The Gym

The gym is probably the biggest down-time destination for service members in theatre. On this base there are four gyms to choose from: the American gym, the NATO gym, and the British gym. Each has its own plusses and minuses. The American gym for example is a giant tent while the NATO gym is a fixed building. The former is generally dirty and has run down equipment while the NATO gym has a stict “two pairs of shoes” policy meaning that you have to change into a clean pair of sneakers once you get to the gym. The latter seems to serve as a sort of filter as the number of people using the various gyms is comparable. The NATO gym of course has its downsides as well, the units are metric (km/h and kg) and the TVs are set on mainly British programming. Watching cricket and British infomercials is only so entertaining. All in all the NATO gym is quite impressive and when you are in it you can forget what condition the rest of the base is in (see picture).
The gyms are in operation 24 hours per day. Trying to figure out slow times to have a better chance at getting on a treadmill is a guessing game as it is not uncommon to have a full gym at any hour due to insomnia or mission status status since this base runs 24 hours per day. American Service members are easy to identify as they have prescribed exercise clothing. Service members from other countries wear whatever they want apparently. The use of Spandex by Europeans is quite shocking. Naturally the gym is filled by all of the styerotypes found in the States as well. The “machine hoggers” who seem to use weight machines exclusively to rest and watch others, the “trendy exerciser” who uses each machine for such short duration and at such a low intensity that they are doing it for show, the “grimacer” who makes exagerated grunts and facial expressions etc etc. Unfortunately the percentage of phenomenally fit individuals you would expect from a military is quite small.
There is a certain desperation to using the gym here. It is as though using the cardio equipment is symbolic of this conflict. Lots of moving parts but no real forward movement. Running in place, biking in place, and rowing in place reinforces the “groundhog day” nature of this place. Contrary to what you might think each Military branch does not have a preferred cardio activity: Navy on rowing machines, Marines on treadmills, Marines on weight equipment, and Air Force on stationary bikes or eliptical machines.
There is no excuse not to get in shape while on deployment. Sadly however obesity remains a problem in the military and many folks on deployment chose the dining hall (described in a previous posting) over the gym.

Christmas in Kandahar

Today is the date that gives the name to my blog. To me December 25th is not significant in and of itself as a holiday but rather represents something more significant about military deployments. It symbolizes what makes military servicemen and servicewomen different from their civilian counterparts, namely sacrifice of the very comforts and freedoms they signed up to defend. On some level the ability for American citizens to have elaborate holidays and spend time with family members rests upon someone giving up that right. I am not talking about giving up one holiday to work/be away from family because after all, people cannot always travel to be with family for the holidays and many people actually have to work. I mean being willing to spend long periods of time away from home in order to do a job, a dangerous one at that. Deployment of course has been a fact in the military, particularly the Navy since their inception. However until the past eight year, deployment to a war zone for an extended tour relatively rare. Now a substantial portion of the population will have experienced six months to 12 months away from home in Southwest Asia. How that will shape our country in long run remains to be seen.
It cannot be overlooked that the vast majority of fighting forces here in Kandahar have customs based on Judeo-Christian beliefs. As such, Christmas is a significant holiday for most of the fighting forces. That is not so for the TCNs here who easily match the military forces in number. That makes for an intersting contrast for a few days here.
The American Forces make every attempt to bring a festive atmosphere to the base for Christmas. The amount of Christmas packages alone is staggering. Entire C5 aircraft are dedicated to bringing in mail. The post office has had to resort to asking for volunteers to help unload the pallets. Recently 34 pallets (capable of carrying 10,000 lbs each) arrived with mail for the holidays. Of note, service members are not just receiving a gift here and there from immediate family members. A reservist co-worker of mine received 19 packages from co-workers from his civilian job. In fact all of the US commands here receive an abundance of mail and packages from concerned/greatful citizens on a regular basis. Candy, snacks, and toiletries are the most common contents of these packages. In the middle of the night last night, stockings filled with just such items were dropped off in front of the barracks rooms of members of my regiment in a move organized by concerned citizens back home. Christmas meals are being served throughout the day at the DFACs. Each NATO member country seems to have reserved a DFAC for several hours for their troops to have a ahared Christmas dinner. As is apparently the case with every aspect of this war, no expense was spared.
For me being away from home for the holidays this year will no doubt make me appreciate future holidays when I can spend time with my family. When I do that I also know that my thoughts will be with those who cannot enjoy that luxury as I hope yours are.
Merry Christmas from Kandahar.

Food on Base

"The way to a man's heart is through his stomach" Of course that old adage needs can be adapted to my current circumstances "The best way to keep a service man or woman happy is through his or her stomach." There is lots of truth to that statement. Morale is directly linked to the availability of warm food and the quality of that food. A significant portion of discontentment that is noted at the end of a field exercise for example can be attributed to the meal situation.
The government has taken the rations issue to heart and allegedly
spends $90 per day per soldier on food here in theatre. Large bases
like Kandahar benefit more than smaller forward operating bases due to
being closer to the supply chain. Kandahar Air Field (KAF) boasts
four (and a half) dining halls. These facilities are free to service
members and all contractors on base. Unlike Iraq and Kuwait where the
food is the same regardless of the dining hall you visit, here on KAF
the dining halls have culinary themes. 'The Cambridge' features
cuisine from the UK, 'Niagara' has American/Canadian food, 'The
Luxembourg' has mainland European food, and the 'Asian DFAC' features
of course Asian food.
It is not hard to predict that most troops tend to gravitate towards
the DFAC that features the cuisine they are used to back home. The
Asian DFAC is a draw for the Third Country Nationals (TCN) on base and
those seeking stir-fry. (As an aside the title TCN is meant to be a
PC term for hired laborers. These workers are mainly from the
Philippines, Bangladesh, India, and Pakistan. They perform food
service tasks, laundry, housekeeping, and sewage jobs.) A menu is
sent out weekly via email to all personnel on base. Depending on the
day and meal time you can enjoy such dishes as Beef Bourginone, Lamb
Jhalfhrezi, Makhani Dal, Chicken and Fresh Mushrooms, or Prawn Chow
Mien. The American food is frequently an uninspired Burger with Fries
or BBQ Beef. In each DFAC you will have several entrée choices and a
soup and salad to chose from not to mention several deserts. Of
course the enticing names of the food can't really detract from the
fact that the meet is poor quality and everything is smothered in some
sort of generic sauce. In addition, the serving sizes are large and
you can tell that there is not an emphasis on calorie counting.
Unless you are intensely physically active (like soldiers out in the
field) you can easily gain weight (see picture). Four meals are
offered per day. The fourth meal time is 'midnight rations' for those
on night shift or night owls.
As I mentioned before, this base is significantly overmanned (and with
the recent announcement of troop increases it will be even more so in
the upcoming year) and this reality is most evident in the DFACs.
Overcrowding is rampant and utensil shortages are not uncommon.
However, with a little research peak times can be avoided and with a
little forethought you can stock up on items that can spare you a trip
to the DFAC for a meal every now and then.
Ultimately, despite all of the complaints listed above, the eating is
great here for military standards. I would rather be here than out on
a small FOB eating meals-ready-to-eat (MREs).

Communications with Home

I am writing this as I am on hold with a Neiman Marcus representative back in the USA. As I am waiting I am entering my 5th minute on holdI am hoping that this call will not cut off after 20 minutes as is frequently the case when making what is called a 'morale call' back the States on the Defense Switched Network (DSN). DSN is basically a military telephone network. The purpose of the 20 minute cutoff is of course to allow the largest number of troops to call home on this free network. DSN telephones are not readily available with most phones being located in the offices of important ranking officials. Unfortunately that means that the lower your rank, the less likely you will have access to this free service. That is an issue because a) a junior service member might need more contact with home (due to inexperience/lack or previous deployments) and b) they have less income to spend on telephone charges.
One alternative to DSN in theatre is calling card call (AT&T or SPAWAR) used at a phone bank. With the AT&T card you are getting 1/3 the minutes you paid for e.g. a 550 minute phone card gives you 180 minutes. The call quality is hit or miss with frequent echoes and dropped calls. Also, the calling centers are invariably converted shipping containers where you sometimes have to talk over 20 other folks making calls. The cubicles are full of graffiti and the phones are beat up. I'm sure a large part of the communicable diseases here can be traced back to the phones.
A third alternative to call home is to get a local cell phone. The local vendors will issue prepaid calling cards to go with the phones which have Afghan telephone numbers. Texting someone in the states costs 50 cents per text so you can imagine the minute charge for voice calls. I had a patient last year in Iraq who had a $900 monthly cell phone bill! Rumor has it that the cell phone company has Taliban ties and that they can essentially monitor cell phone communications.
Given the time difference with the US (9.5-12.5) hours the evenings and nights are the busiest call times here. It is not uncommon for the lines to be jammed so you have to try many times to get through and the likelihood of a dropped call is high.
A final method of communication is Skype. Despite our poor internet connection speed (64-128kb/s download; 32-64kb/s upload) one is able to do video calls with home during off peak times. The image is grainy and prone to getting bogged down but it nonetheless offers the ability to see family once in a while. Voice over Skype works well. Mind you, internet is not universally available on the Kandahar Air Field and is virtually non-existent on the smaller bases.
Of note, most communications (aside from cell phones) are one-way i.e. family members back home cannot reliably call the service member when they need to. That brings up the issue of whether instant communications is a benefit or detriment to the war effort. Already the military has to enforce a communications blackout for 12-24 hours after a US fatality so that news of the death does not reach family (via instant communications) before the military has the chance to make the formal announcement. What I see as a problem for some soldiers is being expected (self-generated or generated by family back home) to communicate daily. When the long work day ends here (depending on your job and location it may never end) the day in the US is just beginning and soldier may be expected to switch hats from forward-deployed war fighter to spouse, significant other, extended family financial supporter. In that role they often need to tackle problems back home from bills, to home maintenance, to relationship problems. The psychic toll of not being able to unwind at the end of the day can be significant. In fact the majority of 'combat stress' cases I saw in Iraq last year were not combat related at all but rather 'home-front' stressors.
Could fights and stress be reduced if folks had to wait to weeks to exchange correspondence? Would people back home be more independent if they couldn't rely on daily communications from the deployed family member? Would writing a letter (instead of an instant message or a phone call) lead to less conflict by eliminating impulsivity?

The Wild West

In many ways this base resembles the Wild West just like the movies.
For one, there is spotty law enforcement (rules enforcement –with basically
everyone being armed there is no real law breaking). There seems to
be an "everything goes" mentality in some areas. Only slowly is some
conformity is being introduced. A few weeks ago everyone on base was
notified that license plates were being introduced on the base to
finally be able to track vehicles (aka non-tactical vehicles).
Currently there are no consistent means of identifying vehicles. Some
companies will have an 8.5"x11" piece of paper taped to the windshield
with some cryptic identifying information on it but most go without
any marks. The problem is compounded since we have a very limited
number of vehicle models on base and so many vehicles look the same.
The most prevalent vehicle is the international version of the Toyota
4-Runner which is known as the Hilux Surf here. With most
non-tactical vehicles being imported from Pakistan, the driving is on
the right side while the traffic flows on the right side. So there is
a setup for accidents or erratic driving and so the need for good
vehicle identification is understandable. There are basically 3 paved
roads here with all other routes being crushed gravel or impacted
dirt. Passing vehicles churn of large dust clouds making walking here
hazardous to your lungs. A road grid of sorts is in the works but
most signs are ignored and since there are no side-walks people and
vehicles come into frequent confrontation. There are also no street
lights. Currently a $5000 reward is out for information identifying
the driver in a hit-and-run that killed a soldier.
The 'wanted' posters are not the only other similarity to the Wild
West. The social center of the airfield is a collection of eateries
and shops collectively known as the boardwalk. The establishments are
arranged in a square with an internal 'quad' that contains a
basketball court, "fields" of packed dirt and rocks, and believe it or
not, a street hockey rink. The latter is a testament to the Canadian
presence. A covered wooden walkway around the inside gives the place
its name. The place is a melting pot for all of the NATO forces. I
can picture the swinging saloon doors. Crafty entrepreneurs have are literally working out of shipping containers along the board walk.
The fact that everyone is walking around with a weapon is another
similarity to the Wild West. The only thing missing is shootouts at
high noon.
Housing varies significantly as well. Some folks live in large tents. Other options include the 35 man-7 room dwellings that I live in, stacked container housing units, and for the select few, 2-story concrete dorms. The latter are being constructed for NATO troops. It is not uncommon to see them laying out on cots, sunbathing in Speedos. That sight is probably where my PTSD will come from, not rocket attacks.
To sum things up: the varying accomodations and the overall slow move towards rules, orderliness, and conformity must have been what the American West was like back in the late 19th century.
The picture is of a boat that is located on one of the lots on this DESERT base. Go Army.

A Combat Stress Control Psychiatrist's Thoughts on the Ft. Hood Shooting

The tragic shooting rampage at Ft. Hood last week has special significance to me as I too am a military psychiatrist. I deployed to Iraq for seven months in 2008 as a combat stress control psychiatrist (see picture)just as Major Hasan was scheduled to do. Major Hasan completed the military medical school (Uniformed School of Health Sciences) in Bethesda (4 years), then completed a residency at Bethesda/Walter Reed (4 years) and a fellowship in disaster psychiatry (2 years-ironic since he created a disaster), and practiced in Bethesda for several years before being transferred to Texas and finally being tasked to deploy. Of note, he incurred approximately nine years of mandatory payback service to the Army for all of his training. When it came time to start paying back the Army he caved.

The media coverage seems to have entertained every possible motive for the shooting including religious zealotry, posttraumatic stress disorder (PTSD) by proxy, domestic terrorism, and retaliation for having been discriminated against. Family members of the shooter have commented that he was 'mortified' about deploying to a combat zone. The given reasoning is that Major Nidal Hasan counseled so many PTSD patients that he had a distorted view of deployment and thought that his life would somehow be in constant danger. Having been deployed to a combat zone as a combat stress psychiatrist I can assure you that he would be in minimal danger. In fact he would most likely be in an office going routine patient care much like he has done back in garrison.

An even more absurd theory to me is that he developed PTSD "by proxy" from talking to his patients. That means that he now has PTSD from hearing about traumatic experiences rather than actually having been the victim of the trauma. That is akin to getting PTSD from watching a horror movie. A more likely experience from hearing frequent traumatic experiences is compassion fatigue. Compassion fatigue is basically losing empathy for your patient because you have heard similar stories or worse stories many times before or because you feel like your patient's are exaggerating symptoms/downplaying recovery for the sake of compensation. Regardless of whether he had PTSD or compassion fatigue, it does not follow that he would unload several magazines into co-workers.

It has also been noted that the shooter was extremely reluctant to deploy to a combat zone. In my opinion a military health care provider should be eager to practice in a combat zone because that is fundamentally what differentiates him from his civilian counterparts. In fact the field of medicine has been significantly shaped by war experience. For instance, emergency medicine as we know it was in large part developed from war time experiences, particularly Vietnam experiences. While I can imagine someone with children perhaps being reluctant to deploy, the shooter was by all accounts single and not a father. Again, reluctance to deploy does not translate to a shooting spree.

Why then did he shoot into a crowd that included his co-workers? We may have to wait for the trial to find out, but what is certain is that if he had not had access to high performance firearms. Could the tragedy at Ft. Hood have been avoided if guns were not accessible to the general public? How much damage would an impulsive, angry man been able to do if he did not have high performance weapons and ammunition on hand? Gun rights advocates would tend to gloss over the fact that the shooter had a weapon and instead point out that the shooting spree may have been aborted earlier had more people in the crowd been carrying weapons. No comment.

In the end the shooter's legal defense seems to be aided by the media in that they are proffering so many potential motives/defenses for his behavior. I think he is likely mentally ill -schizophrenic, and that his symptoms made him very susceptible to extremist propaganda that ultimately led him to shoot innocent Americans. Time will tell.

One Month Down

I have reached the one-month mark of my deployment! Four more to go. Deployed personnel manage the duration of their tours in many ways. . Some scratch off one day at a time. Some count week by week. Others will only start counting after they reach "Over the Hump Day," i.e. the half way point of deployment. Some elaborate "countdown timers" are in use over here. Some timers are simple spreadsheets that count backwards and give you percentages of time remaining and time elapsed. Others are more sophisticated and can feature an image (PG-13 of course) that is gradually revealed in proportion to the elapsed time on deployment.

The one month mark is a special milestone. First, you are eligible for the deployment/campaign ribbon once you have reached the one-month mark in country. In my case that makes the Afghanistan Campaign Ribbon/Medal. While relatively exotic over the first few years of the conflict, this ribbon is becoming more common place in US military service members. In contrast the Iraq campaign ribbon is almost ubiquitous among Army service members who served within the past six years. Since this is a NATO conflict, troops who serve in Afghanistan also earn the NATO ribbon/medal after 30 days in country. The military also starts paying 'Family Separation Allowance' of $250.00 to service members who have been deployed for more than 30 days. I have no idea how that amount was determined. I should deposit the $250 each month for future therapy sessions for my kids for not having their father around for five months or to compensate my wife for having to be a single parent to three kids.

I remain amazed at what people will do for a piece of colored fabric i.e. a ribbon. This human propensity is apparently taken advantage of starting at the Cub Scout/Brownie level in the United States. In discussions with service members in my capacity as a psychiatrist I frequently explored fantasies of earning a Purple Heart because of the prestige of it and how rare the ribbon is. Unfortunately there exists a disparity in how readily awards/medals are awarded between the varying services. The Army is the most liberal is issuing medals and the Marine Corps in notoriously stingy. In my tour in Iraq last year it was commonplace for all unit commanders and senior leadership to earn a Bronze Star apparently for simply doing their job for 12-15 months. I suppose the ease of which medals are issued is an attempt to shore up morale that is flagging due to the prolonged nature of the war and the demoralizing effect of guerilla tactics.

One 'benefit' of the two wars we have been fighting since 2001 is that our military has more actual combat seasoned troops than it has had since WWII. If even a fraction of these service members remain in the service for their entire careers and assume leadership positions then I believe that future military decision will be made with a significantly higher degree of practical expertise than say decisions during the 80s, 90s, and first few years of the 21^st century. In the line community the likelihood of completing a career without a combat zone deployment is becoming a rarity. In the physician community certain specialties are being deployed more than others. Mental health providers may well be the most deployed while deployment remains a very rare occurrence for uniformed pediatricians and obstetricians. In fact deployment including sea tours remains so rare for the latter two specialties that the question has been raised why we need uniformed pediatricians and obstetricians/gynecologists at all. Civilian providers could easily provide those services on the mainland and even large overseas bases.