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Note: For some of you, this post is under the heading of “Too Much Information,” but I think that it’s particularly important to work against our natural inclination to cherry-coat our lives for public consumption.

Thursday I woke up with a swollen right hand and a light rash on the sides of my abdomen. Both places itched terribly. By that evening, I had to take antihistamines to make it bearable.

Friday was worse. This is a picture of a fraction of the rash on one of my sides.

A nurse practitioner gave me a script for steroids and more antihistamines. While the itching was somewhat controlled, the rash continued to spread Saturday. I felt a bit like when Spiderman unlocks the black spider-suit and it covers him. Luckily, I was able to see a doctor Monday. Among other things, he ordered a huge dose of steroids to be administered just like in the movies!

It was the most painless experience I’ve had with needles, from blood draws to vaccinations. And more importantly, it seems to have worked. The rash on my legs still itches, but everything is slowly clearing up.

Despite the completely unknown cause, I’m thanking my lucky stars it happened when it did; a week later would have messed up my Yellowstone trip, which I leave for tomorrow!

Like a lot of things here, I am trying to understand the differences in situations as well as the why behind those differences. I definitely don’t have it all figured out so as always, feel free to comment with your thoughts, especially for my friends who grew up outside the U.S. medical establishment.

I first became aware that the medical profession here is very different from what I’m used to about a month after I arrived in Afghanistan. I was talking with the office IT guy about why I only see him in the afternoons. I learned that he is, in fact, a doctor. Actually, make that the department head of a major division of a hospital. (Wow, really!?) For the past 5 years, he works half the day at the hospital and the other half of the day as the “IT guy” in our government office. It seems like an odd combination to me, but he responded that the IT work pays for him to do the doctoring work. Of course, we all know that IT pays well, but…pays that much more than being the head of a hospital dept??

After this, I started noticing how many of the guys (there are only a few Afghan women that I interact with) I know who are called “Dr.” Afghans are very big on titles and formality so I assumed that these people have a PhD. I later learned that almost all of them actually graduated from a medical program (faculty). They could practice medicine. But instead, they work elsewhere.

In the U.S., you will often find people, from other countries working as taxi drivers, in retail, or in other service industries, who were doctors or other advanced professionals in their home country. That situation is usually the result of the bureaucracy to prove their foreign credentials in the U.S. However, that doesn’t explain why Afghans, who graduated from medical programs here, are working in completely different professions.

I asked one “Dr” I know who works as an assistant to a Deputy Minister. (Note: all of these guys have very good English skills both as a requirement to get into the medical program as well as because of their use of it in the program.) He told me that out of his graduating class, 10% work as doctors. When he was applying for hospital jobs, he was offered a position in one of the provinces  for around $10/month.

Obviously, this is a pittance for a professional job, especially a doctor. But what makes it completely unbearable is the fact that there are so many development organizations in Afghanistan who need translators and professionals to work for them. There is a HUGE discrepency in pay scales because of the amount of money good, well spoken Afghans can make if they work for an NGO, an embassy, the UN, ISAF, etc.

I actually found out that the donor community recognized this was a problem and made an effort to ensure that professions (such as doctors) could get reasonable salaries in their chosen profession. Doctor salaries were increased 3-fold (I don’t know the details of how this was paid for). However, based on the estimates I got for potential salaries, if those doctors instead become translators, compared to the propped up medical salary, they will still make 4 times as much. (I should probably note here that this is for a basic translator position, a job which is generally looked down upon in this culture as not very skilled or resourceful.)

Of course, all of this crazy information about salaries means that very few people will work as doctors; most will instead do various office jobs for donors. It also means that there are very few doctors left to actually practice medicine here (and those few are potentially rather unqualified). So it should come as no surprise that Afghanistan and other countries in this region rival the world for their poor health care and maternal mortality rates. (See this article.)

The pay scale discrepancy that our development dollars has created has huge implications for the quality of care Afghans receive as well as changing the cultural attitudes to even getting this kind of education in the future. These are the things I think about when I pass this:

For the most part, I think I had a fairly good set of expectations about living and working in Afghanistan. I understood some of the security procedures, I knew the basics of the housing and living situation, and I knew that the work would be by far the most challenging thing I have done in my career for a variety of reasons. Of course, there’s no way to be completely prepared for this kind of adventure.

And at this point (2.5 weeks), I know there are two subjects that I didn’t fully comprehend when I got here. Worse still, I’m still coming to grips with them.

This post is about one of those subjects: illness. To be completely honest with you, I was told, “everyone gets sick here,” and I fully expected to get traveler’s diarrhea or a cold, possibly both in my time here. Between not preparing your own food and living and working in such close quarters, I knew my time would come. I also know that I don’t have the most stellar immune system so I shouldn’t rely too much on that. So before leaving the US, I bought multi-vitamins, iron supplements (now that I see how much meat is eaten here this seems overkill), Emergen-C, Zicam, and a variety of medicines to take when the inevitable happened.

My first night here I met a co-worker who had been here for about 2 weeks. She lives in my house, works in the same location, and had already met my counterpart. She was excited to give me a lot of background documents as well as contextual information the next day at work. However, a full 4 days after my arrival, I finally saw her again at dinner (need I say looking terrible). And it was a full 7 days before she was actually at work. Initially, she had a debilitating kidney infection, which when treated moved to her bladder, which left her with terrible back pain.

Then a day ago, a mentor emailed me relaying the following about her work with two other gals in Egypt, “we had pneumonia to bronchitis to giarrdea to scabies to every possible infection you name!  Do everything you can to keep your immune system up given the change in habits, diet, and surroundings.” Wow, seriously?! That many illnesses for 3 people in probably 6-8 months time. It doesn’t make sense.

Not only do underdeveloped countries have a lot of diseases and viruses that have been eradicated in first-world countries (hence the multiple vaccinations before coming), but there are other problems, which become clearer once you look over our balcony.

From Wikipedia: “Urban dumpsites are used in lieu of managed landfills in KabulKandahar and Herat, often without protection of nearby rivers and groundwater supplies. Medical waste from hospitals is disposed in the dumpsites with the rest of the cities’ waste, contaminating water and air with bacteria and viruses.”

I would add to this that having flies indoors is way more common and generally accepted than in the US, again, adding to the spread of germs.

So I have learned that the reason “everyone gets sick” is because, unlike in the US where its mostly about washing hands, the air itself is full of bacteria. We know not to drink the water, but how do you avoid breathing? Our bodies are constantly fighting off things unseen, which in turn makes us more susceptible to those bizarre illnesses we rarely hear of.

I can now add one final reason that expats get so sick. Antibiotics are amazing in fighting off bacteria, but they don’t necessarily fight only the bad bacteria in your body. They also affect beneficial bacteria, making one, again (are you tired of this yet?), more prone to get sick with something else.

This is where I come in. I took a round of antibiotics, and now I have, what I’m hoping is only, a cold.

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