FORWARD OPERATING BASE KALA GUSH, Afghanistan - A calm breeze carries the smoke from the Americans' cigars into the craggy mountains of their enemies, just as it does every night at the place known as the end of the earth.

Hosting the smoke session for the troops is the medical staff of this remote base in the eastern Afghan province of Nuristan. Dr. Douglas Gugger of Philadelphia - senior medical officer, unlikely Navy man, new father of two - leans back in his red-and-blue camping chair. He smiles.

Talk turns, once again, to the aid station's new mascot, a two-inch-long gnarly creature called a camel spider, now residing in an empty biohazard syringe container. It is, as Gugger says, "freakin' awesome."

Just then . . . BOOM!

The Taliban is trying to ruin cigar night.

A radio crackles with numbers and acronyms. "We just took a rocket," someone says. The sirens, seconds later, and the loudspeaker pronouncement, "This is not a drill," confirm the hit somewhere on the outskirts of the base.

Like leaves blowing in the wind, the troops disappear to their huts, grab body armor, and rush to battle positions at the base perimeter. The crunching of stones under scrambling boots fills the quiet before the fight.

Gugger drops his lit cigar on the ground, runs into his hut, and puts on the body armor he never thought he would need. Then he returns, picks up the stogie, and puts it back in his mouth.

His right-hand man, Kyle Burditt, a physician's assistant and Navy hospital corpsman from South Carolina with far more battlefield experience, joins him.

Cigar night is back on.

Leaning on the sandbagged wall of the bunker outside the aid station, the two friends watch artillery guys a few yards away tear into the surrounding hills with retaliatory blasts of flame. In the distance, from a nearby village, the faint sounds of the Islamic call to prayer welcome the night.

The men, both known as "Doc," wait for injuries or an order to stand down, whichever comes first. They smoke. They throw rocks at nothing.

Gugger's cell phone vibrates in his pocket. It's 7:35 p.m.; 11:05 a.m. in Philadelphia.

"It's my wife," he says, staring into the phone.

Back home, Amy Gugger, 33, is juggling the couple's two new babies: Abraham, 10 months old and adopted from Ethiopia in December while Gugger was at training; and Micah, born while Gugger was home on a two-week leave the month before, a surprise gift after the couple tried to become pregnant for three years.

"Is everything OK?" the new stressed-out mother asks, wondering why her husband is late making his nightly phone call.

He speaks to her inside the aid station, and minutes later he's back outside.

"I lied," he says, heavily.

The cigar has turned to ash. When the order comes to stand down, Gugger heads into his hut, one night closer to going home, one step closer to being a true father to his children.

Can this work?

Gugger isn't telling Amy about this attack, or the dozen attacks that the base - the last American presence in Nuristan - has so far faced. He isn't talking about how he's dealt with fear and frustration by healing Afghan children. He isn't saying much of anything about his strange life here.

The Navy lieutenant is part of a joint U.S. force called a Provincial Reconstruction Team (PRT), with members from the Navy, Air Force, Army and federal government. Their mission is to rebuild a province in one of the poorest, most battle-scarred nations on earth in order to win Afghan hearts and minds before the Taliban (and al-Qaeda) reach them first. This kind of work is supposed to win the war.

But to succeed, the Nuristan PRT must try to build police stations, wells, and roads - while giving a crash course on things like project bidding and legal contracts to mostly illiterate tribesmen unexposed to centralized government. The 100 PRT members, culled from military posts throughout the world, must empower the local provincial government that will lead once the United States withdraws. Trouble is, the Americans aren't speaking with the governor of the province - he's widely considered corrupt.

"Nothing in my last 20 years in the Navy taught me anything about this," says the Nuristan PRT's commanding officer, Navy Cmdr. Raymond J. Benedict, a Toms River kid who has spent most of his working life on amphibious vehicles.

If Benedict and his team have even a little success, then maybe the United States can succeed in all of Afghanistan. But if not - if giving billions of dollars to a country and rooting out the worst of its society doesn't stop its people from hating America - then what will?

This question looms as the longest war in American history enters its 10th year.

Tens of thousands of troops have arrived, along with a new commander, Gen. David H. Petraeus, perhaps the most compelling military leader since Gen. Douglas MacArthur. Petraeus wrote the Army's Counterinsurgency Field Manual and then employed its strategy in Iraq in 2007.

But Afghanistan presents a different challenge. American popular support for the conflict is dropping like a 500-pound bomb. Large swaths of the country that were once relatively safe, like Nuristan, the most linguistically and ethnically diverse province in the country, are now hotbeds of insurgency. And the Afghan government, which the United States is supposed to be working with, is broken and despised.

The clock is ticking. Benedict, Gugger, and the other PRT airmen, soldiers, and sailors have nine months in country to figure it all out. Petraeus, and the United States, might not have much longer than that.

An exceptional journey

A lean 6-foot-1, with dark hair and classic good looks, Gugger, 33, is the guy you want doing this Herculean job. The eldest of a dentist's three sons, he played lacrosse at La Salle College High School, the Catholic prep school just north of Philadelphia, before graduating in 1999 from Boston University with a communications degree. Gugger moved to the beach in Southern California with some friends - living briefly with Rob "Mac" McElhenney of It's Always Sunny in Philadelphia. Gugger's hair was long, he worked as a steak-house busboy, and he got an Aztec tribal tattoo. He tried a job at an advertising agency.

When he came back East, he went to medical school at Temple University, where a classmate told him Uncle Sam would pay his way if he enlisted. Gugger talked with Amy Ford, then his fiancée, about the opportunity to start life without medical-school debt while serving his country at the same time.

"We made the decision together," she says now.

Gugger's father and brothers weren't in the military; he didn't dream of fighting for his country. He didn't even shoot a gun until he enlisted (and even then, he barely passed his marksmanship tests). He never anticipated finding himself, a Navy sailor with an M.D., in the middle of a ground war. "I imagined him on an aircraft carrier in the Gulf somewhere," says his mother, Anne Marie.

Gugger enlisted, began training as a doctor at military facilities, and simultaneously pursued two of the most respected professions in modern American society. Meanwhile, he and Amy, a hospital marketing director, began building their family, deciding to adopt after years of trying on their own. Amy kept a blog, "Our African Love Story," to document an experience that would be far more difficult than she could ever have imagined.

October 2008. Amy writes, presciently: "We will have many more hurdles to overcome on this exceptional journey."

June 2009. Amy is ecstatic that after Gugger graduates from Navy flight surgery school in Pensacola, Fla., he will be stationed in Willow Grove, near both of their families. The only problem is the "hideous" mustache he wore at graduation. "Awful, trust me."

August 2009. In a shocker, Gugger must deploy to Afghanistan by early 2010. He will not go with Amy to pick up their new baby from Ethiopia, and he will miss their first year together. "We don't know today how we will make it through. . . . We have struggled for the past three years to become parents; now we must fight again through the end of 2010 until Doug comes home. . . . I am tremendously proud yet overwhelmingly horrified."

Sept. 3, 2009. The Guggers get their first picture of Abraham Getamesay Gugger, their new son, from the adoption agency. And - on the same day - Amy finds out she's pregnant. "Today was the day our family was formed."

Gugger ships to Indiana for training; Amy's father accompanies her to Ethiopia to pick up Abraham. By December, Gugger, home from training, meets Abraham for the first time before leaving for Afghanistan. Dressed in camouflage, eyes closed, he enfolds his new son and kisses his soft curls.

Together, Amy and Doug struggled to bear a child, and ended up with two. Together, they'll deal with this "exceptional journey." Amy writes of her husband:

"He is living every day, not for himself but for a cause. His existence and his work is more meaningful than ever before. As sad as I am and as sad as I know he is to be gone for so long, he has a calling, a purpose and a mission to serve.

"The road right now is winding and dark, but our spirits shine brighter than ever before . . . because we know we are serving His purpose. The power of faith will light the way."

A means of survival

One of the counterinsurgency's edicts: "Embrace the people." Every morning, that's what happens at Gugger's battalion aid station at Kala Gush.

Above the TV in the rectangular medical hut hangs a picture of an Afghan boy who was riding a bicycle without a seat when he was impaled in his groin. In the photo, the boy, with olive-shape eyes and crisp-cut hair, smiles wide as he's hugged by the American medical staffers who saved him.

"That kid up there, he's going to love Americans for the rest of his life," Burditt, the physician's assistant, says. "Everyone we help and don't make a Taliban is a good thing."

Despite the regular attacks on the base, few Americans are injured beyond the occasional shrapnel wound. Most of those treated are Afghans - police officers, soldiers, contractors, and, increasingly, local women and children. Healing one child, Burditt says, can be more important than a U.S.-funded project, "because a kid doesn't give a crap if you build a road."

The 12-year-old boy, Zahir Achmad, had first gone to a local clinic, but doctors there botched the stitches, causing an infection. Then Zahir's father, Jalil, a local police colonel, took him as a last resort to the U.S. base, where corpsmen and medics used a shipment of drainage devices they'd been sent by mistake to withdraw excess fluid and, very likely, save the boy's life. "That's my pride and joy for this deployment so far," says Burditt, who has two sons of his own.

But on the Achmads' way home that day, the base was rocketed. The medical staff worried that Taliban lurking in the area had killed the father and son.

So when they arrive for a follow-up visit one morning, Gugger immediately gives Zahir a high-five and furnishes him with a strawberry milk carton and Tastykake Peanut Butter Kandy Kakes - from Philadelphia, of course.

In his Pashto language, Zahir asks where Erika is. Air Force Staff Sgt. Erika Villiard is a karate black belt not afraid to speak her mind, ever, and easily able to keep up - even dominate - in a mostly male military environment.

But she hides a softness. Before her deployment, Villiard worked as a labor-and-delivery nurse at a military base in Germany, a job she adored, and she has a natural way with children, from newborns to, well, 12-year-old boys with a crush. She shows up at the aid station, cooing: "Oh, my sweet baby boy, I missed you so much!" The bear hug she gives Zahir is all he needs to know about what those English words mean.

Villiard weighs Zahir - 661/2 pounds. "You're a little chunky butt, aren't ya?" she teases. He's checked for cavities - he has one. Here's some toothpaste, better go see a dentist.

Someone digs into the pile in the corner of the aid station, where body armor, machine guns, and children's toys share space. Soon Gugger and Zahir are having a catch, clear across the room.

The boy makes his way to one of the gurneys. Gugger and Burditt snap on black plastic gloves, pull the curtain and examine his wound. Lying on his belly, Zahir winces.

Gugger and Burditt glance at each other, coming to a nonverbal agreement on the diagnosis. Gugger gives Zahir a thumbs-up and declares: "You're good!"

"They work so, so hard with my son - not just my son, but all the Afghan soldiers, all the Afghan police, all the Afghan people," Jalil Achmad says through an interpreter. "When I bring my son in here, everybody was so friendly, so nice. I just feel like this is my home."

That's high praise. Nuristan is an isolated, sparsely populated, and predominantly illiterate province on the Pakistan border, with 18 ethnic groups and few roads or radios. Nuristanis, the last Afghans to convert to Islam, in the late 1800s, say they have been ignored or discriminated against by leaders in Kabul ever since. They speak languages heard only in their valleys, and are unusual for their blue eyes and red hair. Mostly farmers, they celebrate their mujahideen warrior roots and claim credit for driving Russia out of Afghanistan in the 1980s. Nuristanis are not natural allies of the Taliban, but the longer the Americans have stayed, the stronger the Taliban and related insurgent groups appear to have grown.

Zahir settles into a large office chair, spinning around and around. He stops to stare in wonderment at the still-unnamed camel spider in its makeshift insectarium. And he hangs out just long enough for the mail bird - the postal helicopter - to arrive with packages from family in the United States.

Villiard scores Twinkies.

"Give him a Twinkie!" Burditt calls out, feigning horror at Gugger and Jalil's sharing a Tastykake.

Each child who comes into the medical hut gets gifts - lollipops, bouncy balls, and Tastykakes. And each time, Burditt seizes the opportunity: "Oh no! Don't give them Nasty Cakes!"

"Every Tastykake you give out, you're making another Taliban," he says, digging in.

Villiard loves this game, eager to use her Southern cred (she's from North Florida) to ally with South Carolina's Burditt. She gives Zahir a handful of Twinkies, calling them "real American food."

Zahir adds the Twinkies to his other take-home goodies: two plastic balls, four pairs of shoes, and school supplies.

"Seeing military people all day, every day, and then seeing kids is a breath of fresh air," Gugger says.

But it's more than that. As a new father missing his own children's lives, as a new doctor who aches when his patients do, Gugger has found an outlet, and a means of survival, in helping Afghan children.

And knowing he's making some progress toward his nation's success - that with each wound healed he's making Americans safer - sustains him. Little does he know that military commanders in Kabul take an entirely different view.

A priority target

The PRT has a few missions each week, but for the most part troops are tethered to the dull monotony that is life at Forward Operating Base Kala Gush. In all directions, sun-splashed brush and boulders dot the surrounding Hindu Kush mountains. As the sun moves through the huge sky, it changes the color of the mountains, from greenish-brown to light tan.

The base's hue blends with the natural environment - tin-roofed wooden huts, pebble pathways, concrete blast walls under sandbags and huge earthen barriers. But the unnatural creation is built to be temporary; a pop-up city with 24-hour electricity, high-speed Internet, hot showers, and enough cafeteria food to provide 300 troops and contractors four meals a day.

By 8 p.m., the base is pitch-black. Troops get around with color-filtered lights - far less powerful than flashlights but undetectable to the Taliban's preying eyes. The darkness magnifies the attack on the other senses: grinding sand in the teeth from overnight wind storms; humming from fighting vehicles and generators; wafts of sour smells from burning trash; barking from a stray, unseen dog; buzz, buzz, buzz from the ubiquitous flies.

And then, boom. Whish, BOOM. BOOM. BOOM . . . whish . . . BOOM.

Eyes open. Radios come to life. Is that incoming fire? Or just outgoing? If it is outgoing, are they shooting at something that is also shooting at us?

Gunfire is louder going out than coming in - massive booms that sound like large concrete blocks dropping in an apartment upstairs. For some civilians, like linguists and the occasional journalist, distinguishing the 155 mm rounds of an American Howitzer from incoming mortar shells on a Taliban cell-phone timer is difficult and terrifying.

But most troops seem merely inconvenienced, and many sleep through much of the outgoing fire. Having seen action in Iraq and Afghanistan, they can handle danger. Most attacks on the base overshoot or undershoot the property by a few meters; in the PRT's first few months here, only one hit a building.

There's no question that the Kala Gush base is a priority target. "The Taliban opened this fighting season to push coalition forces out of Nuristan," says Navy Cmdr. Joseph Carnell, the PRT's second in command and a Cherry Hill East graduate.

This is America's last stand in a province that sits on the porous, American-hating border with Pakistan. The Taliban killed nine Americans on a base in Wanat, Nuristan, in 2008 - apparent retaliation for the deaths of 17 Afghan doctors and medical staff in a mistaken Army helicopter attack on a health clinic a few days earlier, on July 4. The next year, in what is known as the Battle of Kamdesh, 300 Taliban fighters killed eight Americans. The bases in Kamdesh and Wanat were abandoned days later.

And this summer, the Taliban killed 10 people working with a Christian aid group, including six Americans. They had been providing medical care in Nuristan.

Benedict says Forward Operating Base Kala Gush has good defenses, protected by a long open stretch between the base and the mountains. Mortar shells and rockets can reach the base, but they are crude and not aimed.

The American fire, though, is not always directed at insurgents. Asked what he is shooting at one night at 1 a.m., an artilleryman says he is firing "for deterrence, just to let people know that we're here."

In Kala Gush's optimistically named "Morale, Welfare and Recreation" building, or MWR - where PRT troops, contractors, and two National Guard units pack together to use the phone and Internet - the stress is raw. And the "morale" part can be elusive.

One man pleads with his girlfriend on Skype after she dumps him: "Is there another guy? Is it just the fact that I'm gone and cannot be with you every day? Because I wan to have a life with you. . . . Is the sex bad? . . . I'm trying to offer you a better life. I'm trying to offer you a house. Damn, baby, I'm trying to take care of you."

He's back on Skype later, complaining to his buddy back home: "I'm out here getting shot up, getting blowed up and s-, she's out there . . . ."

Because someone's always using the computer in the 24-7 MWR, when an attack occurs, face-to-face conversations with life back home are suddenly interrupted. With hurried excuses, soldiers, sailors, and airmen run to the base perimeter, looking for Taliban. They carry anger over a coldhearted ex, or a pang for the adorable daughter dancing for Daddy on the computer screen. The soldier's lot has always been separation from loved ones, but in no other war has technology made that distance so palpable.

Tears, then a smile

Never had a bath. Never visited a doctor. Never tasted the sweet relief of cherry-flavored Chapstick on dry, dusty lips.

Sewella is about 7, although she doesn't know for sure, with dirty blond hair, hazel eyes, and a two-piece orange robelike outfit dotted with purple flowers. She comes into the aid station wide-eyed, her two fingers mangled by a boulder, and seems shocked by the number of foreigners all interested in making her feel better.

Sewella is immensely popular among the Americans, not only out of sympathy - the Taliban shot her father dead - but because of her obvious toughness. It took her 21/2 hours to get here with her uncle, a boy himself, and she doesn't cry as her finger is treated and soaked in water that quickly turns red.

But when she sees the needle, tears flow and she buries her face in her head scarf. Thunder roars outside as the American translator, spreading Chapstick on her lips to distract her, tries to convince her that the needle will fight the infection now spreading through her body. If untreated, she will lose her finger and could die. She's already running a fever.

"You'll be OK," Gugger says, looking her in the eyes. "Shhhhh."

Gugger grinds his teeth as he sticks the needle in her arm. He hates to cause pain.

Her finger wrapped, she's given a Hannah Montana raincoat, shoes, jeans, underwear, lotion, and shampoo. A linguist presents a new bracelet and headband.

Gugger tells her: "You're the strongest girl in all of Nuristan."

She pulls the veil from her face, revealing drying eyes and a growing smile.

Handshakes and Tastykakes

It's a call he gets every few weeks from the soldiers at the base front gate: "Doc, there's a really, really old man here. And it looks like he's dying."

Gugger rushes over, and there he is - barely 5 feet tall, with a thick white beard and square-framed glasses held on his head by his tribal cap. Gugger and the old man exchange handshakes and walk back to the rectangular hut of the aid station, with its small medical cross on the front door.

Gugger wraps his arm around the old man's shoulders. They're both beaming. "I'm not sick," he reveals. "I just came to see you guys."

The old man has one name, Sharmalik, and he lives several hours away, about 10 miles. He has come by foot, just to say thanks.

"The people in the village talk about Americans, but I say, 'Don't talk about Americans! They give us medicine, they give us roads!' I say, 'Don't talk about Americans!' "

And if someone does express anger toward the United States, or sympathy with the Taliban, the old man has a solution: "I beat them with a stone!"

The Russians, who fought the Nuristanis in the late 1970s and '80s, were "really bad," while the Americans are "really good."

Watching Sharmalik drink a small carton of milk through a straw is endearing. Navy Petty Officer Third Class Dominique Rodriguez gives him two plums; he kisses her hands. "I was very nice-looking when I was young," he tells her, through a linguist's laughing translation.

This is all the thanks the medics and corpsmen need. Most of the time, it feels as though the people they're trying to help are trying to kill them.

"You remind me of my grandfather," Gugger tells Sharmalik.

The old man listens for the translation, and responds, emphatically: "You are my brother, you are my son, you are my everything!"

Just then, Sewella, the girl with the injured fingers, arrives for a follow-up visit. This time she's accompanied by her grandfather, Golamerza Malik. The Taliban recently killed his son, 25, for giving information to the Americans.

The new visitors cause a great deal of excitement. Sewella's hair is greasy today - she used the shampoo they gave her last time but didn't know she was supposed to rinse it out. While she's attended to, Sharmalik happily sits on a gurney, licking a pink Dum Dum lollipop before putting it in his pocket, unwrapped, for later.

Gugger is beside himself with happiness. With two babas - or grandfathers - in the aid station, he knows just what to offer. "I'm winning over hearts and minds with Tastykakes!" he says. He photographs everyone, and then has the two old men, who have never met, pose together for a picture.

Sewella is going to need surgery, something that cannot be done on base. The medical staff collects $100 among themselves to pay for the taxi to the children's hospital in Kabul. Sewella, oblivious, watches Family Guy on the aid station's little TV, mouth agape.

"That was awesome," Gugger says after everyone leaves, to no one in particular.

Contact staff writer Matt Katz at 856-779-3919 or


In a crucial diplomatic moment, the Americans meet tribal elders.