Dealing with patients the Afghan way

A doctor in a poor, crowded, public, Central Asian hospital is like an oriental potentate. People petition you as to weave your way through the crowds blocking the entrance and plead with you to see them, thrusting their rolled-up x-rays in your face. They all have an injury, pain, or deformity, but know only the loudest, most persistent, or the one who has cultivated a powerful interlocutor will be seen. These are not always the most severe cases or those that if treated will produce good results. It looks like chaos to me, but it is a system, as systems go, based on patronage, power, and persistence.

I had forgotten how difficult it is to extract a medical history from the Afghans. When I first wrote the chapter about Afghanistan for A Leg to Stand On my experience in the country was still fresh in my mind but the frustrations of working in this ahistorical medical fashion had left a conflict that I had a difficult time putting into words that people familiar to a Western system could understand. I did not do a very good job of explaining that the history is the most important aspect of evaluating a patient for further treatment. I was taught that at the end of a good history I should have in my mind a working diagnosis, which my exam and clinical tests narrow in number or confirm. This is one of the beauties of clinical medicine and is also one way to cement the doctor-patient relationship, by talking with the patient.

Looking at the x-ray without a history is also, to my mind, a form of "cheating." A good orthopaedic surgeon should be able to make a reasonable differential diagnosis based on history and physical. And not only is a first look at the x-ray unfair, it is a spurious goad into forgetting about the rest of the patient. It can lead one down a blind alley of shadows that look quite out of the ordinary, but in fact have nothing to do with the problem at hand. One must first establish the problem; x-rays are not problems.

Orty was very impatient with me when he edited this part of my story a long time ago; he did not believe that patients would lie, the word I used to describe their answers to my questions. "Why would or should they?" He asked. Perhaps lying was the wrong verb, though I felt that many of the patients blatantly used my naïve ignorance to counter their own needs. They thought their lies would qualify them for care, or better care, or even admission to a hospital whose admission criteria they knew they did not fit. My husband's insistent red marks, indicating that all my words trying to sort out this incongruity were boring and no doubt a figment of my overly-intrusive nature, caused me to change the thrust of that part of the chapter. But I never felt that I adequately examined this need of patients to dissemble, either with frank lying or selected, resolute silence.

The Afghan doctors at the Emergency Hospital in Kabul and here at Balkh Civilian Hospital in Mazar make no bones that the patients' histories are suspect and not to be trusted. This, I think is one reason they have systematically skipped this whole segment in the diagnostic process. They go straight to the x-ray. To them it is cutting straight to the chase without the back story.This black and white film is the petition necessary to gain recognition, physical evidence that something is wrong, the shadowed reality of all that ails the patient. The x-ray becomes the validation of the pain or the disability.

When I brush aside the x-ray and ask what exactly the problem is, the x-ray is trust into my face again. The picture of an offset fracture or the irregularity of a joint is more real to the family and patient than the fact that the patient has no pain and uses the extremity with full function. When I ask the patient to roll up his sleeves, ask again that both be rolled up, and look first at the uninvolved side for a normal comparison, I'm immediately taken for an idiot while the patient, or all his male relatives, point to the deformity on the other side. I nod, but continue my exam. I ask why, 8 months later, they have now brought the patient to the hospital. What exactly is the problem. I'm handed the x-ray and told they thought the crookedness would straighten out. That is what the shakastabund, the traditional bone setter, said.

Yesterday the "problem of the shakastabund" was made more clear on two separate occasions by two different orthopaedic surgeons. When the patient with a fracture goes to a trained medical doctor, the doctor usually tells the family that they should go to the bone setter. The primary doctors have no high opinion of the local orthopaedic surgeons and do not refer to them. This non-referral may have to do with petty grudges, the vagaries of this culture of hanging onto power at all costs, or just plain pettiness. The bone setter does what he has been taught to do, which is bandage the limb with a tight bandage and splint it with cloth hardened with egg or other stiffening materials and bits of wood slivers. Some of the shakastabunds have an understanding of what they are doing. I have a picture of the most beautifully immobilized leg wrappped in precise overlapping layers of cloth as skillfully as the royal embalmer would wrap a pharoh for mummification. I still have the decorative patterned slats of wood that I was told are typically used by the bone setters. But I've also seen some rather crude and physiologically untenable splinting that have led to severe problems. "Presents from the shakastabund," I call these swollen, blistered extremities, some of which are dead from inappropriate treatment and have to be amputated.

Is it harder to get a history in Afghanistan than Africa? I think so, but maybe this is just my problem with language. I have only worked in Anglophone Africa, where I understand both the patients and doctors better. In any culture traditional healers have little need for a medical history and the patients are not asked such intrusive questions as we are taught to do. Sometimes I think they resent our asking. Taking a history supposes that an order can be sorted out when all the pieces of the puzzle are in place. The "order" in a traditional system--the reasons for disease or injury--have little to with the mechanisms we are trained to consider important. Things just happen, and insha'allah you deal with what lies in front of you. Maybe the history is only something thrown in to confuse us.