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Diseases of Affluence

RECENTLY I WORKED as an internist-intensivist at the Canadian Combat Surgical Hospital in Kandahar. Most of our casualties were Afghans: National Army soldiers, National Police and civilians caught in crossfire. They were diminutive men, almost always less than a hundred and forty pounds. I cannot comment on the body masses of the Taliban—they were never brought to us. But they are not likely larger than those of the soldiers and the police. And because, in war, soldiers are fed first—prospering right up to the moment they are pierced—the civilians were even thinner.

For someone used to the life and the pathologies of the rich and settled, much about practicing medicine in Afghanistan felt unfamiliar. One of the striking differences was the way gunshot victims’ abdomens looked in CT scans. Back home, I was used to seeing organs stand out with some prominence from the abdominal fat. In fact, in Canadians, the state of the kidneys can be partly assessed by the degree of inflammation in the perinephric fat that envelops them. It’s the same with the pancreas, and the liver often looks like it belonged to a French goose fattened for foie gras. Indeed, the idea of “normal” in a Canadian body proceeds from the assumption that it might be normal to spend one’s days tied to a grain spout, beak pried open, being filled with cracked corn.

Not the Afghans. The surgeons, in fact, often commented on how the abdominal contents spilled out once the abdominal wall was opened; every loop of bowel immediately visible, unobscured by mesenteric fat, which, in Canadians, would cling to every organ like yellow oily cake. Excessive fattiness is precisely why, when caring for the critically ill in North America, glucose levels are tightly controlled with insulin—a procedure necessary even for those not thought to be diabetic. Stressed by the infection, or the operation that has brought us to the intensive care unit, our sugar levels rise, paralyzing our white blood cells and nourishing the bacteria chewing upon them. But it was never necessary to give the Afghans insulin, no matter how shattered they were.

Go here for more on this perspective on the body types in Afghanistan compared to what they are in the West.

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