Pakistan postcard

This is an unedited group email that Siobhan wrote whilst in Pakistan.
Please be aware that it contains some graphic medical details.

Dear all and etc.,
I believe this will be the only ‘postcard’ from this MSF mission in Pakistan. Please excuse the length, after several months the muse finally beckoned and I followed in those rare moments of space to think a little….

40 hours in Islamabad
As I commence to write it’s mid December and I’m recovering from the relative culture shock of a quick weekend in Islamabad – it was a necessary pause after a pretty intense month in the field – the only opportunity for several more weeks – and although still on-call by phone for remote ward rounds, advice and various little emergencies the change of scenery was good, as were the conversations not based around work, as well as the luxuries of an inside bathroom, reliable electricity supply, cheese from thoughtful European arrivals and more interesting fluids to drink. It was a little bizarre though, I was sitting waiting for a friend in a seriously fashionable salwar kameez shop and realised that I was fulfilling the dowdy country cousin from the North West Frontier Province (NWFP) role nicely. There were these rather glamorous ladies wafting past in designer numbers with nails and heels and it could have been any country in the world if one ignored the actual design. Indeed I had my eye on a lovely outfit in cream upon which leather rings were tastefully patchworked until I realised that if I wore it in Darband it would be around the whole village in seconds that the foreign doctor was trying to corrupt the young women with indecent styles. So I wrapped my chada a little more voluminously around my person and sat in the corner and watched…
And then we were driving through the capital’s planned streets, which reminded me of course of Canberra (although Islamabad has a little more soul), from a Chinese restaurant to a gathering of bright young 30-somethings in order to play pool and listen to an eclectic mix of Asian and
Western pop, and there was a huge Christmas tree on one street corner and it was all a bit overwhelming for a few minutes and I wanted to be away from it all again, back in the field, back where my life consisted of a small hospital, a house-cum-office, and the four minute walk in-between (via the back way for women) past the chickens and the goats and the children running up to shake hands whilst singing ‘aaasssaaalllaammmaaallleeekuummmhoooowwwwaaarrryoooooo?’

The setting
So where exactly is the field? It is at the end of a road, 6 hours from Islamabad, in the town of new Darband, which was made in the 60s when a massive hydroelectric dam was built: the largest in the world at the time. On one side of this dam are the mountains of Kala Dhaka. The Hindko population of the town is about 16000, the local hills around 80,000 and the Pashtun tribes of Kala Dhaka 200,000. The project was started ostensibly to support the health of these tribes, who inhabit what was once a princedom and is now a PATA or Provincially Administered Tribal Area. How a PATA actually functions remains unclear to me, however I understand that they have a semi-autonomous status and in return recognise the existence of the province and are represented politically at this level. Anyway the people of Kala Dhaka are no less Pashtun than any other of their brethren; guns are de rigueur for all males past their boyhood, although these are left at the bottom of the mountain when passing out of KD. They also follow their ethnic rules of hospitality or pashtunwali, i.e that a visitor is a guest who must be honoured and protected at any cost. Thus although the fighting of the other parts of the NWFP is less of an issue here, the presence of visiting ‘undesirables’ from other Pashtun areas (from a Pakistani law enforcement point of view), and other minor security incidents, have affected the running of the project intermittently.
Tragically political representation hasn’t filtered down to decent health access and standards of living for all the people of this area and indeed the poverty and health problems are rather confronting. However the people are in general a pleasure to work with, and approach their difficulties and privations with that curious mixture of stoicism and indifference that I have sometimes seen when working with other tribal people before. Sadly such benevolence makes them vulnerable to manipulation by others – from their own members who filter funds into private pockets to ‘foreign’ (i.e. from other parts of Pakistan) teachers who become ‘doctors’ in the afternoon and gaily sell injectable antibiotics and steroids and all manner of other potent medications from the non-functioning basic health units scattered throughout the mountains after classes have finished for the day.

The hills of Kala Dhaka are hauntingly beautiful from across the valley; a valley that deepens by the day with the steadily draining dam throughout winter. The sides of the hills are steep - this can best be described by the fact that not infrequent presentations to our hospital are those of unconscious women who were working in the ‘fields’ and fell, rolling down the slopes and thereby suffering significant head trauma in the process. In the areas around Darband en route to the nearest large town of Mansehra the hills are also terraced intricately. The terraced fields can be a few metres in length and one metre in width only. This is a populous country, around 180 million I believe, so even the seemingly inhospitable parts of this land are moulded into a sustenance producing something. One drives on cliff-hugging dirt roads though the villages from Darband and pass women scything anything that grows whilst balancing water, branches, plants, mud, goat-pats, or just about anything atop their heads. Meanwhile the children are playing cricket balanced on rocks and the verges of the road and the men can be seen standing around discussing those things that men discuss, whilst occasionally shepherding a bullock, some goats, donkeys or sheep or the odd camel. This is of course all in marked contrast to the fact that there are several large military zones between Darband and the towns of Oghi and Mansehra, and in a country that spends a gross percentage of its GDP on military this means a certain something. In reality the military presence doesn’t really affect how we work, as our dealings are with the ministry of health and the civilian police. From a practical perspective the most annoying thing is I have no photos of some truly spectacular country.
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We were not always in the field for such long periods. I accepted the position knowing that the project was on semi-remote control due to an uncertain security context. On arrival the expatriate team, consisting of myself and Gilles the field coordinator (a French ex-pâtissier /actor / musician / logistician with a daschund, icecream and coke obsession), were both running the project and living out of a four-roomed apartment of a guest-house in Abbottabad, a small city which is the last place to change money on the two lane highway to China. Brightly decorated trucks in various states of disrepair ply this single main road day and night with dingle dangles hanging from all available vantage points for good luck on the journey.
Abbottabad prides itself on its military infrastructure (the largest military academy in Pakistan is reportedly here), its relatively temperate climate and its disproportionate number of Public and medical schools. Perhaps ‘Public schools’ should be clarified for those who have not spent time in India or Pakistan. They are Public in the British sense of Public but generally consist of one or two rickety buildings with large signs such as ‘Best Educaters (sic) Public School and Hostel Abbottabad English Medium Grade prep to 8’. There remains that ancient English tradition that anyone who can possibly afford to send their son away to school will do so. I have seen the haunted glances of young boys marching in a single shivering file on the obviously compulsory Sunday afternoon walk through some dusty back streets and had my heart stretched almost as much as looking into the eyes of malnourished and anaemic children from the heartlands of Kala Dhaka… sometimes we are unbelievably cruel to our young.

In any case Abbottabad is the remote control base, only 70km but around three hours’ drive from Darband, thanks to those roads mentioned earlier. The referral hospital for our project is there: a large teaching establishment that sadly suffers both from a severe lack of nurses (they have all gone to Saudi) and wretchedly in many wards a lack of hygiene. There are some excellent doctors on staff, but there is also a system in which encouragement for better care in the private system and manipulation by pharmaceutical companies pervades. The pharmaceutical problem, as well as difficulties with general access to care can be extraordinary. Unfortunately only a limited amount of medications and equipment can be provided by the public hospital, and I have seen lists on the walls of ‘drugs available this week’ written atop. Thus the attendants (and everyone must have one) are handed a list of medications and things to buy at the end of the morning ward round (gloves, needles for lumbar puncture etc.) and they tootle either down to the private pharmacy in the hospital (which has a huge rent due to in-house demand) or one of the 30 odd pharmacies jostling for space directly opposite across the road to fill the script. There are direct kickbacks for doctors to prescribe brand medications. No one prescribes generically at all, and indeed no prescription is necessary for any medication available on the regular market. Hence, excess, inappropriate and dangerous prescribing and consuming is rife. One example: the guesthouse owner’s son had a case of non-bloody gastroenteritis and he was taken to see a Professor of paediatrics in a private clinic. I was asked the same evening to give him his injections. I looked at the script that was an A4 page of medications. There were two different intravenous antibiotics and two oral antibiotics on this (the child had an uncapped cannula in one hand (i.e. venous access) that had been placed in the clinic that morning). In addition there were two different vitamin preparations (one intramuscular), two pain relievers (one intramuscular), an iron supplement plus oral rehydration salts. The child was well nourished, well hydrated, and interactive. The symptoms had been of less than twenty-four hours duration. I was completely flabbergasted.

The prescribing issue is a vicious circle. Patients expect lots of medications and the brighter the colour the better. (MSF medications are generally rather dull coloured, which does not endear us to the population.) Injectable medications are also preferred. Good doctors fulfil these expectations. Good doctors prescribe lots of things and preferably in injectable form, especially antibiotics and steroids. In addition as there is no restriction on what can be bought in a pharmacy without prescription anyone who prescribes is a ‘doctor’. The justification I have been given for this polypharmacy is that people need steroids to feel better and that three different types of the latest antibiotics are required because (a) the hospital / people’s homes / people are not clean and (b) that the bugs are resistant in Pakistan and (c) in any case often the local medications are of very poor efficacy (recently a federal minister suggested that 50% of locally made drugs were comprised of completely useless substitutes) - so the circle goes round. The issue of injectable medication is already causing significant grief for the government: 10% of the population have either hepatitis B or hepatitis C and one of the reasons for this rate is due to unsterilised needles and needlestick injuries in a country gone mad over being pricked.

Remote control has its own challenges – lots of phone time and learning to be extra strict about communication flow – this has been both good and bad for the obsessive component of my personality. For someone who’s never been immensely keen on talking on the phone it’s been quite a turn around. The standing joke in the coordination team in Islamabad is that if you’re in the same room with me and want to chat it’s better to call or at least send a text. However I discovered early on that in order to be of use and really know what was happening in the hospital both evening phone ward-rounds and being open to calls asking for advice on patients at all times of day and night were essential. My job description was detailed but fluid – essentially oversee anything medical in the project and the field co. oversees the rest.

Perhaps some detail is required: As mentioned the project was commenced to ostensibly serve the people of Kala Dhaka. They were affected by the earthquake of late 05 but ironically were not quite accessible enough to bring the droves of NGOs that thronged the Abbotabad region into more direct contact. Abbottabad itself was revolutionised by the influx of aid workers at that time, which is apparently why it is now considered the most liberal of the NWFP cities. MSF ran an inflatable hospital out of Mansehra, 30 minutes from Abbottabad and that is how the organisation first came in touch with the area of Kala Dhaka. Fast-forward a few years and MSF is doing another exploration into the area to assess the needs. The needs of Kala Dhaka were considered to be enormous, but at the time the main issue for the people themselves was a new one: an epidemic of cutaneous leishmaniasis, a disfiguring skin condition caused by protozoa spread through the night-time bites of a particular sandfly. The ‘vector’ – the sandfly, had always been in the region, and probably one of the young men working in Karachi brought the disease in from down south sometime. So one aim of the original project was to set up a diagnosis and treatment centre for the cutaneous leishmaniasis. The problem is it’s not that easy to prove a diagnosis, so frequently in other epidemic areas the diagnosis becomes clinical, although MSF policy remains currently to treat only proven cases. Secondly the treatment is really not that nice: painful subcutaneous injections of the lesions with relatively toxic substances, and if this fails then painful intramuscular injections for twenty days. (Recall that nasty cures are often the case with ‘neglected’ diseases, i.e. those that are not often seen in the West, and therefore not worth investing in. The ironic thing with leishmaniasis though is that since the Afghanistan conflict with the US and its allies there have been numerous soldiers contracting the condition so research is on the rise again.) By the end of last year the leishmaniasis epidemic appeared to be waning. We’re not sure if that’s truly the case or if the solutions are just not worth the travel, except in the most disfiguring of cases or where function is affected (if lesions cover the hands or feet and lead to secondary infection and swelling for example), and even then the tyranny of distance and poverty probably affects peoples ability to come and ask for help. In any case the other aspects of the project have been replacing leishmaniasis, and by the time I arrived people were coming for these as the word got around about the standards of care. MSF had repaired a non-functioning ‘hospital’ to run a 24-hour emergency room and an 18 bed in-patient facility, and run a referral service for surgical cases via ambulance to the referent hospital in Abbottabad. We also enticed some female doctors to some and work and started offering female outpatient department services in April of 2009. (Male doctors in this area of Pakistan have very restricted access to female patients and unless in cases of dire urgence aren’t allowed to examine a woman except for her face and distal limbs.)

The women’s health service also means we also manage difficult labours for the untrained UNFPA workers. The reality of the situation is that most of the labours that both the UNFPA and MSF see are women in dire straits after things have gone wrong at home, and sometimes not a lot can be done. Don’t get me wrong, I’ve no problem with home births, especially if there’s been some antenatal care beforehand and everyone involved accepts the risk-benefit ratio. What I do have a problem with is the local population’s belief that every woman needs an infusion of oxytocin (a hormone that causes uterine contraction amongst other things) in order to labour, with no appreciation of whether the woman is actually ready to give birth (women often insist they are 10 months pregnant but then again dates are a relative concept in this society) or any idea if the foetus is in a favourable lie or not. This problem is present throughout the region if not the country as I have had a sympathetic half hour with an obstetrician in Mansehra who was lamenting how women also present to her hospital unit at 36 weeks or less and grumble incessantly as to why they aren’t being injected and then leave to buy the infusion over the counter and birth at home: a tragic, if somewhat ironic role reversal of excessive intervention it must be appreciated. But once you have had more than one woman brought in front of you in a state of shock with the limb of a dead baby hanging out of her vagina, because of mistaken practice and the irresponsible availability of such medications over the counter, you start to lose your sangfroid over the matter.

Anyway, the underlying aim of the project however has always been to set up some mobile clinics or improve primary care inside Kala Dhaka itself. The idea being that access to a referral service within the district would also lead to earlier presentations of the severe medical problems than is currently the case. There have been one or two forays, but progress has been slow. There are several reasons for that. The foremost was probably MSF’s original error of mistakenly making the initial logistic tour with a politician – we have been trying to live that down ever since. Other issues include the fact that there never really has been a functioning health system inside of Kala Dhaka despite the presence of Basic Health Unit buildings. There is significant intra-tribal conflict that affects decision making also. Some of the elders insist on favours for approval, which we cannot do, and a single nay will negate an entire jirga (tribal meeting). However, slowly, slowly things change. People have liked the quality of care offered at the hospital and now there is a single small regular mobile clinic in the village of Mabra on a weekly basis. This requires a boat trip and then a one and a half hour walk up steep hills with backpacks for the team, but thankfully they seem to get a kick out of this. There are assurances for the future in some bigger villages and MSF will stay here for some time to try and make that happen. The need is there, and the people are asking, it just requires extreme patience and trust.

So my job has been to oversee all the medical aspects of the project. Until just before the New Year I was also covering an expatriate nurse/pharmacist position, as there was not really scope for such a person full-time during remote control. Given we have 8 Pakistani doctors, around 20 nurses/nurse aids, and 2 lab technicians working directly for us, plus 2 Ministry of Health doctors on ‘incentives’, and around 20 lady health ‘workers’, 2 lady health ‘visitors ‘ plus a dai referring to our service this has entailed quite a lot of coordination, besides the clinical work and the ongoing development of the program. My role is also that of the doctor who approves referrals from the field, gives advice if needed about patients in the field, and advocates and/or tries to recover patients lost in the greater medical system, or indeed spat out of it prematurely. Managing the pharmacies has been a significant headache, with unclear directions and changes from Paris on the way these were to be handled in Pakistan; we run a small pharmacy in Abbottabad and a larger one in Darband. However over the last few months with a significant amount of bribery and flattery a Darband nurse has been able to gradually learn most of the areas of pharmacy management, and together we have tackled the recalcitrant MSF software, which should make this part of my replacement’s job slightly less arduous.

Being based in Abbottabad had one advantage of being able to keep a closer eye on the referred patients. To plead with the doctors if the prescribing got a little bit out of control in the referral hospital and to negotiate tests and try and ensure diagnoses were made prior to discharge! The issue is usually one of socio-economics combined with language barriers. There are a lot of bright doctors but diagnoses cannot be made unless people arrange themselves investigations that are required (i.e. about 70% of tests are ordered ‘outside’, so if they can afford it the attendant tottles off with blood vials or arranges themselves to take a patient across the road to a CT scanner). The practicalities of this would make anyone disillusioned: so many junior doctors become cynical, and frequently the patients and attendants give up and go home, often to deteriorate or die. Our defaulter rate in the referral centre was considerable prior to my predecessor’s bright idea of putting our own nurse in the hospital 24hours to meet and greet the referred patients, give them food tickets and arrange and finance the tests and treatment. The Pashtun speaking patients also didn’t have any idea what is going on in the ward rounds or what the doctors were saying to them in Urdu or Hindko, so sadly they would often succumb to the touts of local private clinics and hospitals (unfortunately sometimes the cleaners or orderlies making their own buck on the side), who would convince them that the care would be much better elsewhere even if they had to sell their last goat to obtain this.
On the other hand, despite being really hectic and being even less free to move about outside the hospital and home (as a woman), being based in the field is a lot more rewarding. The hospital is open plan around a grassy internal courtyard. One enters past a room where all the attendants sleep overnight, and then another where the MOH doctors run their outpatients. Here the one or two Ministry of health outpatient doctors can see more than 200 people per morning, i.e. between 0930 and 1300. There are always several patients in the room at the same time and if there are two doctors they consult in the same room in any case. The taking of a history and examinations are relative concepts, but their work forms the triage for the emergency room that MSF runs further up the open-air corridor.

The hospital itself is based at the end of the one main road into Darband. A further 50 metres down the hill and one comes to a grassy slope which looks down upon the water of an estuary which serves as a boat access point to the village. I’ll insert some notes I made one day whilst taking half and hour to sit on the grass overlooking this area (technically not allowed without a chaperone although fortunately I was unclear of that at the time).

I’m sitting on a hillside overlooking an estuary of the slowly draining dam of the Indus. When I arrived in September – the first visit – where I am now was under water. Now the water level is 50 metres below me. There is a boat just leaving, impossibly low in the water with thirty passengers aboard. It has become stuck in the mud and some oars have been pulled out to try and help shift the bulk. The boat is heading to Kala Dhaka – the small mountains I can see before me…dark and very steep. Darband is one point of call this side, a village that grew out of the damning of the Indus in 68. Our little hospital is there. It’s Sunday, the expats’ rest day – so after a late ward round and some coaxing of our doctors to bend their energies towards completing the dreaded statistics (note bribery of tea and samosas required), I’m taking a rare spot of sun on the few square centimetres of my person that are allowed to be exposed, trying to avoid vitamin D deficiency even if I’ve already become a brunette. The word ‘verdant’ comes to mind – the recently underwater hillsides are lush with grass and have started to be used as temporary grain fields – ploughing an unnecessary component. I have a goat and her two kids for company, one of the youngsters convinced of some nutritious value in my scarf. There are also a number of drying goat-pats dotted all around, spread out like plates that will be later used for fuel, their aroma only adding to the redolent atmosphere of the moment…
One can become a little strange when goats are the main source of company.

Our Darband home/office is two minutes by the main road (aka men’s route) and four minutes by the back path from the hospital. It consists of a series of rooms open to two courtyards that are separated by a curtain. The expats life is on one side of the curtain: bedrooms, kitchen, office cum eating/lounge room and the outdoor bathroom. There is a roof, and if one goes up veiled but then hides behind the branches of our big tree there is a small 1m by 1m space where one can look out to the lake and the mountains and stand in the sun and not be seen by anybody at all. Bliss. Darband is a small, closed and gossipy community. Women do not walk alone outside set paths. They’re not allowed to go and watch the cricket being played on the local dust bowl. As the only foreign female for most of the time I have had to be extra careful about offending sensibilities. The lack of personal freedoms has not been easy, no matter how many yoga or combat sessions have been undertaken behind closed doors.

The health is tragically forceful collision of old and new world medicine. The people of Darband district tend to show the western diseases: the asthmas, the diet related diabetes and heart disease, the allergies and so forth, whilst it is the patients from Kala Dhaka who tend to present with anything from tetanus to tuberculosis, and everything in between. But there is definite overlap in the two groups, and the hill villages outside of KD have many people with very poor basic health conditions as well. However the extremes can usually be seen from Kala Dhaka: a child with a broken arm and bone showing through the skin for a week; an elder who suffered a stroke and has been unconscious for a several days who has been carried down the mountain by a rotating group of 10 plus men on a wooden and rope bed; another child with severe macrocephaly (a pathologically large head), brought by his parents who realised than in changing his clothes each month they had to cut the top to get it over his head; the cachetic older women suffering from severe tuberculosis; the patient with melancholic depression who has eventually fallen into a coma through lack of fluids; the severely malnourished children fed on grains and tea.
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I’m continuing this little epic atop our roof in Darband. It is another Islamic holiday just before the Western New Year. I’ve just arranged to discharge a young boy who presented with the semi-dance-like movements of sydenham’s chorea as part of rheumatic fever, something we rarely see in non-indigenous Australians these days. He will need to be on monthly intramuscular penicillin for the next 10 years at least and I’m wondering how we will be able to arrange that for the future when MSF comes to leave these parts. I once faced the same issue in a leprosy colony in India and am reminded of the permanency of problems and the paucity of solutions that can be provided by NGOs.

But I digress, and come back to thinking about Pakistan, and what the various outcomes of this experience: Ironically, my French has improved a lot and I can now at least chat my way through a meal. More appropriately I’ve also picked up the very basics of polite Hindko and Pashtun. There’s been interesting personal challenges as a housemate, a clinician and a supervisor. Being a preventionist at heart, I have at least tried to institute a few little preventative health components and some follow-up (i.e. secondary prevention) policies. (The ball has started rolling for tuberculosis surveillance in the mountains of Kala Dhaka and some education of the local population has commenced in various common chronic and preventable conditions.) I’ve learnt a hell of a lot more about tuberculosis, interuterine deaths, tetanus, leishmaniasis, malaria, severe malnutrition, rheumatic fever, renal colic, brucellosis, diabetic comas, and head injuries with maggots than I ever really wanted to know. I’ve been really thankful of my generalist training and to my teachers. Keeping a hand in emergency work over the years has been something that I sometimes did with a grimace in that kind of ‘it’s good for you’ type of way. But in being here and being the final clinician who either in person or on the phone is making the assessment as to whether to treat, or transfer, stop treatment or indeed not treat at all, I have recognised that that exposure has been invaluable.
However my penance in emergency has not been more constructive than the experience of working in general practices serving a variety of socio-economic groups, and in indigenous and refugee health in Australia. The tertiary hospital there represents an ideal world. 99% of the time things happen as they are supposed to happen. Tests and medications are available. Diagnoses can be made. Treatment can be given. Patients for the most part can be discharged to the tender loving care of a reasonable level of community medicine where there are GPs, practice and community nurses, social workers and all the others who work their butts off to prevent people bouncing back within five minutes to the hallowed halls again. Facing the lack of options and resources in Pakistan has been made easier not only by experience in other resource poor countries, but also by my Australian experience of working with those who can face similar challenges. It has been as simple as deciding whether it is better not to provide the medication of best evidence on an ongoing basis because people wouldn’t be able to afford it, and settle for something with reduced efficacy but somewhat cheaper. There have been more difficult decisions: after successfully resuscitating someone twice having to call it quits on ventilating a patient in a diabetes-related coma – looking at the fatigue on the faces of my staff around me and knowing we didn’t have the resources to keep on manually ventilating the patient overnight, and knowing also he wouldn’t survive a transfer. But the positive decisions also: realising that the best nursing care in the region was in our little hospital and it was better that we treat a child with another diabetic coma presentation plus severe malnutrition ourselves rather than risk a transfer to somewhere where there might not be the staff to get him through the night. The issues don’t have to be as life threatening as this. For example one cannot counsel someone with minimal access to any source of water, sleeps with 10 other people in a room and who changes their clothes fortnightly to treat eczema with skin hydration, emollients and a sensitive clothes wash. In any practice of medicine there is always the need to find some sort of balance between the evidence of best medical practice and the stark reality of circumstance. Just here the circumstance is frequently a little starker.

I’ve also been fortunate to work with some really inspiring Pakistani people; logisiticians, administrators, guards, nurses and doctors, who work damn hard to keep this project running despite all the political game playing going on around them. With the health professionals I’ve had many of those poignant conversations that you have when you work as part of team in a difficult environment: life, death and the various religious interpretations of these. What does ‘not for resuscitation’ really mean in the context of overwhelming belief that Allah decides the outcome? How can we possibly explain to this girl of 13 that her failing heart, a consequence of rheumatic fever, will kill her in a few years and there are no resources in the system to help repair it? The majority of the doctors are Pashtun themselves, and a couple come from areas that have been severely affected by the ongoing conflict. The injury of relatives has not been infrequent, families have been evacuated, homes destroyed and relatives have been kidnapped. And yet despite this here they are trying to make a difference in the backend of nowhere, lacking a number of resources, and with a population that creates legendary fear in the normal Pakistani psyche.

On a lighter side there have been many lovely opportunities to enjoy Pakistani hospitality, which can be very generous indeed. I attended the wedding of one of the MSF doctors just before the second Eid. It was an arranged marriage, with the couple only meeting the day before the wedding, despite, or perhaps because of, the bride being a doctor, indeed a surgical trainee herself. In any case it was a lovely wedding, although the most amusing component was the stampede of the guests when the food was finally served. I learned that the politeness generally reserved for foreigners did not extend to the buffet table. Fortunately I was rescued by the function manager, who served me directly whilst we watched the mêlée. This included two older women who literally scratched each other in an argument over the last of the chicken, an event that is apparently quite normal.

I remember also visiting our neighbours’ in Darband and chatting to the grandmother of our sometime female translator. The electricity supply in both Darband, and Abbottabad, despite the hydroelectricity, is very fluctuant indeed. However there’s nothing like sitting around a brazier in a dark smoky room, with the odd household goat and some hot tea for creating a warming atmosphere, whilst one grumbles in body and very rudimentary spoken language about the trials that the younger generations bring upon us.
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It’s after mid January and we have been back to Abbottabad for a couple of weeks whilst the field co. takes a holiday. I stay with a Fatima, a French nurse who has joined us recently to share my load a little. Thankfully her presence means that we can stay in Abbottabad rather than trying to work out of Islamabad and coordinate remotely two different bases. We’re also back where there is a semi-reliable source of internet and, oh the luxury, hot water. The six weeks in the field were frequently very demanding, with barely time to sleep properly and no time at all to do the reports and statistics that have been gaily piling up around me. Christmas and New Year were marked only by multiple gifts of food and calls from a few countries reminding us of the Gregorian calendar (with thanks). I felt very guilty leaving an increasingly busy hospital environment, but even if Gilles has been here the option was not there to stay whilst the security risks in the terrain heat up a little with a forthcoming by-election for a federal seat. I am hoping that the game playing of the local parties in this election does not entail an evacuation of all the local staff as well – the hospital is doing good work and its closure would be disastrous for the surrounding communities. But sadly, such is the political situation in much of Pakistan at the moment, particularly in the NWFP. We can only hope that we can return after the elections have taken place.

The assistant field coordinator is a medical doctor also, I am helping him a little to cover Gilles position whilst he’s away. Tufail is Pashtu but raised in Dubai so has both an insider’s and the outsider’s perspective, as well as a decent sense of humour, about the day-to-day frustrations of working in rural Pakistan. The lines of communication have to stay open: the non-medical topics which we sorted out today (Sunday, that day of rest) included how to help a distraught father from Kala Dhaka who was seeking help for his already dead new-born baby; the no-show of a MSF nurse to her shift due a disagreement with the coordinator; a letter sent to us and the authorities from some disgruntled people in Darband suggesting the we close because our staff were indecent and that we didn’t give enough injections and that we hadn’t given a job to someone’s cousin; an offer from some other local people to deal with the people who had sent the letter in a culturally appropriate way; how to best get the oxygen cylinders replaced because the contractor we had been using was doing something dodgy; and that we must decline to send a doctor to the political rally outside our hospital, who had been requested in case there was any fighting, but that everyone should be made aware that the emergency room was still open for when any injuries arose.

So I will finish with one final memory and one request. The request is that for anyone in good health can they please consider donating blood to their local blood bank in the near future? The issue of blood donation, and finding donors for desperately unwell patients has been a major challenge in my work. There are beliefs about the effect on one’s virility in men amongst other reasons, even if ironically one’s wife might be bleeding to death from a dodgy obstetric situation. Thankfully now we have some local Darband Imams who are willing to rally their congregation in times of need, but even with their influence we sometimes get caught out with tragic consequences.

The memory is that of a wonderful older Pashtun woman who was receiving painful intramuscular injections for her leishmaniasis lesions that were covering both her feet and preventing her from walking. One morning, during the round, she had had enough, and started singing her pain. One of our doctors responded in kind. And then they both sang their way in this haunting chant through the rest of the consult.

siobhan