Outpatients

Jonathan Joseph

13th January 2031

There is a certain weary comfort to a Monday morning here; despite the horrors in the prefabs and the faintly gamma-positive sleet pocking the poly roof of my office, I take some solace from the generic, familiar schlep of the starting week.

I have been up for three hours already, a nagging occipitalis ache dragging me neck first from an uneasy sleep on my surplus noncom cot. In contrast to my usual fractious, broken dreams, my office looks the same as always - a small pokey appendix epoxied to the back of the main ward. One small desk, one half-destroyed chair - the seat as hard as permafrost, one semi-opaque sheet of plastic masquerading as a window, one extremely modern laptop - my sole luxury - is probably the single most expensive item in a hundred kilometre radius. There are over a thousand carbon and partially silicon based entities within effective sniper fire range that would cheerfully kill me for it, but so far I think I've kept it a secret. A beautiful distillation of thirty years of west coast technofetishism, the computer fortunately doesn't look anything like a computer does here in the technological doldrums of the Middle East - they still coo over a Macbook in these parts.

stories of whitewashed caves, dentist chairs, chugging Honda generators

I have no fixed schedule here, but many demands on my time. My charges have the sweet plaintive demands of the truly helpless, raggedy stick and bone shapes only faintly tenting the rough blankets that are the only bedclothes available in the chilly main ward of the hospital. As usual I make a morning tour of the ward, a depressing euphemism for a shuffling survey of the two small bays that are the full extent of the hospital. Zalmai is awake - I've never seem him asleep - his sightless head tracking every small sound I make as I negotiate the defunct medical clutter he insists on heaping on and around his bed, a pitiful hedge against further pain. We found Zalmai about a month ago; he had crawled over twenty kilometres from the Maheepar Pass to the suburbs of Jalalabad. I was led to where he lay by one of the filthy interchangeable urchins who hang around the compound and who know we will pay a few afgani for information on the latest unfortunates to stagger out of the western mountains. Zalmai had heard me coming, the chill winter morning air telegraphed my approach clearly to his undamaged ears. Mewling pathetically, he had scrabbled backwards, bloodied palm prints darkening the cracked, dried mud of the grubby no man's land of the road verge. He looked up at me - his excised, bloodless, empty sockets somehow a much worse horror than the terrible battle gore I had seen and treated - they had taken his eyes.

The Pardis Hospice is a mean, swingeing, annex shoehorned into the small space that used to optimistically be called the Jalalabad Hospital main car park. Now a gomied dumping ground for shrapnel-ruined medical equipment and discarded prosthetics striking improbable vogues, the park is also home to our three ex-NATO inflatable medical tents. Transitory structures long past their half-life, the prefabs are home to that most contemporary of war victim - the organ thieved.

We've been here for a little over three months and I've already seen, treated, consoled, and sometimes watched die, over seventy victims of the mountain gangs. It's a hard road from Kabul, and all are fair game; scooter punks who think they know it all, Médicins sans Frontières newbies, economigrants nomading their way to the Pakistan border and back in tattered annual caravans of privation. The gangs seem to prize Christian aid workers most of all. Last week, a shattered Isuzu pickup dumped the legless, not yet lifeless, torso of a Jesuit priest right at the entrance to the main prefab; he was also missing his eyes, and as we found out later, both his kidneys and liver. He died with his eyelids pinned back, never saying a word, his fists hiding a crushed rosary. The ones that live are harder to bear, so many stories of whitewashed caves, dentist chairs, chugging Honda generators, blank, black eyes - and so much pain. Oddly, these surgeons are curiously attentive to the aseptic technique, only a handful of our patients ever seem to develop opportunistic post-operative infections, and, judging purely on surgical finesse, these butchers seem to wield their antique scalpels with aplomb.

The ward stirs as more breakfast grumblings join Zalmai's quiet demands for flatbread and black tea. Several dislodged dressings add to the night fart miasma with the high sweet smell of putrefaction, and the splosh-clatter of a bed pan hitting the floor adds to the fun. I dispense some gloves, filter up and get to work.

Air quality permitting, I try and hold the group sessions outside. When the particulate meter settles into a quasi-quiescent tick-tock metronome, we bundle up the patients into hand-me-down NBC suits and stretcher/carry/cajole our charges into the ambulance (an ungainly USMC anti-mine deuce and a half) and head south east to the poppy fields near the Khyber Pass. Since the mujahideen went synthetic savvy and the UNODC quashed production with the simple expediency of tactical nukes, the endless opium plantations have been abandoned and gone to seed. The orbital feeds now show a more colourful Afghanistan, like an ironic mockery of old empire cartography the landscape is a startling seasonal scarlet against the otherwise unrelenting high altitude view of the endless browns and greys of the Middle Eastern prairie.

Zalmai wheels, turns, pitches and yaws across the poppy field

The poppies hide the other prefab I maintain, a quiet place that is tolerably well preserved by fading UN logos and still functioning outer skin chameleon polymers. Ignored also, because of its notional salvage value, the prefab offers us a valuable hiatus space, only occasionally spoiled by a few empty beer bottles and rank hobo piss. Appearances aside, I still feel that there is useful work to be done here. We (mostly me) are one small part of what in quainter (more naïve) times might have been called a guilty conscience. But it's pointless trying to anthropomorphise a corporation; the lesson I've learned from fourteen months in field is that WorkSpace is nothing but deliberate. Unencumbered by the human flotsam of pity, or empathy, or consideration, the WorkSpace behemoth moves deliberately and with perfect self-focus.

The Combat Revenue model is a well-worn, well-practiced algorithm that allows for the faintest expressions of largesse at carefully determined intervals. The CR tacticians noticed early on in shock and awe profiteering that they had to allow for a degree of mercy, an amelioration of take, to maximise their returns. It seems that even the best-insulated corporate psyche quails eventually in the one-way bazaar of war.

This is where I come in - one small articulation (a feeble prosthetic nod to decency) of the post-war official WorkSpace Health and Reconciliation programme. Like a shot in the arm of battlefield stimulant, we had an amazing first year in Jalalabad - epic funding, baksheesh up the wazoo, access all areas - even for a Guardian-reading tosser like myself, it was hard to resist local government-sanctioned largesse... This year's been rather different. We are no longer the flavour du jour; by October, WorkSpace PR had already moved onto a free HIV-immunisation programme for the Cape Town townships, and the scooped torsos and cleanly delineated stumps of the organ thieved were old news. Funding dropped to less than ten percent of year one, we lost most of the international team, the patient suicide rate soared, we moved to the prefabs in the car park and I lost the one decent camp bed left in southern Afghanistan.

We still have the poppy prefab though, and on a spring day with the early red petals tinting the view, we make some useful progress with our crippled coterie. Zalmai, in particular, loves the plantation; he knows that there is nothing to run into, the worst he can expect is a turned ankle in a rabbit hole. It's become a tradition, as soon as the ambulance hits the bumpier surface of the gravel road leading to the prefab, Zalmai grabs my sleeve and turns his eyeless face to mine (a mute plea I can never resist) and points to the ambo door. I slow the truck and punch the door release.

Zalmai hoots and leaps, rolling easily on his left shoulder, the poppy buds leaving sticky resin on his crappy jacket and brown dust and early sun forming a glowing corona around his thrashing form. Then he's up, running, arms outstretched, a child's aeroplane freedom - a thing of beauty compared to the adult fetishism of war hardware that Zalmai unconsciously mimics.

The Afgani children that I have met all seem to share an uncanny ability to imitate the clanks/drones/rumbles/snicks/clicks of the American armour they have grown up with all their lives. Zalmai wheels, turns, pitches and yaws across the poppy field filling the air with a pitch perfect echo of an A12 tankbuster on afterburner, punctuated occasionally with the bumblebee gargle of the chin chain gun.

The activated charcoal in the aircon has long since been inactive and the prefab smells like camping trips and the drying wetsuit tang of childhood seaside visits. I peg back the membrane door as far as it can go and we all shuffle in, Zalmai bringing up the rear, taxiing reluctantly into the musty space.

Currently our complement is only seven. A recent c. difficile outbreak, a spectacular gastrointestinal revolt that left the whole ward retching and grieving in equal measure, resulted in two deaths. There was only one surprise, a goat farmer who had wandered into the hospital compound, unaided, only missing a lung and his left hand. He died four days later, after the difficile infection swept through the wards.

Also present are some other stubborn remnants of this year's intake: Max, a shaggy, denimed member of the ubiquitous tribe of nomadic westerners that form a grubby, globally-spanning gulf stream of trust-fund disillusionment and disestablishmentarianism. Six months ago Max found himself muling out of Kabul with an amphetamine-packed colon and a nearly valueless solid roll of hyper-inflated Afgani currency. The Rough Guide is woefully short on hitching advice for the Kabul-Jalalabad road and Max's abortive attempt to flag down an ancient Peugeot estate resulted in a third-hand colostomy bag and a free ride to our hospital car park. Ashur the Syrian, my star pupil, a dead man walking. Ashur was a DOA at Jalalabad Central hospital, a bloody bundle of rags that had been cursorily admitted by an exhausted night staff and then rolled on a broken trolley into an unused corridor in the ER. Doubling as a trauma surgeon during the first few weeks of my secondment I found this gory heap as I took five and sucked down my millionth smoke of the night. Ashur is what we call a full donor - multiple organ theft and over fifty percent of limb reduction. Incredibly he was conscious when I found him, his one remaining hand pawing blindly at the fetid hot air of the ER. I was new in-country back then and I was gear-rich and drug-fat from my new WorkSpace coffers. The hospital wing they had assigned me for the organ theft project was full of box fresh, state-of-the-art kit designed exactly for the life extension of this type of victim. Ashur was at the thin end of a survival spectrum probability but back then I was full of enthusiasm, energy and naïve hope.

He made it through the night; his cored torso emptied of offal and filled with a million euros worth of modular life support. That long night was a vague memory of grey market Marlboro consumption, the blinking LEDs of the medical gear and the gurgle/rattle of a jury-rigged trachea/air filtration unit connection. Ashur is a continuing miracle, wholly dependent on ageing med gear, scrounged feedstock and smuggled hormone replacement analogues; yet he has an easy, beatific smile and always some time for Zalmai. Ashur reminds me of a turn of the century cyborg wet dream gone wrong. Like a crippled borg lacking the transcendent scope of Stelarc's vacuum-bound nude explorers, Ashur is his own street, making his own uses of the tech we can scrape together for him.

Gula always brings up the rear, she invariably insists on carrying the Job from the ambulance to the prefab, an essential piece of kit for the group sessions. Nearly two metres tall, Gula's single huge right arm easily flips the modular Job pod off the roof rack and onto its undercarriage of sprung wheels. Gula has not spoken since she came to live with us in the prefabs, she has no overt medical needs and I can only assume she was also a victim of the mountain gangs, the clean stump of her left humerus betrays the trauma of involuntary surgery, not the impartial mangled legacy of a farm accident. Gula's huge beautiful green eyes miss nothing and she acts as our minder during the vulnerable hours we spend in Job immersion during the counselling sessions.

Even with the pharmacological mitigation and enclosure comfort provided by the Job, therapy with my patients rarely shares the structured, ethereal angst of a first world counselling session. Dealing not with the maybe, the bogeymen of possibility, the faint spectre of disaster - all distant cousins to true pain; these fragmented souls have already seen and felt far too much real trauma to compare even fleetingly with my pampered Albionside client base. After a year of patching up tattered psyches, gibbering will-o-the-wisp surgery survivors, I have developed an involuntary rage response when I think back to the work I did at my Acton practise. When I remember the plaintive middle England whining of mortgage rate hikes, second job exhaustion, the draconianisms of my own erstwhile employer, and the dull throb of thwarted careers, the gorge rises and I frantically pat my pockets for the Marlboros.

the rest of the group forms a circle around Zalmai and me as we interface

Here in Afghanistan, in this millennial crucible of conflict, pain is real and my patients have experienced the full gamut. Not for the first time I am struck by the depressingly familiar irony of the urgent consumer strivings of my own cosseted countrymen for tastes/flavours/newness - bring me a new shirt, a new tie, a... new thing... anything. Daily I am reminded of the timeless Couplandism - "purchased experiences don't count"; here, instead, in-country, almost everyone is looking for a refund of their own bitter, involuntary transactions. It's a hard lesson too, after a whole life of absent-minded gratitude for an accident of birth - a genetic dice roll - it only took a year in Afghanistan to realise that my former life was a hollow and valueless as a scooped thorax of one of my pillaged charges.

I have a full quiver of therapeutics, though, and fading WorkSpace funding notwithstanding, I've got good gear. During the prefab sessions, when we're making a semblance of progress and the tears flow usefully and cathartically, I feel like I did when I de-planed in Baghdad - a clean arrow of determination fletched with the belief that I can make a difference - salve the terrible open wounds of conflict damage. Technology helps, the long chain polymer perfume of new tech, the replete power packs, the semi-autonomous repair packs, the vacuum sealed MREs - though I have painfully and incrementally discovered that all these hedges against chaos and disorder are merely a delay, a brief hiatus of intervention that lasts only as long as the new car smell. After a year of petty theft, pilfering, abrasive desert winds, and the inevitable over-usage entropy, out of all my original kit only the Job is running at anywhere near full capacity.

The Job is a two person therapy model, with empathy bias. Designed in 2030 by a Dutch-Italian WorkSpace subsidiary, therapy Jobs were built around a central core concept: To feel is to understand. The one hundred and fifty years of the psychotherapy industry had always been hobbled by one glaring central limitation - to know someone is not to know their pain - and without that knowledge there can never been true understanding, and in turn, succour. The therapy Jobs make the tenuous, febrile moments of therapeutic insight a concrete reliability. Using the manipulation of mirror neurone activity - the observationally triggered physiological process that occurs when conspecific animals (humans included) witness each other's pain - the Jobs use pharmacological and electroneurological interventions to augment and enhance the biological empathy response. This includes the primary nociceptors - the propagators of noxious stimuli. This means that in Job-facilitated session the therapist feels the patient's pain. Considered somewhat of a Wild West field by the old school of non-interventionists counsellors and therapists, Job therapy is not for the faint-hearted. The pain, both phantom and real, of (for example) missing limbs, despite being buffered and baffled by a series of filters controlled by both the therapist and the patient, could be extreme. Still fringe, and therefore deemed "deployment-acceptable" in non-first world contexts, the empathy school was taking some of the first painful steps towards true understanding and healing.

Today it's Zalmai's first session, somewhat of a rite of passage in these de-traditioned times. I ping the Job a wake-up sequence from my smartphone and it uncurls from its wheeled repose. Carapaced like an over-plated armadillo, the Job snicks-snucks-clicks into the standard new patient configuration. Designed to minimise further unnecessary distress, these Job models lack the sanitary/elimination hook-ups of the standard corporate Job models, and they also have a much more friendly on-board AI avatar - gender-variable dependent on the client. Forming the now standardised defensive outward looking perimeter (a welcome evolution of session security initiated by Gula), the rest of the group forms a circle around Zalmai and me as we interface. I lead Zalmai to the patient saddle, the Job flaring open in a welcoming proboscis embrace. Seating Zalmai and hooking up the pharma-feed and the skullNet takes a few minutes, a pause capitalized as usual by at least four of the group lighting up, I don't really mind - H&S is a distant concept these days. The Job chirps an environmental particulate/carcinogen alarm but I squash it immediately - first world puritanism can go fuck itself.

Having made Zalmai comfortable and giving him a few minutes to acquaint himself with the Job, I then hook myself up in the therapy seat. Accessing the public landing space I prep a stylised simulacrum of the poppy fields outside. In the therapySpace the neurointerface provided by the Job means that during the sessions Zalmai will see again (a direct optical nerve hack that anywhere else in the West would be available as an outpatient procedure), and I want him to have a nice view. The quiet, small voice of the Job whispers - go - in my ear and the session begins.

At nearly thirty-seven thousand kilometres above southern Afghanistan, the geo-stationary WorkSpace relay milsat is a barely detectable stellar mote in the clear, frigid, night sky. Suspended in a cylindrical vat of liquid helium, and protected with a ring of bulky tanks of propellant, the mind of the satellite pulses gently with a superconductive glow. It doesn't really think; WorkSpace tends to impose a max AI capacity on geosynchronous weapons platforms with kinetic missile capability. Nonetheless, the dim, dog-like musings of the sat envelop its operational output like a primary colour finger painting: Mmmm, 98% operational efficiency. Recreational uplink in 953 seconds - woof. Milchcow rendezvous in seven orbits - drool.

The sat has a number of tasks - comms routing, mildata storage, AI backup - but, primarily, it's a gun. A big gun. Optimised for targeted, non-radioactive orbital bombardment, the milsat is a fourth-gen geosync platform built by WorkSpace in 2029 and leased to the US government for the duration of Afghanistan 2.0. The sat has seen some service, crude satisfaction routines humming with gratification as the dumb matter kinetic missiles were deployed at hypersonic speeds from the blunt muzzles of its EM accelerators. Expelled at speeds close to escape velocity, the streamlined chunks of depleted plutonium that the sat uses for ammunition require no explosive payload. Impacting at over twelve kilometres per second, the dull grey rods of plutonium convey a impact explosive analog of over 20 kilotons. With no gamma after-effects, the weapons platform is the tool of choice for the discerning on-the-ground US military coordinator. They even take it in turns, thrice-PHDed war technicians squabbling over who gets to pull the trigger on a modified PlayStation paddle from an invulnerable state-side bunker.

Latterly, though, the military machine has moved on to oilier pastures and the milsat has been backburnered to standard comms duties - piggy-backing commercial TV feeds a dimly perceived jangle of irritating bits. As the terminator creeps across the terrigenous skeleton of the mountains of Afghanistan, and the morning brings some welcome relief from the freezing spring night, the milsat wakes up to a rare but extremely important ping: get ready to launch. Hard-coded synapses shiver alert with an anticipation of pseudo-pleasure - re-deployed it may be, but the sat is a combat machine - they made it to want to fight. Milliseconds later targeting data hits its buffer, a priority wrapper indicates a desired completion timeframe for the action, an imperative variable tells the sat that the order is reinforced with a WASTE modifier, somewhere in WorkSpace someone (or probably more likely somebot) has decided that a WorkSpace initiative has exceeded its mandated usefulness. In the more litigiously nervous environment of the developed world this would result in a cease and desist order and fund withdrawal; out in the Middle East boondocks a more expedient MO is used: explosive deconstruction and removal.

The sat processes the targeting data: A geoloc overlay pinpoints the bombardment coordinates, a more self-aware entity might puzzle over the rationale and/or military significance of a near-deserted patch of poppy plantation several kilometres south of Jalalabad, and a less capable machine might doubt its ability to hit a tiny disused prefab. The milsat is fully upgraded, though, and has a 94% success termination potential for targets <0.5 metre square. 250 milliseconds following receipt of directive its primary EM cannon is unfolding from its dormant configuration. Fully three seconds thereafter a two metre needle of ultrahard plutonium is making a ersatz shooting star in the dawn sky of Afghanistan. Nearly an hour later (an aeon in machine time) the sat's after-action scan detects a rising cloud of atomised rock and dust rising into the morning sky. Its sensors are also sensitive enough to detect in the particulate cloud the fatty-carbon remains of several mammalian combatants, it also wonders briefly and unconcernedly about the flash of machine thought coherence it detected just before missile impact.

Resource allocation is not one its core competencies, nor does is possess combat morality algorithms. The sat powers down to dormant, to again moronically eavesdrop the tsunami of commercial bandwidth flooding its router.

Pardis Hospice is closed for business.

© Jonathan Joseph 2011 All Rights Reserved