Medicine at the frontier

Many MSF projects are set up in response to emergencies: earthquakes, outbreaks of epidemic disease or the fallout from violent conflict for example. It is perhaps the classic image or perception of the organisation  – rushing “into the breach” to save the day.

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

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

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

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

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

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

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

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

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

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

Being far away from home isn’t easy. While life on mission has many rewards – not least the chance to go places and see things that few others will experience – it implies time away from family and friends.
This means missing things like birthdays, important gatherings, births and, sometimes, even deaths amongst those close to us.

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

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

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

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

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

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

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

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

buffalo

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

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

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

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

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

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

Have an Asian buffalo day!

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

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

Joe with Safina

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

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

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

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

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

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.

Joe Starke

Jonathan (Joe) Starke is a South African doctor with a keen interest in emergency medicine. He is currently on his first mission with MSF and is working in an emergency room and inpatient department in Pakistan’s North-West Frontier Province. So far he has encountered cholera, endured sweltering heat, monsoon rains and survived a bout of dysentery. He finds the entire experience exhilarating and this is his blog…

“Working with MSF has been a long standing dream for me. In many ways, the previous jobs I have chosen to do have been, in part, a preparation for going on an MSF mission.

The time I spent practicing emergency medicine has prepared me well for my current position, but even more important has been my Remote Site experience. I spent 15 months on mainland Antarctica and a total of 12 months on two sub-Antarctic islands, (Marion Island and Gough Island) over the past few years doing medical support for the researchers of the South African National Antarctic Expedition.

The challenges of the isolation and restricted living environment in those beautiful places have prepared me rather well for the isolation and restriction that we face in Pakistan’s North-West Frontier Province. But it also prepared me for the vital role that team work plays in all MSF projects.

Outside of medicine, my interests orbit mostly around questions of the future of humanity and what role the individual has within the unfolding of this challenge.

I like to read, enjoy writing and find great pleasure in spending time in nature – something that it is a little difficult at the moment, but which I look forward to finding time for as soon as possible.”