On saying goodbye

December 28th, 2009 by joestarke

The last day in the field is a blur: some final handover of reports and evaluations and lessons learned the hard way before I forget; a sumptuous lunch followed by a grand afternoon tea organised respectively by the wonderful staff in my two departments; pictures and hand-shakes and exchanging contact details…

I do not like saying goodbye. I would prefer to slip away quietly in the night, but to do so would not allow me the chance to say thank you to all the people who have worked so hard during my time here: the drivers and watchmen who have helped to keep me safe, the office and support teams for making so many things happen in the background so that I didn’t have to worry, our chef and house staff for taking such good care of us and the excellent clinical team for delivering the true purpose of our project: high quality patient care. Thank you to all of you, without your ongoing efforts, my presence in North-West Frontier Province in Pakistan would have been without value or result.

I spend my last evening in the field quietly: warm and watching a movie – a simple and unexpectedly special end to what has been at times an incredibly challenging period in my life. The next day I am up far too early for my liking. It is cold and all I want to do is stay in bed, but my transport to the capital is leaving. I say some final goodbyes to my expat team (my family away from home) and suddenly after weeks of being ready, I no longer want to leave…but all in a moment and a cloud of dust, Dargai is behind me.

My last days in Pakistan are spent debriefing and writing reports in Islamabad. On my last night, two of my expat team arrive unexpectedly from the field and I am treated to an impromptu farewell party including home made sushi, beautiful decorations and entertainment by a local musical duo. The packing I had planned to do is postponed and I enjoy another very special evening. On the final morning it takes all my will power to leave the warmth of my bed. The distinctive smell of 4am greets my nose as the driver and I shift through the deserted streets on the way to the airport. Silent for most of the way he eventually turns to me and asks: “Is your mission complete?” and, despite some reports to finish, despite the never-ending work that I leave behind, I am able to say “Yes”.  I have done what I came here to do.

We go through one last security check-point on the road: one last slalom between concrete barriers; one last pass in the firing line of the machine-gunner in his sand-bagged bunker; and I am reminded that I have just spent six months in Pakistan and it is the end of what has been a very long and difficult year for that country and myself.
The firm fleshy hand of the driver is my final farewell and then, I am gone.

I want to thank those of you who have followed this blog. The work of MSF relies on the support of people all around the world who recognise the need for what we do and agree to help us, whether through a period of work with the organisation or financially. Please spread the word about MSF to everyone you know. The more people who know about us and the efforts we make to bring healthcare and other services to populations in need, the greater the impact we will be able to have and the more projects (like our current ones in Pakistan) we will be able to operate.

And finally, whoever and wherever you may be, take time to appreciate the good things, the special things that you have in your life. If the last six months has taught me anything, it is that to be here (in this life) is an amazing opportunity, don’t waste it!

Closing snapshots of life and work in NWFP

December 22nd, 2009 by joestarke

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.

Phonecalls at 1am

December 18th, 2009 by joestarke

Being a doctor entails now and then (and sometimes more often than that) dealing with strange situations at unusual hours. I have worked in emergency medicine on and off for nearly 10 years and some of the most interesting cases I have been involved with have needed help at some of the most cruel and dark times of the night.

Throughout my time here in Pakistan, the emergency room is regularly busy into the wee hours and I am frequently on the phone at those times helping the on-site staff make decisions about patient care. As a result of our recent withdrawal from the field due to security concerns, I am not able to be on site in the hospital at all at the moment, and I am now spending more time on the phone that ever.

I am not a 1am person. Sleep in all its essential deliciousness is very important to me and my brain shuts down somewhere round ten thirty in the evening. But here I have had to adapt to a different routine: the phone rings sometime after I have fallen asleep. Initially, the noise is incorporated as an aspect of my dream, but eventually I wake up. With scratchy eyes and croaky voice I answer. Frequently the line drops or the connection is too bad to make out the story on the other end (frustration!) and a little cycle of call-backs from both sides begins until finally we can hear one another clearly. It will be one of the MSF ER nurses. Perhaps there is a patient with a bad head injury after a road accident or assault. Maybe it is a known cardiac patient with severe chest pain and low blood pressure or a tiny newborn who is struggling to breath. What to do?

We go through the standard checklist of presenting problems, examination findings and vital signs. Are there any blood results available? What is the chronic medication? What treatment has been given so far? My team is well practiced and they know what I need to hear to grasp what is happening. We discuss the case until a plan can be made. Perhaps a dose of an emergency drug is needed, sometimes additional tests must be requested first. On difficult days it is a discussion about whether to terminate resuscitation for a patient that has collapsed and shows no signs of life despite a long and concerted effort at revival. We have faced all these scenarios together many times and I have come to rely on the sound judgement and dedicated efforts that my team makes for all our patients. Sometimes there will just be one phone call in a night and on rare occasions none at all – how I cherish those uninterrupted hours of sleep! But usually it is necessary to discuss a case several times before a final decision is made. These are often rushed conversations in urgent tones, there is no time to waste and the tired brains on both ends of the phone are urged into a higher gear. We do what we can, watch closely always ready to respond and hope for the best outcome. Sometimes all goes well, sometimes not and we know that tomorrow night we can expect more of the same.

I don’t think I will ever get quite used to the penetrating sound of the late night phone. It will probably remain an alien and unnatural thing. But, certainly here and now, it is a reality I must continue to face.

As a result of the excellent standard of care MSF staff continue to provide in our emergency room despite limited resources, more and more patients are presenting with emergency problems at all hours. Whilst before they would have bypassed our little hospital in (sometimes blind) hopes of better treatment in a bigger city, now they know to stop and let us help them. And so, to be woken a few times at night is really just part of the job, as it is for doctors all around the world. Though the rings under my eyes are darker than they were a few months ago, I am happy to be able to support a service that is there for people who really need it. So I better get off to bed and get a few hours in while I can!

Sleep well all of you who are able and, for those of you who, like me, are sometimes called on to guard the night, know that you are not alone and your efforts are not forgotten or in vain.

Neglected wounds

December 15th, 2009 by joestarke

Patients with chronic diseases need regular follow-up, ongoing education about their illnesses and access to a reliable supply of quality medication. Unfortunately here in North West Frontier Province, this ideal is seldom if ever achieved. Due to many factors, including poverty and difficulties in regularly accessing healthcare facilities, many patients who should have close monitoring and support instead suffer through a confusion of haphazard and sporadic treatment. As a result, they progress through an inevitable and tragic deterioration.
Type 2 Diabetes is very common here and so are its complications, including problems like gangrene, kidney failure, blindness and metabolic derangement leading to coma and death. Because of the devastating damage it causes throughout the body, it is an important example of a disease that needs well-regulated control. But, most of the diabetic patients who come to the MSF emergency room and in-patient department have been denied this in the past and consequently they are often in very bad shape.
Ziarat Gul, a man currently admitted in our ward is no exception. Blind in one eye and with a long white beard he is a hunched, frail old man who has become well known to us over the past few months. He guesses his age is somewhere between 60 and 80, but he looks closer to 90 to me – the weathering of a life harder than it needed to be.
When he first presented he had a carbuncle – a large area of infected skin similar to an abscess – on his back that had been festering for some time. He had been unable to get proper treatment for the wound or afford to purchase his vital medication, and his blood sugar was dangerously high. Infections are a real problem for patients like this: the uncontrolled diabetes (caused by the missed medication) weakens immunity, increasing the likelihood of infection and, once an infection takes hold, it pushes the diabetes further out of control – a vicious cycle in which this man was trapped.
Luckily, once identified, the problem was simple enough to treat: a special diet, daily doses of the right tablets and dedicated wound care. Though it has taken a lot of patience on the part of the MSF nurses and several debridements by the MSF surgeon to remove the infected tissue, this previously neglected wound is dramatically improved. From a painful crater in his back, it is now a healthy, neat surgical wound after a successful operative closure today.
A success story like this is very gratifying for us because this man is one of the lucky ones. He managed to get to the MSF hospital while there was still time for us to help him. Others are not as fortunate. Over the months that I have been here, we have admitted many diabetics with infections whose disease is out of control because of chronically poor management. For most this means an extended stay in our hospital until things improve, for others it ends with the amputation of a foot or leg with all the long-term impairment that can bring. And for a few, it is their last illness in this world.
It is not easy having to accept that a person has suffered or died from a preventable cause, from something that, had it been seen to earlier, would have been completely treatable. And so we hope that the story of this old man who is now on the mend will be told, and will spread in the community and that others in need of similar help will come sooner to the hospital. Soon enough for us to nurse them and their neglected wounds back to health. Inshah-Allah.

When accidents happen

December 9th, 2009 by joestarke

Awareness of road safety is not big here in NWFP. Firstly, many of the roads hardly deserve the name and that certainly doesn’t help. But more significant is the general attitude of what I can only describe as recklessness (or perhaps carelessness?) displayed by most drivers and pedestrians alike. The result: road accidents are a frequent cause of the local population presenting at our emergency room, and the injuries are often horrific.

 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.

Work (and lives), interrupted

November 26th, 2009 by joestarke

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?

Problems of the heart

November 19th, 2009 by joestarke

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!




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.



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.

On moments, and the passing of time

October 24th, 2009 by joestarke

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…

The sunken eyes of hovering death

October 9th, 2009 by joestarke

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

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

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

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

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

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

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

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

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

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

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

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

Lost in translation

September 30th, 2009 by joestarke
"Pashto Peak" as seen from the rooftop of our house

"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.


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.