Free Better by Atul Gawande Page A

changing conditions of war. As the war converted from lightning-quick, highly mobile military operations to a more protracted, garrison effort, the CSHs had to adapt by converting to fixed facilities. In Baghdad, for example, medical personnel moved into the Ibn Sina hospital in the Green Zone. This shift brought increasing numbers of Iraqi civilians seeking care, and there was no overall policy about providing it. Some hospitals refused to treat civilians for fear of suicide bombers hiding among them in order to reach an American target. Others treated Iraqis but found themselves overwhelmed, particularly by pediatric patients, for whom they had limited personnel and few supplies.
    Requests were made for additional staff members and resources at all levels. As the medical needs facing the military increased, however, the supply of medical personnel got tighter. Interest in signing up for military duty dropped precipitously. In 2004, according to the army, only fourteen other surgeons besides Murphy joined the reserves. Many surgeons were put on a second or extended deployment. But the numbers were not sufficient. Military urologists, plastic surgeons, and cardiothoracicsurgeons were then tasked to fill some general surgeon positions. Planners began to contemplate ordering surgeons to take yet a third deployment. The Department of Defense announced that it would rely on improved financial incentives to attract more medical professionals. But the strategy did not succeed. The pay had never been competitive, and joined with the near certainty of leaving one's family for duty overseas and the dangerous nature of the work, it was not enough to encourage interest in entering military service. By the middle of 2005, the wars in Iraq and Afghanistan had stretched longer than American involvement in World War II--or in any war without a draft. In the absence of a draft, it has been extremely difficult for the nation's military surgical teams to maintain their remarkable performance.
    Nonetheless, they have, at least thus far. At the end of 2006, medical teams were still saving an unbelievable 90 percent of soldiers wounded in battle. Military doctors continued to transform their strategies for the treatment of war casualties. They did so through a commitment to making a science of performance, rather than waiting for new discoveries. And they did it under extraordinarily demanding conditions and with heroic personal sacrifices.
    One surgeon deserves particular recognition. Mark Taylor began his army service in 2001 as general surgeon at Fort Bragg's Womack Army Medical Center, in North Carolina, to fulfill the terms of the military scholarship that had allowed him to attend George Washington University Medical School several years before. He, like many others, was twice deployed to Iraq--first from February through May 2003 and then from August 2003 through winter the next year, as a member of the782nd Forward Surgical Team. On March 20, 2004, outside Fallujah, four days from returning home, the forty-one-year-old surgeon was hit in a rocket-propelled-grenade attack while trying to make a phone call outside his barracks. Despite his team's efforts, he could not be revived. No doctor has paid a greater price.

P ART II

Doing Right

Naked

    T here is an exquisite and fascinating scene in Kandahar, the 2001 movie set in Afghanistan under the Taliban regime, in which a male physician is asked to examine a female patient. They are separated by a dark blanketlike screen hung between them. Behind it, the woman is covered from head to foot by her burka. The two do not talk directly to each other. The patient's young son--he looks to be about six years old--serves as the go-between. She has a stomachache, he says.
    "Does she throw up her food?" the doctor asks.
    "Do you throw up your food?" the boy asks.
    "No," the woman says, perfectly audibly, but the doctor waits as if he has not heard.
    "No," the boy tells him.
    For the purposes of