Medicine at the frontier

If life is a ceaseless river of time, then moments are the droplets making up the rushing stream. Moments are the opportunity we have to be aware of ourselves in the world, to realise that we are indeed alive.

But, most of these momentary opportunities pass us by because we are lost somewhere else in time, lost in the past or the future – anywhere but the here and now. This is why it can feel like life is somehow slipping through our fingers, even though we never mean for this to happen.

Only by grasping the moment we are in when we are in it, can we slow life down enough to really be there and experience it. And when we do, it truly is an incredibly elaborate mosaic.

I am over the halfway mark in my MSF mission. The time has passed both quickly and slowly; sometimes smooth and easy, but just as often it has been a grinding, halting struggle.

I can feel the passing of this time in the length of my hair and beard (I am in quite bad need of a trim) and the growing weariness in my body. I mark it by the daily dwindling of my vital supply of multivitamins. I know it by the comfort I now feel in once unfamiliar surroundings and the ease with which I now interact with those who were once strangers.

Being here has included some truly unconventional moments; and while some have been difficult to bear, I still feel privileged to have been present.

The jumble is hard to unravel sometimes, as it fits no standard pattern. There have been moments of anticipation, like waiting for a desperately sick child to show some sign of recovery; and ones of relief such as the blissful instant when the cool wave of air from the fan first hits my sweaty skin after the power has been out for a while on an impossibly hot day. There have been moments of despair while watching life slip from the eyes of a premature baby whose only mistake was being born in the wrong place at the wrong time. Moments of joy in watching buffalos bathing and children playing dusty, care-free games; and moments of exhaustion and resignation after another long but ultimately unsuccessful patient resuscitation. Even, occasionally, there have been moments of hope that things can and will be better for the people here and that we are a small part of making that happen.

Each of these moments is like a mini-life all of its own – a complete existence encapsulated in time. I believe that bound up somehow in each is the key or answer to life itself. If we can be fully and honestly present in any moment, whether it be superficially “great” or “terrible”, I believe we have the chance to glimpse something of this elusive secret.

It is said that there is no time like the present. I think it is more correct to say that there is no time but the present. So, if we fail to engage these moments in time as they present themselves to us, we are denying ourselves the chance to live.

My time in Pakistan continues to teach me many things. Most of all though, it has reinforced for me that the more time I spend being here, now (i.e. present in the moments of my life) the more alive I am. And only when I am alive like this is the power that I have to effect change (small though it may be) given its opportunity to work.

I am about to go on a much-anticipated leave. I need it body and mind. I am looking forward to moments of relaxation and fun and excitement, moments of escape and rest. My wish for you, whoever and wherever you are, is that you will find a way into the moments of your life, the ones that are there all the time, just waiting for you to enter. Because, they are where the magic happens…

Diarrhoea kills. This tragic fact of present reality is something I first encountered long ago while working in the paediatric emergency ward as a medical student.

Since then I have faced it again and again. It is usually young children who are most affected, and in North West Frontier Province it is no different.

But, no matter how many times I see it, the face of a severely dehydrated child is still shocking – a gaunt, tortured reminder that our world continues to fail some of its most vulnerable citizens.
Perhaps the greatest irony of this tragedy is that the problem persists despite the fact that the solution, the life-saving treatment, is so very simple: rehydration.

We know an impressive amount about diarrhoea and how it kills. We understand the mechanisms through which viruses and bacteria damage the cells lining the intestine causing the rapid loss of vital fluids and electrolytes; we know how and why this drives the body into a dangerous acidotic state and how, despite the body’s best efforts at compensation, this can all too easily push a patient towards hypovolaemic shock (state of shock due to a loss of blood volume because of dehydration, bleeding or vomiting), respiratory exhaustion and death.

But for the majority of sufferers, all this wonderfully advanced knowledge is unnecessary. All that is needed is fluids, fluids and more fluids. Mostly, this fluid can be given orally – no fancy equipment or high tech facilities required – and caregivers and parents can be easily trained to do this in the home at the first sign of trouble with a high degree of success.

The fact that children continue to die throughout the developing world from this so easily treatable disease points to just how much work still needs to be done to meet the healthcare needs of the global population.

The problems include contaminated water supplies, absent sanitation systems, limited access to healthcare and education and the compounding problems of inadequate housing and malnutrition. They are some of the factors which continue to culminate in another sunken-eyed face – a face in which it is possible to literally watch life slip away. And unlike the treatment for diarrhoea, these problems leading to the disease are far from simple.

Many MSF projects world-wide deal with aspects of this ongoing challenge: whether it be task-specific cholera treatment centres (CTCs), maintaining safe water and sanitation in camps for displaced populations or establishing hygiene education programs in the forgotten corners of failed states.

In NWFP we maintain our CTC here in Dargai in a constant state of readiness and while, thankfully, we have yet to deal with a full-scale cholera epidemic during my work so far, we see cases of diarrhoea with severe dehydration (from cholera and other causes) on an almost daily basis.

I think it is a testament to the quality of our work here and the commitment of our staff that we have lost very few of these patients, but I still find myself looking down into the face of imminent death far too often.

I would love to live in a world where no child would die like this. But since this is unlikely, at least for the foreseeable future, I will have to be satisfied to work with an organization that is facing this challenge head -on and I have to hope that, with time and effort, we will get there.

The recommended formula for making Oral Rehydration Solution to treat diarrhoea at home is as follows: to one (1) litre of clean, safe water, add eight (8) level teaspoons of sugar and a half (1/2) level teaspoon of salt. Mix and give regularly by mouth to those with ongoing diarrhoea. Teach this to everyone you know. It saves lives.