Medicine at the frontier

My six month mission with MSF in Pakistan is rapidly drawing to a close. My replacement, Fahad, another South African, has arrived and I have the time to look back over what I have done here. Certainly I have not managed to get finished all the things I had (with unrestrained idealism) hoped for at the outset, but some small progress has been made. Some further links with the local community. Some treatment success stories. Perhaps even some lasting influence on the way medicine is practiced here in NWFP. And if that is all, then it is enough for me. There is much more that still needs to be done, but it will be done by other hands than mine.

As the last few days wind down, despite my tiredness and my readiness to move on, I am torn. There are things here with the power to make me want to stay: places, opportunities to use and share my knowledge and experience but most of all, people. I have had the chance to meet and work with an incredible group of dedicated and talented people from Pakistan and from all around the world. Thank you to all of you for your commitment and hard work. Though it may not always seem so, it does make a difference.

Moving through town and at work, my brain records snippets of what is going on around me, filing them away. I see a small boy, running alongside the railway track; he is wearing a bright purple woolly hat against the early morning chill. He turns and smiles at me and I wonder: in this place where I have seen the tragic consequences of so much violence, when exactly that innocence will be lost? My bed and desk are covered with slips of paper that I pore over: lists, and list of lists of the things I need to get done before I leave, things I need to hand-over to my replacement, reports and summaries and protocols I need to write – a mountain of words to climb that seems impossible in the time I have left and yet it is essential, to ensure continuity, to ensure that any worthwhile momentum I may have generated in our work will not be lost.

The images of patients stays with me: the wizened, gaunt face of a man on his death bed, dwarfed by the size of his own white beard, his lungs severely scared by TB; the history in the eyes and hands of a woman with joint pain, who I am unable to help in the way I would like, partly because of the languages which divide us.

And other scenes from this other world that I have been part of for a while that refuse to be overlooked: heavily armed soldiers on guard duty outside the fort with the sweeping panorama of the mountain rising above them in the distance; the menagerie of sheep and goats, cows and chickens, donkeys and buffalo, walking and grazing and toiling in the narrow streets; the sun setting to the sound of the evening prayer as I walk on the roof, learning some basic Spanish with the help of a new colleague.

All these things will stay with me. For though I will soon leave Pakistan, it will never leave me as I find myself profoundly changed by having been here. Wherever I go in the world after this, whatever I do, I will carry these images, these snapshots of how life is in this other place. I will be forever grateful for the perspective I have gained, for the things I have learned, and I know that they will help me to be more appreciative of just how fortunate I am in life. Holding onto this, perhaps I can go on to take full advantage of the many opportunities I have with renewed vigour, in the sound knowledge that there are many who cannot even imagine such chances. A worthwhile goal I think, and a responsibility I now accept with profound gratitude.

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?

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…

"Pashto Peak" as seen from the rooftop of our house

Sundays have become very important to me here, particularly Sunday afternoons. We officially have a six day work week, and though most Sundays I have to go into the hospital as well, it is usually only for a quick ward round or to assist with one or two emergency patients.

This means that Sundays give me some time to myself to read, to think and to write – very valuable moments to myself during what can be a hecti
c pace of life.

Most of these blogs you have been reading are conceptualised on quiet Sunday afternoons, often while sitting on the expansive flat roof of our house. The view is one of greenery and the slopes of the jagged mountain range that surrounds our town.

As a Capetonian far from home, it is a great comfort to me to be living in sight of a mountain again – yes, yes I know how we “Capies” like to go on about our famous mountain, but it really is beautiful to me and I miss it a great deal.

So, “Pashto Peak” as I have unofficially dubbed the closest part of the range (after the Pashto language which is predominantly spoken here), has become a favourite point of contemplation. This brings me to the challenges of providing medical care when you are twice removed from the patient by the barriers of language.

If my combined language abilities were to be somehow summed up on a cocktail menu, then I would be mixer of the following: A large portion of English Lager, a generous dash of Afrikaans “Mampoer” (this is a form of South African moonshine a little bit like schnapps but quite a lot stronger), a squirt of Xhosa Umqombothi (a traditionally home brewed beer) and a tiny drop of Spanish Sangria.

Now I have no idea how this would taste in reality, or what it might be called – “Lost in Translation” perhaps? – but so far it has served me pretty well in the working and social environments in which I have found myself.

Here in Pakistan, however, this cocktail is quite useless (not to mention the fact that  alcoholic drinks are forbidden, and mention of such is considered culturally insensitive…). I am totally reliant on translation in order to function effectively here, and it has re-emphasised for me the importance of good communication in healthcare settings.

The two senior staff with whom I work most closely in the clinical context both speak very good English, which is a good first step. But, neither of them is from this region, so their first language is Urdu rather than the locally spoken Pashto. But almost all the patients we see in the ER and IPD (inpatient department) speak only Pashto…and so we are stuck again!

Luckily, almost all the more junior nursing staff speak Pashto as their first language and Urdu as their second and so altogether, and with much patience (and not a little bit of frustration), we navigate patient interviews as follows: me to the senior nurse in English to junior nurse in Urdu to patient in Pashto.

The patient then contemplates a response and then: patient to junior nurse in Pashto, to senior nurse in Urdu, and back to me in English.

Phew!

During much of the sometimes lengthy discussions, I am silent and this has been an interesting experience in improving my ability to interpret facial expressions and body language (not always too accurately I’m afraid).

Exactly how much is lost in this tautological transfer of information is hard to say, but I am often surprised by the answers that eventually come back to me: either far too short, far too long or totally off the point altogether. Not to mention the frequent intrusions by family members of the patients who are very fond here of giving their version of the story which, once translated, not infrequently turns out to be rather different from the patient’s own version…sigh. And so, we start again with a re-phrased enquiry until finally, the necessary details start to become clear.

This slows things down a lot of course, but the staff and patients are very tolerant of my persistent questioning and somehow we manage to get it done.

Oh, how much easier things would be if we all just spoke the same language! Except of course that with language and culture being so closely linked, how much unique and valuable diversity would be lost as well?

In the end then, there is nothing for it but to push on through and keep sipping this new language cocktail, which is starting to taste better and better by the day.

Perhaps, by the end of my time here I will be able to add a sprinkle of spicy Urdu and Pashto to my own cocktail of languages and they might just be the secret ingredients which turn it into something truly delicious.

So, for now I will say: “Pa ma cha de cha” (travel well on the road ahead) until next time.

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 …

Outdoor chess set in the garden

So, having completed my first month on site at the end of last week, I can truly say that I was tired in body and mind. Luckily, MSF recognises that working in a project like this can wear people down pretty quickly and thus makes it possible for staff to take regular breaks outside the “hot zone”. And this is how I came to spend this past weekend enjoying some serious chillage in Islamabad, the capital.

The MSF co-ordination team for all our projects in Pakistan is based in the capital and so I was able to stay in the expat house with some of the more senior staff, which was a good opportunity to build relationships and share news and info from the field. It was also a good opportunity to enjoy the wonders of air conditioning (I don’t think I have appreciated a modern convenience as much in my entire life!), eat some different food (though our usual diet on the project is tasty and appreciated, it does border on monotony at times…) and to see and experience a more open and relaxed side of Pakistan.

Skyline silhouette in the jinnah park Islamabad

In Islamabad, the security situation is far more relaxed than in NWFP, which means we have a much greater freedom of movement. It was a real pleasure to be able to visit some of the markets and browse idly in books shops (this is one of my favourite things to do and I was very impressed with what was available). We were also able to go out at night and enjoyed some excellent hospitality at several of the cities many restaurants. But the highlight of the weekend for me was an afternoon stroll in the park. It was wonderfully freeing to be able to enjoy such a wide-open space and to feel like I was really “in” the place (since our usual restricted environment makes us quite apart from it all at times). Along with Fabio, a Brazilian expat doctor who is coming to the end of his time in Pakistan, I made an invigorating circuit of the very beautiful Jinnah Park, which is just over the road from the MSF office. We saw children at play, watched locals enjoying games of soccer and cricket and generally appreciated the normality of things here compared to our usual set up. It was an afternoon well spent and I will look forward to my next weekend off very much – they tell me there is a swimming pool and that sounds quite marvellous!

 

My life and work in Pakistan’s North-West Frontier Province has a certain rhythm: 6am wake-up, breakfast, into the transport, do the inpatient ward round, spend time in the ER, then home for lunch and repeat in the afternoon aiming to get home by 4pm (but usually around 6pm or 7pm!).

Due to security concerns, we are not usually allowed out of our residential compound, except to go to work and then only in the vehicle and only before dark. And so, we spend a lot of time indoors. Though we have an exercise bike, some weights and a punching bag (very necessary for exorcising frustration!) exercise options are severely restricted.

sunrise in NWFP

As a keen hiker, this has been a bit of an adjustment for me, especially since we are in sight of some spectacular local mountains where I would love to stretch my legs. In the last few days, however, this established routine underwent an unexpected and refreshing change.

Due to a relative stabilisation of the security situation in the Swat valley to our north, people displaced from the area in the past are being actively encouraged to return. As our town is on the main route to Swat, we have witnessed this procession growing from a trickle into a steady stream of trucks, buses and private cars since the beginning of last week.

Now, while this situation comes with its own frustrations for our project (particularly the daily military curfew which restricts our movements and has led to some very long days at work), it has offered the opportunity for a rare and special experience: a proper walk…outside…on the street!
You see, because of the curfew, the usual access roads for our transport to reach our residence are blocked and so, for the last few mornings, waking extra early to ensure we are moving before curfew begins, we have had the chance to take a short walk to our nearby office where the vehicles can collect us.

This probably seems a strange thing to write home about, but in the cool quiet just before sunrise this is, despite the many challenges, a very special and beautiful place, and a stroll in the fresh morning air does wonders for ones state of mind.

So for all those of you who are able, I strongly recommend you take a walk today. Preferably somewhere scenic, perhaps with someone special. It is a rare pleasure when properly appreciated and a free gift to yourself. ENJOY!

The reason that MSF is working in the North-West Frontier Province (NWFP) of Pakistan is that there is a clear medical need.

Patients who, in places with more advanced resources, would recover from their illnesses and return to their lives sadly do not always survive here. This is particularly true of unwell newborns, and it was here where we were recently able to make a decisive difference.

On the 10th of July twin girls were delivered at the MSF-run MCH (mother and child health unit). They we premature (only 28 weeks old) and each weighed only 1 kilogram.

At birth, they were pale, cold and unresponsive. After initial resuscitation by the midwives, they were brought to the nearby MSF emergency room. And, thanks to the skill and knowledge of our nursing staff and the availability of the necessary equipment and medication provided by our project, these two new arrivals were stabilised and were soon exclaiming their appreciation at the top of their little lungs. They were later transferred by ambulance to the nearest paediatric unit, and we have been receiving updates of their ongoing good progress over the last few days.

There are a lot of frustrations and difficulties to working here. Things often go wrong despite our best efforts. But, due to the sustained commitment of our excellent team (both clinical and support personnel), things are going right more and more often, and that makes it all worthwhile!

I hope you will all join me in welcoming these two tiny new arrivals to this sometimes strange and often wonderful world of ours.

It isn’t easy getting from Cape Town in South Africa to the North West Frontier Province of Pakistan.

To do so means spending a lot of time in airports: Cape Town to Johannesburg, then to Zurich, Brussels and finally, Islamabad. The rest of the way is by rough road and only with the permission of the military at several checkpoints.

But this is not just a journey of distance and time, it is also one of mindset. To work for Doctors Without Borders (MSF) – as I will be doing here for the next 6 months – is to agree to represent an organisation that aims to reach out to those in need in some of the most challenging and complex environments on earth. It means to adopt a code of impartiality, advocacy and the giving of assistance irrespective of race, gender or political/religious ideology.

Joe with friends

I am an emergency room doctor and I arrived here to join a team of doctors, nurses and support personal currently bolstering the standard of healthcare in a region that has suffered a great deal in recent years. In the week since we stepped into the exhausting 50 ^oCelsius (122 F) heat, it has become very clear to me that the needs of the people here are great.

As an international organisation that has its origins in the western world, it has not been easy for MSF to be accepted here, but the high standard and dedication of local and international staff has opened the way and we are now welcomed and appreciated.

Looking ahead, it is clear that this is going to be one of the most challenging jobs of my life. But, I am proud to be working for an organisation that changes lives and I feel immensely privileged to have the opportunity to help people in what is, metaphorically speaking, an axis for one of the turning points in the history of the modern world.

I look forward to sharing my experiences with you here over the coming weeks and months.