Desi Talk – that’s all you need to know 4 VIEWPOINT August 5, 2022 Ignoring Afghan Women And Girls Is To Do The Taliban’s Work For Them I n Afghanistan, women now talk about their futures in the past tense. I was on a Zoom call recently with two young university graduates in Kabul, when I asked them about their plans. “I hoped to go . . .,” they answered. “I planned to do . . .” But they won’t. They can’t. They have been judged and the verdict rendered: They are female, and for that, from the Taliban, there can be no mercy. It’s been 11 months since the fall of Kabul, and the vanishing of women is nearly complete. The men who rule my country wield their control with a casual cruelty that can be breathtaking. Just this month, the Taliban told female employees of Afghanistan’s finance ministry - well- educated, well-qualified women barred from their workplace for these past 11 months - to send in male relatives to do their jobs because the ministry’s workload was becoming quite heavy. Vanished. Just like the freedom to work in your chosen profession. The freedom to travel without a chaperone. The freedom to decide what you will wear in public. The freedom to go to school beyond sixth grade. None of that will be necessary, the Taliban says. Not for Afghan women. The blue burqa awaits you. At puberty, your education ends, your autonomy ends. Your future is a memory you never had a chance to make. Eleven months is all it took. The great vanishing of Afghan women is happening again before the eyes of the world, just the way it did in the 1990s when I was a child growing up under the Taliban’s first regime - a girl with no choice but to attend secret schools, walking frightened through Kabul’s streets among the blue shrouds of invisible women. I am a woman now, in exile abroad, and I haven’t forgotten what those days felt like - just like I haven’t forgotten what I saw in the years after the Taliban’s retreat in 2001. I haven’t forgotten the Afghan women who returned home, those educated exiles who had studied overseas and came back to take jobs in our public and private sec- tors and showed all of us that our futures were exactly that - our futures. Ours to shape. In August, you’ll be seeing Afghanistan in the headlines again. It will be a year since the Taliban’s return and the U.S.-led evacuation of Kabul, an evacuation my students and I were part of. You’ll hear the stories of refugees scattered around the world, and of the immigration purgatory so many find themselves in, waiting for the chance to build new lives. These refugees must have access to quality education - women and girls in particular. My school and I are committed to the effort, and the international com- munity must make investment in these women and girls an aid priority, especially in those who will not soon leave the tran- sit camps in which they live. Many girls in these camps have not had schooling of any kind for a year or even longer. To ignore these girls is to do the Taliban’s job for them. The men who rule my nation fear what an educated girl can become and what an educated woman can create. I say, let them fear us. They remember who led the way in reviving Afghanistan after the demise of their first regime. By investing in the education of Afghan refugees, we work to make that past prologue. We are the women of Af- ghanistan. And our futures are ours. Shabana Basij- Rasikh, a Wash- ington Post Global Opinions contribut- ing columnist, is co-founder and president of the School of Leader- ship, Afghanistan. -Special To TheWashington Post By Shabana Basij-Rasikh Racial Bias Is Built Into The Design Of Pulse Oximeters O ne of the most indispensable devices of the coronavirus pandemic is the pulse oximeter, which clips onto a person’s finger, shines out a light and reports back a blood oxygen percentage. Patients use pulse oximeters at home to moni- tor their conditions, while hospitals use them to identify and prioritize the sickest covid patients. More generally, blood oxygen is known as the fifth vital sign, alongside body temperature, heart rate, breathing rate and blood pressure. Pulse oximeters, however, don’t work as well in people with darker skin. There’s a risk of “occult hypoxemia,” where the device says that oxygen levels are fine but patients’ actual saturations are dangerously low. Recent medical studies have quantified this bias and the con- sequences of overestimated oxygen levels. For example, Hispanic and Black patients with the coronavirus were about a fourth less likely to be recognized as eligible for treatment. Obtaining an accurate oxygen reading can literally be a matter of life or death. Despite the recent surge of attention to this issue, ra- cial bias in pulse oximeters is nothing new; in fact, it was embedded into the very development of this technology. A closer look at the history of oximeters reveals how plac- ing a premium on market expediency over equity allows bias to leach into medicine. The first oximeters were developed for military, not medical, use. DuringWorldWar II, fighter pilots were blacking out at high altitudes, so American and German scientists developed oximeters for their respective air forces. These early devices clipped onto pilots’ ears and alerted them when they needed supplemental oxygen. Hewlett-Packard (HP) went on to develop the ear oximeter for health care in the 1960s and ‘70s, with a remarkably liberal, transparent focus on equity. In the October 1976 issue of their journal, for instance, HP ac- knowledged how oxygen readings were affected by “skin and blood pigments, and the surface characteristics of the skin,” before describing how they designed their own device so that oxygen readings were accurate, irrespective of skin color. HP’s device was also tested on 248 Black pa- tients and could be personally calibrated with a patient’s blood. Yale professor of medicine Meir Kryger - who tested some of the earliest models of the HP oximeter as a pulmonology fellow at the University of Colorado - said that the company “actually took the business about pig- ments seriously at a time when nobody was.” But HP’s oximeter was huge and cumbersome to use, not to mention expensive. It cost $13,000 in 1970. The device was thus relegated to a select few research laboratories and understood to be clinically impractical. HP ultimately discontinued its ear oximeter and stopped manufacturing medical devices altogether. In 1974, however, two Japanese companies took the next leap in oximetry when Nihon Kohden and Minolta independently invented devices that measured oxygen levels via the throbbing of a patient’s arteries. The first “pulse” oximeters had arrived, with both companies filing for patents within a month of each other. Although electrical engineer Takuo Aoyagi won this patent race for Nihon Kohden, the company didn’t pur- sue the device because it was just a side project for them. “Aoyagi made a prototype,” Katsuyuki Miyasaka - an anesthesiologist at St. Luke’s International University and a close colleague of Aoyagi’s - explained in an interview, “but there wasn’t much interest in developing it further.” Minolta kept going and, in 1977, released the OXIMET- Met-1471, probably the first fingertip oximeter ever developed. With fiber-optic cables sending light to and from the clip, the device was technologically advanced but, like HP’s, not clinically practical. It was extremely sensitive to motion, too heavy to be used on patients and often overestimated oxygen levels in very sick patients, although it was fairly accurate otherwise. The device was not tested on any people of color because, in a country as ethnically homogenous as Japan, “skin color may not be a problem,” Miyasaka said. After being frustrated with a lack of success at home (only 200 devices were ever sold), Minolta tried to market their pulse oximeter in the United States, distributing the device for various American hospitals to evaluate. William New, a former HP electrical engineer and anes- thesiologist at Stanford University, soon learned about the Minolta device and saw its shortcomings, but also its great potential. New and two other colleagues founded the company Nellcor and, in 1981, released their own pulse oximeter: the N-100. The device was designed to be clinically prac- tical. With LED lighting and a flexible paper-like sensor, Nellcor’s oximeter was disposable and largely unaffected by motion. One of the device’s most popular features was how its tone changed based on a patient’s oxygen satura- tion, enabling easier recognition of low oxygen levels. Nellcor’s timing was extremely fortuitous. LEDs were becoming increasingly available in the early 1980s, just as a series of malpractice lawsuits were brought against anesthesiologists who were eyeballing oxygen levels during surgery. As Nihon Kohden’s CEO recently wrote, Nellcor “caught the wave of technological innovation and market changes at this time.” The N-100 dominated the market, “selling like hot cakes,” according to Miyasa- ka. In fact, one Canadian anesthesiologist described how “Nellcor” and “pulse oximeter” became synonymous. But Nellcor’s device was not an equitable one. The company was so focused on developing an easy-to-use, clinically practical pulse oximeter that it neglected the racial bias built into their devices. In 1987, Kryger com- pared the N-100 to HP’s oximeter and found that Nellcor’s device was not as accurate or responsive as HP’s. Racial bias, of course, isn’t unique to Nellcor: Most pulse oximeters have been calibrated in light-skinned individuals alone. And it’s not enough to say that the medical community didn’t know any better: they’ve long understood how yellow skin color from jaundice, blue from sepsis and naturally non-White skin color could lead to “the skin pigmentation effect,” Miyasaka said, “but they thought that, statistically or practically, you can neglect it.” The supposed innocuousness of biased design continues to justify its existence. HP’s device in the early 1970s was the exception that proves the rule. Although their oximeter was clunky and clinically impractical, it was a paragon for inclusiv- ity because HP engineers made eliminating bias a priority. Racial bias in pulse oximeters, or in any medical device, is never inevi- table. Equity requires intention- ality. Simar Bajaj studies the history of science at Harvard University and is a research fellow in cardiothoracic surgery at Stanford University School of Medicine. He has previously written for The New England Journal of Medi- cine, The Lancet and Nature Medicine. -Special To TheWashington Post By Simar Bajaj TheWashington Post TheWashington Post A fingertip pulse oximeter used for measuring oxygen saturation level on blood and also heart rate. Photo:REUTERS