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.

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.

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.

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.

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.