Rx: Two Bricks, a Turban

Once in a while, Sath Mohammed smiles. On this day it happens as the 11-year-old describes his beloved sport, Afghan wrestling.

The thought of it brings a look of delight to his face. He reaches an arm into the air as if to grab an opponent. Then he moves a leg--or what is left of it--and his face goes blank.

For a moment, he had forgotten that he lies in bed No. 9 under a crudely lettered sign that reads “Bomb Blast Victim” and will never wrestle again.

His left foot was blown off in late October when an errant U.S. bomb hit the road where he and his sister were walking in Afghanistan’s remote Oruzgan province.

By the time Sath reached Sandeman Civil Hospital here in Quetta, a two-day journey, the Pakistani doctors felt there was no choice but to take off the leg at the knee. Even then, they were not sure how he would fare. He has no money for a prosthesis, and infection was still a concern.

“He needs antibiotics, he needs painkillers, and we don’t have them,” said Mohammed Ramzan, an orthopedic surgeon. “Maybe his family can buy them in the bazaar.”

This is the human face of “collateral damage.” It is hard enough for families to deal with the tragedy of war’s mistakes. But for Pakistan, whose health system is impoverished, and for Afghanistan, whose legion of destitute citizens Sath will soon rejoin, it is a Sisyphean task.

Conditions at Sandeman, the largest Pakistani government hospital in the area, illustrate the two countries’ poverty as well as the perseverance and limits of their medical staffs. Hospitals like this are so poor that patients routinely are asked to buy medicine, bandages and the orthopedic plates, pins and screws needed to set broken bones. Or they go without.

The dismal state of health care suggests that the international community will face a mammoth effort as it tries to move the region into the 21st century.

“The real difficulty is that the Pakistani health system was struggling anyway,” said Anna Pont, health project manager here in Baluchistan province for Mercy Corps International, an aid organization. “There’s been a lack of resources for years, the hospitals are running at their limits, and there were a lot of Afghan refugees long before Sept 11.

“It’s very important to remember that while the people coming across the border need help,” Pont said, “the host country system needs a lot of help to deal with the situation.”

The civilian victims of the U.S. bombing campaign are few, relative to the number of Afghans sickened by diseases related to hunger and poverty. International organizations that track such unintended casualties have yet to complete their official estimates. But they say the number is likely to be somewhat higher than the 1999 toll from allied airstrikes in Yugoslavia, which human rights groups put at between 500 and 600 people.

In Afghanistan, it appears that the bombing became more accurate, with some exceptions, as the war went on and military planners received better intelligence. Nonetheless, with so many injured in this and previous Afghan wars, vast resources will be needed for patient rehabilitation as well as basic medical care.

To walk into Sandeman Civil Hospital is to enter a medical time warp. There are no CT scans, no MRI machines, no centrifuges, no computers, no electronic equipment. There is no monitoring equipment at the nurses’ stations, just dented plastic chairs.

In the orthopedics wing, whose doctors’ skills are widely recognized in the region, there are no traction machines. Abdul Wasey, 10, who was injured when a wall collapsed after a bombing in the Afghan city of Kandahar, would be a natural candidate for traction, the application of weights to hold bones in alignment.

The bomb blast dislocated Abdul’s hip, causing painful swelling and making it impossible to walk. Such injuries are generally treated with bandaging and traction.

It’s a relatively simple matter in the West. Not here. Doctors, after searching for some way to rig weights, settled on two bricks, each a little more than 2 pounds.

But how to attach them to the boy? The doctors used a turban--contributed by a patient with a head injury--to hold one brick. A gauze bandage was rigged to hold the other. Abdul’s father bought the gauze at a shop because there was none to spare at Sandeman.

For another patient, the doctors employed a full box of hard toffee. The candy hung forlornly off the end of the bed, tied with a gauze bow like a misplaced present.

Few Doctors, Many Mistakes

On one day last month, Sath and Abdul were among 77 civilians injured by the U.S. bombing who had made their way to Sandeman, according to logbooks kept by the emergency room. A few died soon after arriving. For the vast majority, the treatment they get at the hospital will determine how they spend the rest of their lives.

Early in the war, Sandeman received the most Afghan patients among Pakistani hospitals. In part this was because of the intense U.S. bombing in southern Afghanistan. Quetta is just a three-hour journey by vehicle from the Afghan border and has a large number of refugees. Injured Afghans often have a relative here who can help them navigate the health care system.

Sandeman also received patients referred by smaller and poorer hospitals in Afghanistan, especially as doctors in that country fled the fighting or were pressed into service treating Taliban soldiers. And Sandeman is less costly than nearby private hospitals.

Medical insurance is rare in Pakistan and unknown in Afghanistan. Most Pakistani hospitals rely on the meager funding they get from the government and whatever patients can pay.

In public hospitals like Sandeman, which see the poorest patients, almost nothing is covered beyond the doctors’ services. There also are too few doctors.

A government report on Baluchistan’s hospitals found one doctor for every 1,900 people. In Pakistan, the annual per capita expenditure on health care is $18, according to 1999 statistics from the United Nations’ World Health Organization. In contrast, the annual health care expenditure in the U.S. is more than $4,000 a person.

As a result, when the Pakistani medical system ventures into treatments that require technical expertise, mistakes are almost taken for granted.

Sath, the 11-year-old wrestling fan, was given three blood transfusions, but at least two appear to have been with incompatible blood types. His father, who spoke with an attending physician, was told that his son was having “an allergic reaction.” Western-trained doctors in Islamabad, Pakistan’s capital, said his symptoms--a dark red rash that covered his body and a feverish itching--were consistent with being given an incompatible blood type. Such an error can be fatal, they said.

Sath’s father, a seller of plastic shoes, was already in debt for the cost of reaching Quetta. He had to borrow still more to pay for medicine needed to quell his son’s reaction to the transfusions.

Those who make their way to Sandeman for treatment come primarily from rural backgrounds. These Afghans say they were unaware they lived near Taliban troops, although after long conversation it may emerge that there were antiaircraft guns positioned near their homes, or that Taliban soldiers sometimes used nearby roads.

Nonetheless, many of them view the bombings as acts of God or nature. “The bomb fell down on our house,” they say, as if describing an avalanche. In some cases, when they heard a helicopter flying low and firing, they ran outside to see it, oblivious to the risk.

These patients had little access at home to quick medical care or knowledge to judge whether treatment was adequate. As a result, a number of patients appear to have lingered in the more poorly equipped Kandahar hospitals, possibly costing them a limb or a life.

“Inside Afghanistan nowadays, the people are very poor,” said Khair Mohammed, who initially brought his injured 8-year-old granddaughter, Saleema Bibi, to Mirwais Hospital in Kandahar for care.

“We are farmers. We are working as daily laborers, and there is a drought,” he said. “I had no money, I could not afford to bring her to Quetta, but I got a loan from a person in our village, and when we go back I will work for him to pay him back.”

‘Where Is My Leg? Why Did They Take It?’

Saleema’s legs were crushed by a falling wall during a bombing. At Sandeman, she was placed in the women’s ward, a windowless room where aunts and grandmothers squat on the floor next to their relatives, heating water for tea on small kerosene stoves. The sheets on Saleema’s bed were stained with pus oozing from her wounds. In contrast with poorer hospitals, Sandeman provides linen--washed a couple of times a week, patients say--but no blankets or pillows.

Ragai Bibi, Saleema’s grandmother, fanned the flies that swarmed over the girl, but there were too many to keep at bay. The older woman sleeps on the floor unless there is a free bed. Her husband sleeps along with other patients’ male relatives outdoors in the hospital’s main courtyard, which serves as bedroom, dining room and mosque.

Soon after Saleema arrived, Ramzan, the orthopedist, saw the severity of her wounds. One leg was virtually severed. “This little girl needs an amputation,” he said. “All the bone is exposed; the muscles are exposed. It’s torn beyond healing.”

He grabbed her small foot and manipulated her toes, yellowish by then.

“See, they are gangrenous and becoming dry,” he said. “She has oozing wounds. We tied the vessels, but they continue to bleed.”

Her grandparents opposed amputation, explaining that she would not be able to work in the fields or kitchen if she lost a limb. Ramzan told them that the infection could kill her. But they shook their heads. No, she will get better, they said.

The infection worsened, and eventually they gave permission for the surgery. When she awoke from sedation, her eyes flickered as she became conscious of the ache. Amputations cause some of the most searing pain a person can experience, according to doctors. Then came something harder than the pain itself.

“Where is my leg? Why did they take it?” she asked, her voice trembling, a look of terror on her face. She glanced over at her grandmother and whispered: “What should I do now? Will they bring me a new one?”

Her grandmother fanned the flies and looked at a point on the far side of the room. She saw the life that lay ahead for the little girl and her face reflected a deep and terrible helplessness.

Later, when Saleema fell into a feverish sleep, the grandmother’s words spilled out. This injury will affect their whole family, she said angrily, and what did they do to deserve this? They are not Taliban. As she sat on the floor, she put her head in her hands and rocked.

“Now I think she will not be married because a man who is ready to marry wants a wife who is able to serve him, to serve his mother, his father, his complete family and care for his children,” she said. “She is lame and nobody will want to marry her. She has become a lifelong problem for us.”

If Saleema and Sath and others hospitalized here are fortunate, some international organization will help pay for a prosthesis. Mercy Corps and one or two others offer such help. However, they usually require the patients or their families to pay some share of the cost.

“Sandeman is the only official government hospital for the injured patients from Afghanistan,” said Massoud Khazi, an orthopedist who is proud that he was trained by an American physician in Quetta. “But if we don’t have the equipment, if we don’t have the medicines, we cannot help them as we should, we cannot do what we were trained to do.”

For Fatima, a young mother in the next bed, the clock was ticking.

She had four to six weeks to get the screws and plates needed to set her broken elbow before the bone would begin to heal improperly. Fatima, who like many Afghans goes by one name, said she lost her husband and five of her six children when they ran outside to see a low-flying helicopter firing on their village. Her right arm was shattered by the gunfire.

Khazi said only the insertion of screws and plates would help her regain the use of her arm. “When we don’t fix the fractures internally [with pins], it disturbs the function of the whole limb,” he said. “She will not be able to use her hand and she will not be able to bend the arm at the elbow. She will be lame.”

Already at the hospital for nearly four weeks, Fatima and her brother, Sardar, were almost out of money. The cost of food and medicine had overwhelmed Sardar, a farmer. Then the two vanished. Other patients said they thought they had returned to Afghanistan. Fatima had not even received a plaster cast.

For Taj Mohammed, Sath’s father, this latest trial has been almost more than he can bear. A gentle man, he can’t remember if he is 60 or 65. He said life has been hard but in many ways happy. All of his children are alive, and the family is often together, he said. In a country with an infant mortality rate of about 1 in 5, that means something.

Sath and his sister, Fermina, were injured as they were walking home after visiting an elder sister. Fermina was burned and cut by the blast. When Mohammed saw his children, bloodied and blackened from the blast, he wept. Then he borrowed the money to bring them to the hospital in Quetta, the best he could do for them.

“Look at this small boy and that small girl,” he said. “He is not Osama, and she is not Taliban. So why did America bombard them?”

His hopes for Sath had been simple. “If he was well, he would work with me,” Mohammed said. “We would be able to sell shoes together, and he would sell sweets to the small children to help me and my family make a living. But now he cannot.”

Sath also had dreams. “I wanted to read and to work with my father,” he said.

What will he do now? Sath turned his face to the grimy hospital wall. His father looked out across the ward where the late afternoon light was fading to gray and shook his head.

“He will have to go into the madrasa,” or religious school, Mohammed said. “Live in the mosque and pray for the people; pray for humanity.”