On the way to and from work, I have my eyes closed half the time (no, I don’t drive myself) and find that I catch my breath at regular intervals as a result of the various manifestations of traffic chaos that are happening all around me.

The vehicles here are a kaleidoscope: from lumbering, elaborately decorated trucks to battered donkey carts; minivans and rickshaws; huge tractors with trailers in tow and, of course, there are motorbikes everywhere (though helmets are vanishingly rare). And all of them are heavily loaded (with people – inside and out – livestock, and every type of merchandise, material and equipment) to the point that I marvel they are able to move at all. Every junction point, street market and crossing is a seething mass of impatience – everybody wants to be first, in front, going faster and will do everything they can to make sure this is so. Add pedestrians to this mix, all with a bundle, bag or tiny child (!) to slow them down or obscure their view, all trying to squeeze through the smallest of rapidly closing gaps between the vehicles, and you can begin to understand why this is a catastrophe waiting to happen. It doesn’t have to wait long.

Everyday they come to the ER: broken arms and legs, lacerations and bruises – and those are the minor cases. Then there are those with head trauma, the crushed chests and abdomens, the terminally mangled bodies….But, this is why I am here and the other day this is how I met two 20 year old lads. If only we had met under different circumstances.

They had been on a motorbike together, riding, carefree but too fast. In the crash they both sustained multiple injuries: each had broken a leg, fractured several ribs and both were unconscious.

I was not in the resus room when they first arrived and by the time I got there the MSF nurses on shift had already done a lot to stabilise them. I am lucky to work with an excellent team but we were all pushed to the limit that day. The demands of an emergency like this are hard to relate. Both patients needed my immediate and undivided attention but this was obviously impossible. And in those first few moments I want to shake them, to shout “WHY WEREN’T YOU WEARING HELMETS? WHY WERE YOU DRIVING SO FAST?!?” but what use would that be…

All that is left is to slip into the familiar routine: Airway, Breathing, Circulation, are the cannulas in, lets speed up that IV fluid and keep ventilating, have we checked the back, please get a chest drain kit open for number 2…ok (breathe…), what’s the blood pressure now, let’s review what we’ve done so far. My well-trained team are slick and practiced in their movements and over the next hour and half we do what we can to stabilise our patients. One is beginning to wake up – a good sign – but he is far from out of danger. As for the other, I am concerned that he may already be too far-gone. We manage to get a unit of emergency blood for him, the transfusion might just be enough to keep him alive during the two hour ambulance transfer to the nearest trauma surgery centre, but even if he makes it that far there are no guarantees he will survive.

In another well-practiced routine, we prep and package them for the ambulance. As it rolls away from the hospital, I can’t help thinking that it is all such a tragedy for such young lives. We are exhausted, our only comfort being a job well done. There is every chance we will face the same thing tomorrow.

South Africa has a road accident problem that can easily rival what I have encountered here. So I want to end by asking that wherever you are driving today or tomorrow, please be careful. Wear your seatbelt, put your child in the safety seat (everytime!) and SLOW DOWN. To do otherwise, well, it’s just not worth it.

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.

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…

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.

This is of course a vital role and the speed and effectiveness of the response that MSF is consistently able to mount in these sorts of situations is one of the things which has helped build the reputation of the organisation internationally.

But emergencies aren’t the only time that MSF gets involved however. There are also many projects running worldwide that have a more long-term or stable character and deal with more persistent problems.

Twisted swollen hands, the painful legacy of a failing healthcare system

My work here in the Northwest Frontier Province falls into this category. While there always remains the threat of violent conflict in our region, or the possibility of a natural disaster (such as the earthquake which devastated areas of Kashmir in 2005, to which MSF responded with a high degree of success), the work I am doing here now is not addressing any acute emergency. Rather, the team I work with is attempting to prop up or fill the gaps in a national health system that is struggling to meet the needs of the population.
In this sort of “quietly” urgent situation, it is often those with chronic disease who suffer the most.

Everyday in the ER and MSF inpatient department, I am meeting people each treasuring a bundle, bag or folder filled with doctors letters, lab tests and x-ray reports, prescriptions and sick notes and referrals: cacophonies of paperwork which, due to a fundamental lack of integration, add up to little tattered piles of confusion. Misdiagnosis (sometimes radically), inappropriate treatment or no treatment at all, missed or absent follow-up and review, and often numerous and unnecessary over-investigation without benefit, is the norm.

Without doubt, there are centres of medical excellence in Pakistan where the highest standards are upheld but like in so many other places in the world, these are beyond the budget of the majority of people. As a result, a significant proportion of people suffer the burden of inadequate care.

We hear all this in the usually long and complicated stories our patients tell us about their ailments, and it is difficult to suppress the rising frustration and sadness at things being this way.

At the moment under our care is a woman essentially crippled by Rheumatoid Arthritis. Though this is a disease that is difficult to manage even under the best of circumstances, due to delays in her diagnosis and long and tragic gaps in her treatment, she is far more severely affected than she could have been had she received a consistent and appropriate level of care. Though she is only in her 40’s, even the most simple movement is an agony. Her hands are twisted and virtually useless and she requires full-time care from her family.

Talking with her, I am reminded how many others here are carrying similar burdens and that we are reaching such a small proportion of those who could use our help.

Accepting this limitation is a daily challenge but at least with time and care we will help this one person; and then perhaps tomorrow another, and another after that. One day at a time until we can do more.

me and the team on my birthday, from back left of picture: Miki (Japanese midwife), Lynette (Philipino surgeon), Rachel (Kenyan Nurse/Midwife), Margarita (Philipino Anaesthetist) front from left: Ben (Belgian Field Co-ordinator), Me, David (German logistician)

The support we would usually have is absent and so, to help us get through the difficult days, it is the team of MSF colleagues which becomes a surrogate family.

This doesn’t mean that team dynamics are always easy. After a tough day there is no doubt that we can sometimes get on each other’s nerves. Most often though, after similarly tough days, it is the support of the other expats that has helped me get by.

This doesn’t usually come through in the form of grand gestures. Although, when one of the others returns from a weekend off in the capital with real cheese or similar rare delicacies it does A LOT to lift the spirits.
Instead, it is the simple things like having someone to talk with about a difficult case or being surprised with freshly baked cookies to enjoy at teatime, that make all the difference.

Specifically, I want to thank my team for making my recent birthday an unexpectedly enjoyable one.
I woke up on the morning I turned 32 feeling very nauseous – not a good start! What would later turn out to be a bout of dysentery, got progressively worse and I spent most of the day feeling pretty rotten. But in the evening I was surprised with a proper party including balloons (one of which was fashioned into a spectacular headdress just for me), cake and even birthday presents!

The dysentery has thankfully been resolved and time has moved on, but I will always remember my Pakistani birthday – for the place where I celebrated it, but more importantly for the people with whom I spent it.
MSF is an organisation made great by the great people who make it tick. I feel very privileged to share my time here with some of them. THANKS TEAM, YOU GUYS ROCK!

There is plenty to choose from: hundreds of chickens stacked layer upon layer on the back of trucks and pick-ups, gawking around at their last views of the world as they head to a certain fate; herds of goats wandering anywhere they please, eating whatever they find or dusty donkeys laden with impossibly large cargoes, picking their way through rush hour traffic.

I am particularly fond, however, of the interaction between man and buffalo.

buffalo

You see, for a man from Africa like me, the African buffalo is a very bad tempered fellow – highly likely to visit his anger on a frail little human. Not so it seems, the Asian buffalo! This is without doubt a gentle giant.
On the way home from work each day, I find myself smiling uncontrollably at the site of groups of buffalo, hot and tired after a long day in the sun, thoroughly enjoying being bathed. This simple spectacle takes place in the river that runs through our town. The buffalo, their heads just visible above the water, relax in a state of bliss as their human attendant scrubs and rinses them each thoroughly, hopping from back to back until he has pampered them all.

Something else which lightens up my day is witnessing groups of buffalo loping by, all with henna-coloured hair! Yes, bright oranges and reds between their horns – just for fun of course.

But the sight which made me think to write this post, was that of a small boy (weight: 30kg) who couldn’t have been more than 6 years-old driving a very large buffalo (weight: 800kg+) across the street. In order to do this he was using his stick enthusiastically on the buffalo’s large behind.

No African buffalo would ever put up with such treatment! But this placid soul continued to stroll leisurely along, seemingly without a care in the world.

Pakistan can be a perplexing place, filled at times with anger and hate – unfortunately this is too true of most other places as well. But in the midst of this, we might take a lesson from a peaceful buffalo, and not let the little things get to us.

So, perhaps I can suggest that a luxuriating bath, a new dye job or a gentle walk, can all be ways to leave the frustrations of life behind for a while.

Have an Asian buffalo day!

Due to the difficulties of working in a resource-poor setting, this happens all too frequently here in NWFP. But, many of our young patients, due to the excellent care they receive from MSF staff, do survive and will hopefully go on to thrive, and it is important to remember this in order to keep the spirits up.

So, this is a story with a happy ending.
Safina is 4 yrs old, and she has asthma. In this sense she is like many other little girls around the world; little girls who would love to be playing with their friends but who can find themselves limited by fits of coughing and feeling short of breath. But for Safina there is the added challenge that she does not always have access to the medicines she needs and the supportive medical care that could bring her illness under control.

Joe with Safina

I first saw Safina in the ER. She lay propped up on the bed, eyes closed and breathing very quickly, her chest almost completely closed due to an acute attack. The effort of breathing was rapidly exhausting her and we needed to act quickly. The MSF team went into well co-ordinated action: attaching a nebulisation mask filled with a life-saving bronchodilator, adding supplementary oxygen and establishing an IV line so other emergency medications could be given.

It took quite a while for Safina to settle and we were on edge for about an hour because we feared that the work of breathing would become too much and she would collapse.
But, with time and careful support her chest opened and her breathing became easier, she opened her eyes and looked around. What a relief! From the ER we were finally able to transfer our now stable little patient to the MSF-run in-patient ward.

Over the next few days she continued to receive the medicines and care she needed, and when I reviewed her on the ward round today the difference in her condition was remarkable. She sitting up with a brightness in her face that had been completely absent on that first day I saw her.

Moments like this are what make working here worthwhile.
And, while Safina will continue to face obstacles to staying well in a place where money and medicines are scarce, the presence of MSF in NWFP means that at least she has survived to have a chance at life.

It is easy to take breathing for granted, after all it seems so natural, so effortless. But when we stop to consider that there are some for whom the next breath is an intense struggle, perhaps we will be a little more appreciative of life as it flows in and out, in and out …