECG machines (see below)
      • 2 in Sur­gial Ward (One miss­ing the blood pres­sure cuff.  They don’t have any     sticky   leads.)
        • Ed Myers– ICU/CCU has sup­plies for entire hos­pi­tal and they must share since this is where we put the sup­plies so the hos­pi­tal would have a cen­tral sup­ply room. This should help for account­abil­ity re order­ing etc  Great!
      • Did not inspect 1 in Gyno­col­ogy and 1 in Pedi­atrics, but reports are they are working.
    • 2 Older Patient Mon­i­tors (Med­ical Ward) “Broken“
      • First unit MEC-1000 miss­ing fuse (“T1.6A” out­side or “5TT 1.6A 250V ul” on old work­ing fuse.)  They bought replace­ment fuses, which do not work.  This may be because they pur­chased a 10A fuse, which still fit the socket. I cur­rently have the old bro­ken fuse and the replace­ment fuse they got.  Any ideas on where to look for replacements?
        • Ed Myers– I left fuses for the Philips mon­i­tors they are T1.6amp, head nurse knows where they are they where left for eng Storrs. We only met him briefly then dis­ap­peared. Also left were mem­ory sticks with lat­est soft­ware that i installed. These stick also con­tain manuals/guides. You might want to look at them if you have the time. > Great!
      • Sec­ond unit GT9000 seems to work, but is miss­ing cables.  Appar­tently this is because the cables are now in Kabul with the per­son who is shop­ping for more cables.  This is a good thing.
    • 2 ECG Machines (Stor­age — await­ing deploy­ment) — GE Mac 5000
      • One bat­tery (GE MAC PAC 18V 3500mAH NiMH, GEMS-IT P/N:900770–001) seems to be defec­tive.  Unit works when plugged into wall, but when unplugged, the charge holds for ~ one minute.  We swapped bat­ter­ies between units and con­firmed that this is a bat­tery rather than a unit/charger issue.  If this can­not be locally sourced, one pos­si­bil­ity would be for us to open up the bat­tery case and replace the inter­nal NiMH bat­ter­ies with ones that we prob­a­bly can pur­chase here.
        • Any input?
      • Sec­ond bat­tery works fine.  Both units are now in stor­age, await­ing dis­tri­b­u­tion.  Med­ical Ward wants one.  Actu­ally they want both.
        • Brad says, one was shipped with­out con­nec­tors but con­nec­tors are coming.
    • 1 Bili­Blan­ket Tran­sil­lu­mi­na­tor (Stor­age) — Which they thought was a bro­ken UPS and now that they know what it is, are unsure what to do with.  Appar­ently this is used in neona­tal wards for infant light ther­apy (to treat/prevent jaun­dice) and as a tran­sil­lu­mi­na­tor in help­ing locate veins for IV.  We can explain this to the doc­tors, but per­haps this will require a train­ing demon­stra­tion.  MedWeb?
    • 1 Ohmeda Med­ical Pho­tother­apy (Stor­age) — Also for treat­ing neona­tal Jaun­dice — Miss­ing bulb and inter­nal cables.  Appar­ently Rotary and AI crew is aware of this and will bring needed parts. Is this correct?
      • Ed Myers– this is cor­rect unit needs a new bulb it blew out wiring should be okay. Brad is more familiar.
        • Almas and Qahar (the IT guy) said they know what to do with the part once they get it.
    • 1 Difib­ril­la­tor (Stor­age) — “We have the­o­ret­i­cal knowl­edge how to use it and think it works but we have not yet had a patient who has needed it.”  I neglected to inquire why it is in stor­age, rather than at a loca­tion where a patient might need it.  This is an inter­est­ing point that they do not have patients that need it.  Does it mean that by the time they get to hos­pi­tal, they no longer need it? Would a train­ing ses­sion be help­ful to encour­age its use? Medweb?
      • Ed Myers– I am sure they will need it some­day, no com­ment, it should always be plugged into power to keep bat­tery charged and close to patients for when it is needed. It is a short period of time between V-fib and death.. Dr Steve can comment
        • We will make sure to relay this infor­ma­tion.  Where would be a good place to keep it?

    Sum­mary of Requests:

    • Med­ical Ward wants more patient mon­i­tors.  They have 15 beds.  9 new mon­i­tors.  2 old, under repair.  Want 4 more.  Actu­ally they want 6 more new ones ;)   This doesn’t need response.  It’s just for the record.
    • Med­ical Ward wants ultra­sound machine (which the doc­tor called it a “doppler machine”.)  The cur­rent one is located in Gyno­col­ogy Ward.  Zia sug­gested that it was too heavy to move and so it has remained in gyno­colgy. Prob­a­bly this is an inter­nal issue of the hos­pi­tal and not our issue, but nev­er­the­less recorded.  This doesn’t need a response.  Just for the record.
    • Med­ical Ward wants help get­ting new fuses for patient mon­i­tor. Solved
    • Sur­gi­cal Ward needs sticky elec­trodes for patient mon­i­tors.  I sug­gested that they start by ask­ing the Med­ical Ward to share.  (They did not know the Med­ical Ward had any.  Zia said he will assist with this.) Solved
    • Sur­gi­cal Ward needs a blood pres­sure cuff for a patient mon­i­tor which is miss­ing one.  (Did it go miss­ing dur­ing installations?)
      • Ed Myers– The ICU/CCU area has a cuff for this mon­i­tor Great!
    • New MAC PAC bat­tery for the GE MAC 5000 Portable ECG?
    • Hos­pi­tal Admin­is­tra­tion wants inter­net. They cur­rently have inter­mit­tent inter­net. Zia said when it works it is very slow and it’s often out for up to a few weeks at a time. (Is it Fab Fi?  They seemed to sug­gest so.) He stressed how impor­tant this is, “more impor­tant than any­thing else.” They have emails and things to look up, par­tient records, med­ical info, but often can­not do so.  Zia says there is inter­net in Med­Web Room that Almas knows about, but that it is not shared around.  Will ask Almas about this, but per­haps some­one else knows about this also?
      • It may be that new NATO funded inter­net which is going up at teach­ing hos­pi­tal will cover them too.  Any­one can confirm?

    Rec­om­men­da­tions:
    It would be really con­ve­nient to have a Radio Shack in town, to grab fuses and such. It’s far less opti­mal to have to source things from far away, in terms of time, money and sus­tain­ablity.  It would be good to source items locally.  Per­haps we can help jump start a local dis­trib­u­tor busi­ness by guar­an­tee­ing their inven­tory invest­ment (say start­ing with good UPSs, fuses, EKG elec­trodes, …) their job will be to keep track of where to source such items when nec­es­sary and carry an inven­tory of the most fre­quently used items.  Can you please help assess the mer­its of such an idea?

    Ed Myers– divine inter­ven­tion on may home from ams­ter­dam the last night I met a Philips per­son in the hotel recep­tion are who han­dles this part of the world. This is a great idea for a start up or see if this group is an oppor­tu­nity that all­ready exist. I will send this email tonight.  Thank you Ed, I will make sure to fol­low up.

    Trans­port:
    IN: Salahudin (Mehrab’s nephew and his assis­tant at the Taj)
    OUT: Mr. Dawood, who says hello to all of the Rotary and AI crew he had trans­ported previously!

    We are hav­ing prob­lems get­ting around and have to beg for rides.  We would be more effec­tive if we had a more reli­able arrange­ment with a dri­ver that we can call and pay to give us rides.  Any suggestions?

    ***
    Ques­tion to Fary — Is there yet another place where equip­ment is stored and not used?  In a pre­vi­ous email you referred to “for exam­ple, US mil­i­tary pur­chased $450.000.00 worth of equip­ments sit­ting in the cor­ner of room and dust­ing because they do not know how to use them.”  I was not able to locate this with ques­tions alone.  Also, accord­ing to your esti­ma­tions which equip­ment do the doc­tors need train­ing with (but will not admit it)?  I could use some advice as to how to probe.  Per­haps it is in the teach­ing hos­pi­tal?  We have met with Dr. Khan today but did not com­plete the inspec­tion.  “The per­son with the key” was not around.  We are com­ing back on Saturday.

    Ques­tion to Steve Brown — Qahar said you had a plan to make a Med­ical Library.  Could you share some details of the project?  I have brought many (and have access to more) ebook text­books on dif­fer­ent sub­jects (sci­ence, engi­neer­ing, agri­cul­ture, ESL, etc.) and talked to Qahar about host­ing this data on the local net­work at the Med­ical Faculty.

    Idea — Can nego­ti­ate free PubMED access?

    Soccer with the Boys

    Jan 3, 2011   //   by peretz   //   photos, taj  //  1 Comment

    The cook scored 3 goals. The mechanic Sadik stayed in goal. The guard Metin scored 7. I scored 9.

    Football at the Taj

    Introducing Hameed!

    Jan 1, 2011   //   by peretz   //   Uncategorized  //  2 Comments

    We kick off the New Year with a new author on our site. Meet Hameed Tasal.

    Here Hameed is align­ing the Satel­lite receiver dish atop the Taj. See the ear­phones? He’s not rock­ing out to blas­phe­mous tunes, but lis­ten­ing to the diag­nos­tic pitch that tells him if the info can­non is hit­ting the target.

    And he’s no stranger to big name pub­li­ca­tions (such as Jalala­good) hav­ing been inter­viewed for the Boston Her­ald this April. Worth a read.

    Happy New Year!

    Dec 31, 2010   //   by peretz   //   photos, Uncategorized  //  4 Comments

    Thanks to Anselm for com­ing up with it, we have a new tagline:

    Adven­tures in Khy­ber­space!

    Get it? We’re focused on bring­ing tech­nol­ogy to the Khy­ber Pass. Just a few days ago, we took a drive to it’s West­ern Edge, the Torkham Gate.

    This street scene brought to you by JD, a friend of the TAJ:

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