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.

Family Matters

How do you tell a two year old that you are going to be gone for five months? Since a few days can seem like an eternity how does a young childgrasp the concept of a month or several months? Is it damaging to children to have a parent gone for so long? These questions have not been formally answered by the government or at least not been made available to the public. We'll find out as a whole generation of kids whose parents deployed over the past eight years grows older. Of course you can argue that the family member/spouse is a willing participant and is aware of the likelihood/eventuality of deployment but truly, as a psychiatrist in the NAVY I did not anticipate deployment to one desert country and one completely landlocked country all within two years. I can't help but draw comparisons to jail/prison terms and deployment. Not because I am basically trapped here, but because of the separation from "normal life" and the separation from family.

The effect of deployment on children is of interest to me on a personal and professional level. The personal connection is that I have three children of my own ranging from 4 months old to 4 years old. The professional interest stems from being a psychiatrist by training. After I returned from my first deployment one of my sons had taken to wearing dresses on a regular basis. In actuality they were large T-shirts but he called them dresses and would frequently ask if he looked pretty in the dresses. Now some may think it a stretch to link my absence in his life for 8 months to him wearing dresses but just enough of a link may be there. The concept of a dominant mother figure comes to mind but I suppose I could also point to him being in a pre-school class with mostly girls. On the other hand wearing dresses could be completely innocuous and basically just be a classic dress-up phase (no pun intended). Ultimately he gets attention for wearing dresses and whether the feedback is encouraging or disparaging it nonetheless reinforces the behavior. I suppose if my son incurs medical expenses later in life related to being confused about his gender identity I can link it to my service in the military and sue for compensation.

Getting back to the prison theme now. Deployments range from 6-12 months for most US service men and women. For a time in 2007-2008 it was 15 months for Army service members. Those tours pale in comparison to most prison sentences and yet deployment length gets lots of attention. The Department of Defense has put out a joint venture with Elmo (Sesame Street) to educate kids about their parent's upcoming deployment. Summer camps are set up just for children who have a deployed parent. While I am thankful for those services I can't help but think of children who have a parent in prison. They get no extra resources to cope and there certainly aren't any special summer camps for them. On top of that their parent is gone for a much longer period. Staying in contact can be just as difficult with someone in prison as with someone who is deployed. If you say "at least they don't have to worry about the safety of the person in prison" I would counter that prison may be even more dangerous than deployment. Along the lines of chronic exposure to danger, what do we really know about the rates of posttraumatic stress disorder (PTSD) in the prison population? Not be inflammatory, but does anyone really care enough? Does anyone want to know the answer? Because there is probably no alternative to incarceration so what sort of intervention could realistically be devised? I can see one side making the argument that the criminal made the decision to commit a crime and so he has to face the health consequences that incarceration may bring. Please note, the soldier signed on the dotted line as well and should know that experiencing trauma is part of the job description. While the service member most certainly is compensated for psychological and physical trauma and offered life-long medical care, there are no such resources for ex-cons.

Some Thoughts on the History of Afghanistan

If you read accounts of the Soviet invasion and how they controlled their territory the parallels to current NATO actions are glaring. The ring of relatively flat country surrounding the center of Afghanistan was in Soviet control. Troops held all of the major cities: Herat, Mazar-i-Sharif, Kabul, Bagram, Jalalabad, and Kandahar. They built forward operating bases (FOBs) and combat outposts (COPs) much like we have now. A major difference is that the Soviet's used mines extensively while the US and NATO refrains from their use. Additionally, improvised explosive devices (IEDs) were not being utilized at that time. The standard ambush was more likely back then though concentrated Soviet firepower and Air Support usually made those skirmishes short. Stinger shoulder-fired missiles funneled to the Mujahedeen by the US eventually made Soviet air superiority (helicopters) obsolete and leveled the playing field enough for the Soviets give up on their effort and pull out of the country for good in 1988.
The British have a history in Afghanistan as well. The British invaded Afghanistan in 1839 from India. The rationale for the invasion was in large part to prevent Russia from expanding south towards India. The initial occupation by the "Grand Army of the Indus" was relatively easy and the British resorted to their methods of government that had worked for them in India. However, after two years the Afghanis revolted and in a retreat from Kabul into north India, an estimated 4,500 British soldiers and 12,000 Indian camp followers and their families perished due to a combination of harsh elements (it was the height of winter) and Afghan ambushes. Only one British survivor made it out of Afghanistan, his name was Dr. William Brydon (see picture). Of course the British did not sit idly by after the disaster. They retook Kabul before the end of 1842 and had a hand in governance until 1919. With the signing of the Treaty of Rawalpindi on August 19, 1919 Afghanistan became an independent country. That date is considered the birthday of modern Afghanistan.
The modern geographic borders of Afghanistan were formalized in 1964 when China and Afghanistan agreed to officially demarcate their shared border. Decades earlier, in 1893 British officials set the borders of the country is a somewhat arbitrary fashion with the main goal apparently being to prevent Russia from having any direct borders with India. There is widespread consensus that the geographic borders of Afghanistan are a significant contributing factor to the current Taliban insurgency. The Pashtun ethnic group spans the border of Afghanistan and Pakistan. Therefore any issues affecting Pashtun Afghanis is shared by Pashtuns on the other side of the border. It is no secret that the northern region of Pakistan is a major recruiting ground for the Taliban. In fact the area straddling the southern border of Afghanistan is informally known as Pashtunistan and is the focus of much Department of Defense and State Department attention. In reality tribal loyalties have always superseded a national identity and can be seen as the source of the repeated failures of central government in Afghanistan. How NATO forces address that problem will likely be the key aspect to establishing peace in the country. With more than 2000 years of history to draw from, prospects look poor for a successful democratic Afghanistan with its current borders. As has happened in several countries in the last 20 years (Czechoslovakia, Yugoslavia, and Ethiopia), a division of Afghanistan along ethnic/grounds may be the only viable solution to end the violence.

Multinational Effort

Kandahar Air Field or KAF as it is know around here, is the seat of the International Security Assistance Forces (ISAF) in Afghanistan. ISAF is the NATO campaign in Afghanistan. The US is by far the largest contributor to the effort with 67,000 troops in Afghanistan. The next largest group is British with approximately 10,000 troops. From there on down various NATO member countries are contributing anywhere from a few thousand to a few hundred troops. On KAF I have observed troops from Canada, UK, Australia, Belarus, Slovakia, Germany, France, Holland, and Denmark. I am assuming that English is the shared language but I wonder if all troops assigned here need to know English or if just a certain percentage e.g. commanders need to use it? It wouldn't be good if a Slovakian patrol needs to call in air support and does not speak English. Of course that is just one of the problems with coordinating all of these different nations.

Types of uniforms and regulations regarding their wear vary widely. The Belarusians for example have camouflage short and T-shirts that they can wear. I am not sure what good camouflage short will do in an austere environment. Maybe the reason so many Europeans can be found sun-bathing in Speedos on this base is because they are tanning their legs and arms to blend in with the dirt? As a contrast American forces are required to wear uniform sleeves down at all times, no matter what the temperature. In addition to protection from sun it also provides a barrier to chemical/biological weapons. Aside from your work uniform you are authorized to wear official physical training (PT) gear. So even when you are not in camouflage you are identifiable as a member of the Air Force, Army, or Navy. Note, that even when you are not in uniform you must carry your weapon (9mm pistol for officers/senior enlisted and M16 for junior enlisted). The site of someone in PT gear with a weapon takes getting used to. However even more unusual is seeing "off duty" Canadian military personnel because they are allowed to wear whatever they want (i.e. the full range of civilian attire) but they have to carry their weapon with them. I feel bad for them, in addition to having to worry about enemy action they have to worry about matching their outfit to their M16!

There is a clear distinction between the US side of the camp and the European side. Perhaps due to the sheer number of troops it has in the field, the American troops reside in buildings that universally seem non-permanent. The housing for US troops here ranges from tents (14-man to 200-man), to stacked modular container housing, to six room 36-man single story corrugated metal shacks. In contrast, the NATO forces live in brick 2 story barracks that rival upscale college dorm rooms. The NATO gym is virtually indistinguishable for an upscale gym in the US (e.g. Gold's Gym) and is staffed by professional personal trainers while the US gym is basically a large stretched fabric tent with grimy rundown equipment and inadequate ventilation.

Vehicles differ between countries as well. Since most footage of the war involves American forces, the sight of a Humvee or MRAP is common enough. In the US we see less footage of British fighting vehicles for example. While the American strategy is to attach as much armor as possible to a vehicle, the British drive around in barely armored vehicles. Picture classic Land Rovers with the roof cut off and a British trooper manning a heavy gun without any significant armor. A patrol convoy of British troops resembles a scene from the movie Mad Max. Each country that brings its own preferred vehicles also needs to bring mechanics and parts for those vehicles so you can imagine how quickly costs of a deployment can escalate. I mentioned the right side/left side driving and steering wheel problem in an earlier post.

As a closing thought: What interest does a country like Slovakia have in pursuing Taliban fighters in Afghanistan and by extension, how willing is the country to put its soldier's in harm's way?

First Impressions of Kandahar

No clouds, dusty, smells like sewage. Those are my first impressions as I step off the plane at 530am. Oh yeah, and what is up with the ½ hour time difference from the rest of the world? There has to be some trivia behind that. Actually the Afghan decision not to adhere to the Western standard of one-hour time zone changes may well be symbolic of the country's independence and staunch 2000+ year resistance to foreign influence.

In any case, the Kandahar Air Field is actually about 20 miles north of the city of Kandahar. As far as my research takes me, the modern paved Air Field was first constructed in the 1960s by American contractors when Americans first showed some interest in the region. The most significant use and build-up of the Airfield was by the Soviets in the late 70s as part of their support of the local communist government and then of course during their invasion/occupation in the early 1980s. It seems odd to me to think that the Soviets were probably kicking around the same dirt and wondering why they were here.

Back to my arrival. The 'terminal' is a one story building (as are 99% of buildings here). The unique feature of the terminal is that it is actually made of masonry/cement rather than ply wood or a metal of some sort. The building is known as TLS, short for Taliban Last Stand. The building's facade interior remain pockmarked by bullets from Northern Alliance firefights that finally ousted the Taliban from the base in 2001. I was greeted by members of the Embarkation Department of my new regiment. Realize that I have not yet met anyone from my actual regiment since they were already in Afghanistan when I first reported to headquarters in Port Hueneme, California. The Embarkation Department is responsible for moving Seabees and their gear. After all, that is a big part of what Seabees do when they are called up for a mission. You can't rely on finding construction materials or construction equipment everywhere we go. I had to attend a 'welcome brief' in the terminal before driving to my lodging. The welcome brief basically warned of the dangers of walking on base at night without a reflective belt and more ominously, what to do if you hear the rocket attack siren.

On my drive to my lodging it was obvious that the base was crowded. I later learned that this base is in fact 100% over-manned. 20,000 people on a base designed for 10,000. Not good. The pervasive sewage smell comes from the fact that sewage basically collects in a pond that now, due to over-crowding, is no longer isolated in an uninhabited corner of the base. There is talk of constructing an actual sewage treatment plant but that is many years in the future. I guess one good thing about growing up in Manila is that I now have less sensitivity to the sewage smell. There are only a handful of actual paved roads on this base. The majority are packed dirt. Just picture the dust billowing up after passing vehicles. In the week before I got here a soldier was killed when he was struck by a car at night due to poor visibility (there are no street lights here). The majority of vehicles on the streets are non-tactical vehicles (NTVs) i.e. civilian cars. The most predominant kind of vehicle is the Toyota "Hi-Lux." That pick up truck vehicle was favored by the Taliban. In addition to beat up SUVs and pick up trucks you will see gators and even golf cart type vehicles. Some folks have gotten hold of bikes to ride around on. A strange sight when you see them having to sling their rifles on their backs while riding. An assortment of military vehicles is also seen on the roads ranging from Humvees to Mine Resistant Ambush Proof vehicles (MRAPs). The odd thing is that the majority of cars have right side steering while driving is on the right side. (More on the difficulties of merging European and American forces later). After a quick check in at my new command headquarters it was off to sleep after that all night travel ordeal.

Addendum to Travel Post

I ran into a friend from residency who is now stationed in Kandahar as well. His trip from Kuwait to Kandahar epitomizes some of the travel problems mentioned in my previous post. In an attempt to get to Kandahar from Kuwait he first flew from Kuwait to Qatar. He actually had to go through Qatar customs which is notoriously strict and several folks in his group has magazines and other 'contraband' seized. The stay on the ground was 8 hours. The next leg was Qatar to Baghdad. He was on the ground in Baghdad for 3 hours before flying to Bagram (Airbase near Kabul). There he stayed in transient housing for two days before flying onto Kandahar. The flight plan called for yet another stop (in Farah) but that was cancelled in the last minute in favor of a direct flight to Kandahar. So ultimately, a 3 hour flight ended up taking in excess of 3 days. That sort of circuitous travel seems to demonstrate that cargo is more important than passengers in the Air Force theatre movement system.

Intra-theater travel can be just as difficult. Last year it took mefive days to fly 100 miles from Mosul to Q-West by helicopter. Typically you need to give 10 days advanced notice via an Air Movement Request (AMR) to get a seat on a flight. Otherwise you are on Space Available (Space A) status. I was Space A and since a Blackhawk only fits about 12 passengers, there was little excess space for an additional body. I think I lost several pounds just running back and forth to the flight terminal. More than once the flight was simplycancelled at the last minute or the itinerary changed and no longer included Q-West. Travel experiences in theatre exemplifies the Middle Eastern term 'Insha'Allah' roughly translated as "God willing." For example: "He will make it to Kandahar from Bagram on Monday, Insha'Allah." Translate to "We will seem him sometime within five days after Monday." Basically the term goes hand in hand with throwing your hands up in the air or shrugging your shoulders.

The picture is of a C17 Globemaster aircraft that is used to transport large loads into theatre. The aircraft can accomodate 109 passengers in addition to 170,000lb of cargo.

Arrival in Afghanistan

Departure for Afghanistan

Knock knock. It is 1245pm and because of jet lag I just woke up 15 minutes ago on my second day in Kuwait. "Sir, you have a bag drop at 1300" says the petty officer at the door. Yikes! I had anticipated staying Kuwait for 4-5 days and had emptied my bags accordingly. Gear was laid out all over my room, now I had 15 minutes to pack it and get to the rally point. No meal prior to departure either. As a chronic over-packer I really had to work hard to get everything in my two bags. 130lb of gear not including my backpack and armor. I ran out of my room at 1300h to look at the line to drop my gear but nobody was there! When I went to the office of the folks responsible for travel (known as the Embarkation Department) they told me that the bag drop was at 1500, not 1300. Thanks. At least I could go get some food.

I learned that I would be joining about 40 members of a construction battalion that would be operating out of Kandahar and would ultimately be one of the subordinate commands of the regiment. Those poor guys had arrived in Kuwait at 4am that morning and were now leaving for Afghanistan the same day. That made my abbreviated adjustment period seem decadent. I picked up my weapons from the armory. I am issued the standard officer side arm, an M9 Beretta, and an M4 Rifle (think of it as a compact M16) along with 8 magazines.

We dropped out bags off at 1500 and proceeded to load them into a container for transportation to the flight line (air field departure area). The procedure is the same for any unit movement. Load a container. Hop into busses. Drive to 'lock down' area. Palletize gear (put luggage on pallet that will be loaded onto rear of aircraft). Wait. Wait some more. Load onto different busses. Drive to plane. Take off. It is very rare to get anywhere on a direct route. Some of the folks in my group had heard that previous groups had flown to Bagram first and basically had to sleep on the tarmac for half a day before getting an onward flight to Kandahar. In any the whole travel evolution in uncomfortable and exhausting.

In our case we drove to the lock down area at 1700. Don't ask me why we had to drive busses since the area is about 500 yards from our compound. Once there you are herded into a long tent where you wait for it seems like a minimum of 3 hours before you are transported to the flight line. You are not allowed to leave the immediate area with the design that everyone will be accounted for should the flight time change. Boring. Our wait was three hours. Then we got on busses around 1100h. We drove the 20 min to the flight line where there are many transport planes lined up. We appeared to be heading towards a large C-17 when the busses suddenly stopped and turned around. They drove to a covered area and we were informed of a delay of at least 1 hour. We shuffled off the busses and lounged around. The smokers of course clustered around the 'smoke shack." We took armor off. After about an hour there was a call to get back on the bus. Armor back on. Helmet back on. Shuffle into the crowded bus. Then about 10 minutes later another delay. Many guys I was with slept on the bus. I can't blame them given their long trip earlier that same day. Finally we drove to the plane and climbed on.

The C-17 is one of the largest transport planes in the Air Force. The Hold can fit several vehicles and cargo palettes along with about 100 passengers depending on the layout. The inside of the plane is pure utility. Rollers and fastening devices everywhere. Exposed wires and ducts for easy maintenance. The pilots sit up a flight of stairs. Picture a standard wide body passenger jet with no cargo area but rather the floor being all the way in the bottom of the plane. Some of the center seats were hard to fit in with armor.

The 3.5 hour flight was uneventful. The landing was standard military evasive style with steep descents, tight spirals and lots of banking. I arrived at 530am local time. I made it to Kandahar!

Ali Al Saleem: Gateway to Iraq and Afghanistan

The major air base in Kuwait is called Ali Al Saleem. The base is composed of a large number of transient tents since the major role ofthe base is to move service members (and contractors) into Afghanistan and Iraq. The actual 'permanent party' i.e. those service members formally assigned to run the base, is relatively small. The average amount of time spent on the base is less than 3 days for most people.The Army uses the non-flattering term of Life Support Area (LSA) to describe the collection of tents, dining facility (aka DFAC), PostExchange (PX), Morale Recreation Welfare (MWR) tent, and post office. When you arrive you are assigned a tent that you may share with up to 18 other people. The room has bunk beds with bare mattresses. You are not provided with bedding. The lights remain on 24 hours and people are coming in and out at all hours due to jetlag and flight schedules. Sleep may be hard if you are worried about your gear being taken or worse, you have a weapon that you need to keep track of. Flights depart almost exclusively at night...all hours of the night. Frankly, the process of moving such large numbers of people baffles the mind, particularly since there is no predictable schedule to the flights. The base has a somewhat desperate feel to it given that most people are either just starting out their deployment or in the case of the Army, returning from their two weeks of leave back to the States around the middle of their one-year tour. I had the displeasure of spending several days in the transient section of Ali Al Saleem during my last deployment.
This deployment I was housed in the Seabee compound on the grounds of the base. Given that Seabees are builders, it wouldn't be right to beliving in tents. Over time the Seabees have constructed an impressive collection of wooden buildings on their compound. The main design ofthe buildings is the Southwest Asia (SWA) hut. The building isbasically a rectangle on stilts that is built out of plywood. In fact, plywood seems to be the Seabees' best friend. It is almost as ubiquitous as gravel in theatre. In any case the housing was substantially better than the tents. There are no windows in most buildings. That is done partly to decrease damage from explosions, partly to limit air conditioning costs, and in the case of berthing spaces probably to keep the place as conducive to sleeping as possible. There was noticeably more camaraderie in the Seabee section as opposed to "general population." Iwas initially informed that I would spend up to 5 days at the base but ultimately left after two days.
One purpose of stopping in Kuwait is to overcome jetlag so as to be effective the moment you step foot in Iraq or Afghanistan. Some sources claim that it takes 1 day per hour of time difference to truly adjust to a new time zone. That would make 7 days if you are coming from the US. However, most people as sufficiently acclimated in 3-4 days. The bright sunshine in Kuwait may accelerate the process. If it is your first time in Kuwait base life, the sand/dust, and the temperature all require their own adjustment periods.
Given that people in the base are in transit, eating meals becomes themain activity of the day. The dining hall serves four meals. The fourth is called midnight rations or midrats for short and is meant to accommodate night shift workers or in the case of Ali Al Saleem, folksawaiting flights or jet lagging. The food is standard American cafeteria fare ranging from meatloaf to lasagna. The salad bar is remarkably well stocked given the environmental challenges to preserving produce. The highlight of the week is surf n'turf night where they serve steak and either shrimp or crab legs. So much for MRE's. More on dining in a future post.

How I Got Here

I guess I made a deal with the devil to end up on this deployment. I only just returned from a seven-month tour (eight months if you include training) in Iraq last September. The mandatory “respite time” after a deployment of 6-8 months happens to be one year so I would have been eligible to deploy again at this time anyway had I not volunteered. The deal is as follows: I volunteered for a new assignment that terminated my three year tour in Guam one year early and moved me from being a staff psychiatrist in a hospital to being a regimental surgeon for a Seabee unit. Had I remained in my staff psychiatrist position I would have been virtually guaranteed to have deployed again in a combat stress control role with the Army or Marine Corps for 7-8 months sometime within the next two years. I opted for this assignment because it was shorter and predictable. Of course I had an interest in the Seabees as well. Wearing fatigues to work instead of my usual polyester khaki, and being based in California were additional contributing factors.
Given the prolonged nature of the conflicts in Iraq and Afghanistan the need for mental health care is profound and the task of providing the care can be exhausting, not to mention dangerous. Earlier this year a mental health patient on an American base in Iraq shot and killed five people (including the psychiatrist) in a combat stress control clinic. The shooter did not commit suicide and faces trial. I have no doubt that he will go for the PTSD defense.
Don’t be fooled by my new title of ‘surgeon’, I have not changed specialties. The moniker is used to designate the regimental medical officer. My job is to oversee medical issues for four active duty battalions, an underwater construction unit, and a maintenance unit, and four reserve construction battalions. The regimental surgeon position is an example of “operational” medicine rather than clinical medicine. My patient care will be limited in favor of administrative work. In effect I will be working in a health policy, health care administration, and preventive medicine role. My master’s degree in public health should be beneficial.
While a psychiatrist in the position of a battalion surgeon is not advisable given the potential need for trauma care and the more up to date primary care skills, the inherent “people skills” that a psychiatrist should have mastery over are useful in a regimental setting. Negotiations and meetings seem to take on a different tack when a psychiatrist is in the room. People always seem worried that they are being “analyzed” and so might be more restrained when a psychiatrist is present. While I may in fact be analyzing someone’s behavior and mannerisms, it is surely poor form to then verbalize those thoughts. Ultimately only a patient/client (i.e. someone who wants to get a professional opinion) should be given an interpretation let alone a diagnosis. Moreover it is a common fault of mental health practitioners to make a spot diagnosis based on a brief encounter or some stereotyped behavior. The more responsible path is to get all the necessary data before making a diagnosis. As an example, I often have to remind aspiring psychiatrists and psychologists that behaviors of a person in distress can mirror those of a personality disorder. As the latter diagnosis can have serious implications, including a discharge from the military, all other explanations for the behavior should be examined before a personality disorder diagnosis is given.
A second good reason for having a psychiatrist at the regimental level is that some of the major concerns arising from the current war on terrorism are combat/operational stress and traumatic brain injury. The two conditions warrant their own future postings but needless to say they are the clear domain of a psychiatrist. The visibility of a regimental surgeon can ensure that these concerns are given proper attention.

Getting to Kuwait

I arrived in Kuwait on a commercial plane this time. United has a non-stop flight from Washington, DC to Kuwait City. The flight takes 11-12 hours eastbound. It is a sign of the times that the flight happens daily and is almost always completely full. Even though service members are instructed to dress in “civilian attire” it is painfully obvious who is in the military. “High and Tight” haircuts and military issued backpacks are a dead giveaway. Not to mention the uncanny way in which American service members’ seem to dress: white sneakers, cheap tapered jeans, and an outdated polo shirt –tucked in. I would estimate that about 70 percent of passengers were military and 30 percent were government contractors. To my surprise there was an infant on board as well so add one tourist or returning Kuwaiti national. I suppose a visiting member of congress might also take the flight on occasion. The flight passes over Turkey and south over Iraq, basically following the Tigris River. The flight path is a reflection of the safety of the skies now over Iraq.
When traveling with a unit, a charter flight or military flight is used. The former is frequently performed by a generic sounding airline like Trans-American Airlines with outdated planes like DC-10s. I’m surprised they have flight attendants. I’m sure KBR or Haliburton own a stake in the charter companies. The route on charter planes is almost universally circuitous. Frequent stops are partially necessary for refueling given the weight of luggage (five months of gear including chemical gear, weapons, and body armor). My previous charter flight took off from North Carolina, refueled in New York and Germany, and then arrived in Kuwait from a W/SW approach over the Saudi Arabia. Needless to say the travel can be quite exhausting. It is not uncommon for units to have to over-night at one of the transit stops for maintenance work on the aircraft.
At least part of the “purpose” of stopping in Kuwait prior to entering a combat zone is to get acclimated to the time-zone and temperature in the region. Of note, deployment officially starts when your military ID is scanned at the arrival terminal. Many deployments are measured in days e.g. 212 days on official orders and so the start date is particularly important. More on the Kuwait transit experience in the next posting.

Arrival in Kuwait

My plane touched down in Kuwait City in the afternoon of September 30th. The date is significant in several ways. First and most importantly it means that by military regulations I am entitled to tax free income for the entire month of September. This despite only being in a “conflict area” for only one day. Of note, the military has been know to prosecute even high ranking flag officers (generals, admirals) for taking advantage of this loophole too frequently to conduct “inspections” in theatre conveniently spanning 2 months (i.e. the last few days of September, and the first few days of October).
Second and arguably equally important, the countdown to the end of my deployment has started. This deployment will only be five months long for me this time. I hope to return before my wife’s birthday in early March, 2010. I previously deployed to Iraq for seven months in 2008 albeit in a significantly different role (more on that in future postings). At least my family is now surrounded by extended family in the mid-west rather than being isolated on the island of Guam.
Finally it marks my second separation from my wife and children. My wife and I have been married for nearly five years and have three children ages 4, 2, and 3 months old. I am hoping that the separation is easier on my children at a younger age or at least that they will be more prone to forget my absence as they grow older (thereby staving off abandonment issue –psychiatrist speaking here). Leaving my wife with three children under age five may seem cruel to some but we came to this decision mutually knowing that an even longer deployment was virtually certain at a later date.
I will spend less than a week in Kuwait while awaiting further transportation to Kandahar, Afghanistan where I will serve as the head medical officer for a Naval Construction (Seabee) regiment. The regiment has been in theatre for one month already. In this blog I hope to present a picture of a typical deployment to a combat zone, and to address diverse issues pertaining to the military. Expect several posts per week (provided of course that I have reliable internet access). I will try to post pictures as well.