Larry Zaroff, MD, PhD
Stanford University, California

For the West, Afghanistan is a country difficult to understand. Though largely Muslim, it is a society made up of multiple ethnic groups and classes, beset by ideological disagreements, with disconnected provinces that are unstable, unconquerable, and often anarchic. All Afghans are culturally mixed, yet are highly independent, believe strongly in personal honor and loyalty to their clan, and are quick to use weapons.

An encounter a number of years ago with an Afghan patient who required heart surgery made me realize how widely separate are our cultures. The story begins in the desert, where a camel waited patiently, as camels do. The camel is a philosophical animal, available for water, food, and weight. She felt vacant, used to her driver, who was unable to mount. The reason for her anxiety was water in her rider’s legs, the center of his inability. Though the camel kneeled in observance of her master, he was too weak to lift his leg sufficiently high to mount. At that moment neither he nor his camel could understand why he could no longer join his clan on their rides. His tribe, the Koochis, consisted of Pashtuns who had been nomads for centuries, threading their camel caravans back and forth across Afghanistan. They migrated according to the weather and the grass, moving through the country with consistency, rarely stopping. What use was Abdul, now grounded from the herd? Where would he find honor? What would his loyalty to his clan consist of? Sand? Dust? If his father asked him to pick up a rifle to war with another tribe; he could not. He did understand that he had grown weaker and shorter of breath in the past few months. But once on his camel he could ride well, with dignity. Where was his dignity now? His legs were heavy, swollen, as if a tide had turned to fill a river bed. Who could explain this flood? He, a man of irony, thought of this dry desert and how it could use this water.

 

Finally, desperate enough to consult a woman, he turned to his grandmother. She remembered: “Before you could ride the camel,” she explained, “the wind carried a sword into your body. It heated your body beyond the sand and weakened you. It remains like hot camel dung, ashes burning inside you.”

 

Abdul, now thirty, had grown up in a powerful Northern Afghanistan clan, known for its independence. His father, still the strongest of the camel riders, was the leader of the clan. He was never doubted. Abdul, his only son, six and a half feet of ladder with the shoulders of an ocean, was to follow his father as the clan chief. But he could no longer mount his camel. Without a camel, an Afghan of his nomadic tribe was useless. His father was diminished by his son’s weakness. He must restore his son to health, to mount a camel.


Abdul was fortunate, for in Kabul, a distant friend of the family was a doctor, with a keen ear and an understanding of the culture of the nomadic tribes. He was often asked to bridge the two cultures, modern, Western and ancient, Pashtun. He needed little time to make the diagnosis: severe heart failure due to damaged heart valves. The doctor explained, “Abdul, as a child, you had an infection that damaged your heart. He drew a simple picture of the heart valves. Still, Abdul did not understand. He did finally realize that to mount a camel he must have his heart repaired. "But not in Kabul, not in Afghanistan. I have a brother in the United States. You must go there for your operation.”


Abdul’s heart looked like a basketball, spreading from one side of the rib cage to the other. I was shocked. I had never seen an x-ray in which the heart occupied so much of the film. In severe heart failure he would require days of medical therapy before surgery to replace his leaky valves. Pashtu was his language, but English-speaking Afghans were always in his room; so we began a relationship. Two days before his operation I had a formal meeting with Abdul and the translator to explain the details of his operation. I proceeded slowly, hoping the translator would be able to deliver the message. I told of the risks—a ten to twenty percent chance he could die during or soon after the operation. I waited, listened. Abdul shook his head up and down, looked me in the eye. No words needed, although the translator filled in the details. He would take any risk to rejoin his tribe, be a leader, a man like his father. I then detailed the potential complications: liver, kidney failure, bleeding, brain damage. I even said he might go through the surgery and not be improved. Again Abdul listened, shook his head, now said yes, yes, before I could finish.


Now for the easy part, I would tell him of the team concept of open-heart surgery, of the necessity of technicians, nurses, anesthesiologists. He smiled. He could not live as an invalid. Finally I told him that my hospital was a teaching institution, that my residents would do part of the operation under my supervision. But I would do the important parts. It was as if someone had stolen his camel. He was angry, and turning his head said no. The translator explained: “In his tribe, there is one chief only, one who makes the decisions, one who brings the camels to the water.” I was stunned, trapped. I had never had a patient refuse surgery because of resident participation. I could not withdraw, disavowing what I believed in, what was honest: A cardiac surgeon does not work alone. I was a surgeon but also a teacher who had to instruct younger surgeons to be safe, to treat others. Abdul could not be convinced, nor did I persist.


I asked an associate, a superb surgeon who trained in the United States, but whose origin was India. He understood the culture. He would do the operation. We proceeded. Alas, though the operation was perfectly performed, the heart was too sick to resume a beat. My sadness was great, greater than if I had done the operation. I thought of his father and his tribe, of his lonely camel, now an orphan. I remembered his grandmother and the ashes, finally extinguished. I had engaged a society I understood poorly and turned the encounter into a cultural collision. What could Abdul have understood about my dilemma? What did I know of his camel, of his concept of leadership? We had ventured to restore him to his seat atop his camel, but instead we took a journey that did not find water.

 


Larry Zaroff has had five careers following his residency and two years in the U.S. Army Surgical Research Unit. He focused for 29 years on cardiac surgery, including a stint as director of the cardiac surgical research laboratory at Harvard. There his work centered on the development of the demand pacemaker. He spent the next 10 years concentrating on climbing and did a first ascent of Chulu West, a 22,000-foot peak on the Nepal-Tibet border. His third life has been at Stanford, where he received a Ph.D. in 2000, and where he teaches courses in medical humanities. His fourth career has been as a writer for the NYT science section. He now works one day a week as a volunteer family doctor. He has received awards as the outstanding faculty advisor for the Human Biology program and in 2006 was honored as Stanford's Teacher of the Year.