Medicine at the frontier

When I signed up to work with MSF I wasn’t naïve enough to expect an easy ride or a soft experience. This organisation, by very specific intention, works in some of the most challenging contexts on earth: war zones, natural disasters and other humanitarian crises of all kinds. Despite the very real feeling of reward I get from doing this, I knew it was going to be a difficult job, a frustrating job, a demanding job and that at times I would be disheartened. I was right, for it has been all these things and more over the past few months. What I was not prepared for, and what has been hard to accept, is not being able to do my work at all.

As you may well know from following the news, there has been a dramatic rise recently in the number of violent attacks in Pakistan. Markets, police stations, army barracks, and even schools have been targeted and many have been killed and injured. This is devastating not just for all the victims and their families but for the country as a whole and, potentially, for the world at large. The ever-rising tensions here have implications far beyond the borders of this damaged land. North West Frontier Province (NWFP) where we work is one of the frontlines in the global war against terror and the events of recent weeks only add fuel to a fire of reciprocity that is already raging out of control.

Foreigners and NGO can also be direct or indirect victims of the ongoing conflict. MSF takes the safety and security of staff very seriously so as to limit as far as possible the likelihood of our personnel and medical activities being affected by violence. If an attack did directly involve MSF personnel or structures however, aspects of our work here would undoubtedly be suspended or drastically reduced. So, while we are here, at least in part, to help to alleviate some of the fallout from the ongoing violence, it is entirely possible that the violence itself could be precisely the reason we are unable to achieve this goal.

At this stage, we have not been directly affected by the current wave of incidents but, for the sake of caution, the movements and visibility of the staff on my project have been dramatically reduced and the expatriates had to go back to Islamabad for a few days – and so we come to the reason for my interrupted (and frustrated!) status…

Of course, I understand the rationale behind the restrictions and I am grateful to be working for an organisation that cares enough to impose them but, to be here in the midst of all this need and not be able to help directly (even if it is only for a couple of days) is hard to accept.

We will hopefully be back to normal medical activities soon. In the meantime, though, I find myself reflecting on the fragility of our efforts here. As long as this seemingly intractable conflict continues, there will almost certainly be a need for our presence in NWFP. Sadly though, precisely because of this same conflict, our position and contribution could all too easily be ripped away – both as individuals and as an organisation – by a bullet or bomb. A tragic irony indeed…

I am left to hope that, somehow, real and lasting change can come to this situation. And, considering the systems, ideas and people which are involved in what is an incredibly complex set of problems that exemplify much that is wrong with our world, I don’t think it is unreasonable to say that this is a challenge within which we all have a role. If hope is all we can justify at this stage, then as long as it is hope backed up by determined action, I think there is a chance. What do you think?

Though it is without question a fascinating and vitally important branch of medicine, cardiology has never been my strong suit. It requires a patience that I lack but which is essential to delve successfully into the stories behind the myriad factors and events which have usually conspired to produce a heart problem in any particular person. This is particularly true for the patients I am seeing here in NWFP, where access to quality health assessment, a reliable supply of medicines and adequate follow-up are far from guaranteed. As a result, the cardiology patients I see here on a daily basis are often in a very serious condition with complex and advanced problems that have been mismanaged or neglected entirely – I have really had to hit the books to keep up!

Tariq

It was a problem of the heart that brought a young man called Tariq into the resus room of the MSF ER the other day. Well, he actually came in because he felt very short of breath which would suggest a lung problem but this had in turn been caused by a kidney malfunction…and all of it related back to a throat infection he had caught several weeks earlier. See what I mean about the complexities of cardiology!

When I first saw Tariq he was breathing at over 60 breaths per minute. I challenge you to pause for a moment and try and do this consciously for a while. Exhausting isn’t it? Breathing at this rate for several hours had made him so tired he could barely sit upright or keep his eyes open – he was deteriorating fast and we needed act. The MSF team had already started oxygen and detected that he had a lot of fluid built up in his lungs which was causing the shortness of breath. Sorting this out was our first priority. Using a combination of intravenous and oral medications and a lot of encouragement we managed to stabilise our young patient and could then go about the task of figuring out exactly what had happened.

Sometime later, after a lot of patience and some detailed questioning, the story started to unfold: several weeks earlier Tariq had had a sore throat.

Though he managed to see a medical practitioner relatively quickly, the treatment he received was inappropriate. The infection resolved several days later of its own accord and he thought nothing further of it. Then, about a week before he presented in such a serious condition to the ER, he noticed that his feet and face were starting to swell up. A few days later he began to get more and more short of breath, and finally the problem was so severe that he was rushed to the hospital. What had caused this unfortunate chain of events? Well: in response to the untreated throat infection, Tariq’s immune system (as it was designed to do) produced antibodies to attack and kill the invading organisms – so far so good – but then something went wrong. The antibodies circulating in his blood got “confused” and started to identify his own cells as invaders, and began attacking them in the membranes of his kidneys – the body, what a mysterious beast! During our assessment, we had already picked up that there was blood and protein in Tariq’s urine which was the evidence of the kidney damage and because his kidneys were no longer able to excrete fluid as normal, it began to build up in his body (hence the swelling) and eventually built up to such an extent that his heart could no longer cope with the load. And so we come to the problem of his heart: drowning in fluid it had begun to fail, fluid was forced into his lungs and very shortly thereafter he was fighting for his life.

Tariq

Things could have been very different for Tariq. Had his throat infection been diagnosed and treated properly, that would have been the end of it. Even if he had developed this rare complication but had been able to easily and rapidly access quality healthcare, the problem could have been managed very simply when it was far less severe. But, Tariq is very poor and he lives in a part of the world with a very poorly developed healthcare system. Luckily he managed to get to our ER and as a result, his heart will be beating for many years to come, but this story could easily have been the end of him.

A close friend of mine died tragically in recent days. While he didn’t have a problem of the heart, his death has caused me to reflect once more on the fact that none of use knows how many heartbeats we have left. Don’t waste yours for each one is precious.