So, as is probably the case with any country torn by years of war, poverty, drought, corruption, and an untenable terrain, among other things, the statistics about Afghanistan aren't always straight forward. While the World Bank reports a 49% increase in the opium production, the UN reports a 19% decrease between 2007 and 2008 with a further anticipated decrease in 2009. One thing that everyone does seem to agree on is that Afghanistan has been the world's largest opium producer for at least a year. The export value of the crop is somewhere around $4 billion and it has been reported that more land in Afghanistan is used to grow poppies than is used in Latin America to grow coca. In the past year, the value of poppies has decreased, but still remains higher than most other agricultural products. This is clearly one of the driving forces in its continued production. Other influences include availability of irrigation, local need for foodstuffs, religion, government interventions, or the lack thereof, as well as the Taliban and its enemies. This is clearly a multifaceted problem making its eradication a tremendous challenge.
Eradicating parasitic disease in an underdeveloped country is also challenging, though we are trying to do it one patient at a time. Ascaris lumbricoides is a common parasitic worm infecting many of our patients. The Ascaris life cycle is kind of interesting, and quite frankly, kind of disgusting. The mature worm, which can set up residence in the human intestines, produces eggs which are shed in the feces. In underdeveloped countries human feces are either indiscriminately disposed of, or are sometimes used as fertilizer, so feces are ubiquitous in the soil. The eggs in the soil go through a process of embryonation and develop into larvae. These larvae are then ingested through foodstuffs. Alternatively children go out and play in the dirt and invariably dirty hands make it into their mouths and the larvae get swallowed. Once ingested, the larvae penetrate the intestines, travel to the liver and eventually make it into the blood supply to the lungs. (Here's were it gets really disgusting, if you haven't been totally grossed out already.) At this point, the larvae perforate into the airspaces of the lungs and get coughed up. They then get swallowed back down into the intestinal tract and become mature worms which excrete eggs and start the whole process all over again.
Compared to other parasites, Ascaris is considered to be a relatively short lived parasite with a life span of "only" 6-18 months, which is 6-18 months longer than I would like to have worms. They can get to be quite long with lengths up to 40 cm. An estimated 1 billion people in the world are infected and excrete somewhere around 25,000 tons of eggs on an annual basis.
My first encounter with Ascaris came during an abdominal exploration on a young girl who had sustained a penetrating injury to her abdomen from some sort of improvised explosive device. One of the steps included in an abdominal exploration is a process called "running the bowel" where the small bowel is carefully inspected from one end to the other to make sure there are no injuries. Because of the redundancy of the small bowel, the process includes passing the bowel from hand to hand to make sure that no segments are missed. Normally the bowel is essentially a hollow tube, however, it feels like there are cords of rope in it when worms are present. Needless to say, it's kind of gross.
Apparently when a patient is ill or dying, the worms are
able to recognize a bad situation and make a run for it. So they can start crawling out the mouth, nose or out the other end. The worm pictured to the right came out of a burn patient we have been treating here for the last several weeks. Though she was not dying, we had induced diarrhea with her feeding regimen and this worm just got caught up in the current. Incidentally, we try to provide an additional 10% in nutritional support to account for what the worms are eating.
There is medication to treat these infections. We generally wait until the patients have recovered from their acute illnesses before we treat them. The dead worms are excreted in the stool which has the potential to cause a bowel obstruction if there is a significant infestation. We don't want to take the chance of causing such an obstruction while the patient is still recovering from his or her primary illness. The infectious disease specialist who is here tells me he is planning to take a dose of the medication himself when he returns home - just in case. Between his advice and the giant hair ball that was in my salad the other day, I will probably do the same. Needless to say I don't think I will handle it very well if there are any positive results.
So, as you can tell, Afghanistan has some very redeeming qualities. Unfortunately I think these two issues only represent the tip of the iceberg.
Other than that, not too much else going on here. The weather has still been pretty rainy which has kept the tempo down. And, we have another surgeon who has joined the rotation, so the call schedule is now even more spread out.
There is another medical unit which is going to be stationed here which means more people. Unfortunately there isn't more housing available, so my room of 4 is going to become a room of 6. The additional furniture gets moved in sometime next week and the additional people are allegedly arriving the first week in May. I'm hoping to be in the process of packing to leave at that point. 6 women in a room? Holy giant cat fights...
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