No way, said Afghans who were providing input. "People said `Uh, this is a very fundamentalist area, where you cannot have any image of a living being'," Burnham recalls.
How about images of money, with higher values connoting increased satisfaction? Locals didn't like that idea, either, saying it suggested gambling, a forbidden practice in much of the country.
After more discussions, the researchers finally began to grasp the Afghan perspective: They developed a rating that used drawings of loaves of bread, with more loaves signifying better care. "Everybody eats bread there, wheat is the big crop," says Burnham. Patients "caught onto that instantly," he says. "It was an incredible hit."
Once a reasonably healthy place by Third World standards, Afghanistan has plummeted to the bottom ranks of many international indicators. Three decades of almost constant warfare have decimated the country's health-care system.
Over their lifetime, Afghan women who give birth have a one-in-nine chance of dying during childbirth. In Africa, the rate is one in 16; in the United States, it is one in 2,500. The country's average life expectancy is 53, and its infant mortality rate is about 170 deaths per 1,000 births. In Baltimore, a city that has one of the highest rates in this country, the rate is 13 deaths per 1,000 births.
A few months ago Burnham took part in a workshop with villagers in a rural province. He posed a question to a group of women: Given unlimited resources, what would they like to be doing in five years? The response surprised him.
"The most common answer was, `In five years, I'd like to be alive.' That was really sobering," he says.
In choosing his career, Burnham followed a family tradition. Both of his parents, a streetcar driver and a nurse, were interested in social justice. And as a child growing up in Los Angeles, Burnham heard many stories from his uncles: One was a surgeon for a mission hospital in Manchuria; another was a relief worker elsewhere in China, a third was a pathology professor in India.
After serving in South Korea, Burnham was assigned to be deputy director of a military hospital in Alabama. The director was near retirement and ready to relax; Burnham was soon running the hospital. To his surprise, he found that he enjoyed writing budgets, crafting reports, and performing the day-to-day detail work of keeping an institution running smoothly. Since then, he has used his talent for administration repeatedly.
After his discharge, he studied public health at the London School of Hygiene & Tropical Medicine, and in 1977 found a job as a doctor at a hospital in Malawi, a poor, agricultural nation in southern Africa.
Within months, he was running the place. Over the next few years, he rebuilt and re-equipped it until the hospital was the best in Malawi. He worked 80 hours a week, 40 as a clinical doctor and 40 as an administrator. His highest salary was $14,000 a year.
During the early 1980s, he got a call in the middle of the night telling him to come to the palace of the country's brutal dictator, Hastings Kamuzu Banda, who was almost certainly in his 90s. Banda, himself a doctor, was very sick. A jittery Burnham drove an hour into the principal city, Blantyre, and found Banda breathing with difficulty, his lungs full of fluid.
With lackeys and thugs hovering, Burnham diagnosed partial heart failure. Luckily for both patient and doctor, Burnham prescribed the proper medicine, and Banda recovered. From then on, Burnham was the dictator's personal physician.
After more than a decade in Malawi, Burnham decided that he needed a new challenge. "I wanted to see if my brain still worked," he says. He had spent years dealing with what he calls "five-minute problems" - how much medicine to give a particular patient, or where to get money to fix a broken generator - and wanted to think about problems from a wider perspective.
So he went back to London for a doctorate in public health and within a few years was recruited by Hopkins. (Banda was still alive when his doctor departed. He died in 1997 at the age of 99, three years after losing power in an election.)
Soon Burham started the Center for Refugee and Disaster Response, which provides guidance to public-health workers on the most effective ways to handle humanitarian emergencies. The group has worked in most of the world's refugee hot spots, including Africa, the former Yugoslavia and the Middle East. He remains co-director of the center.
He is probably best known for his controversial 2004 study of Iraqi civilian health, which found that the U.S.-led invasion had led to 98,000 additional deaths. The research appeared in the British medical journalThe Lancet.
Burnham and his co-authors do not argue that coalition military forces directly caused all or even most of the deaths. They say that in the chaos after the invasion, disease became more rampant and medical care more inaccessible.
In addition to his work in Afghanistan, Burnham is involved in a partnership with schools of public health in Tanzania and Uganda to increase training, and a study of the health of North Korean refugees who have escaped to China.
Burnham and his wife, Ginny, a psychologist, live in Baltimore - within a shuttle-ride of his office, allowing him to avoid driving.
Despite having lived here for 15 years, he is still affected by reverse culture shock.
"In Malawi, we saved all our plastic bags," he says. "You never drove your car unnecessarily. If you could walk, you walked instead."
And he retains his impulse to hoard.
"When I go to the store and I see something I want, I buy a lot," he says, laughing. "I come back and my wife says `Gilbert. We really don't need five of those.' "
david.kohn@baltsun.com
