Contrast is rife in Biraul. The very poor sit shoulder-to-shoulder with the… slightly less poor. Nervous, skinny children tag along behind their overweight parents. Modern SUVs skirmish with horse-drawn carts and rickshaws for precious road space. A few doors down from the HD television shop they sell maggot-ridden potatoes. The last month has seen the arrival of ‘Festival Season’ in which some of these contrasts have become even more sharply defined.

One of the larger festivals, Durga Puja, is a ten day affair that has seen the faeces-lined mud tracks outside the office replaced with mud tracks lined with stalls, banners, stands, theatres, loudspeakers and even a couple of merry-go-rounds. Bright colours settle impermanently on any available surface, even those of unsuspecting livestock.

Festive cow
Festive cow © Luke Chapman

The shops selling staples, fruit and vegetables have been complemented by a large number of stalls selling cheap jewelry, plastic toys, incense and a hundred other things generally considered inedible. I repeatedly witness an exchange which had been quite rare in Biraul up until now (but I imagine is pretty rampant this time of year in the UK high street):

Customer: “Greetings Shopkeeper, do you perchance sell things of no practical value?

Shopkeeper: “Why of course, things of no practical value are my specialty in this, my humble place of trade! How much is Sir looking to spend?

Customer: “Spend? Oh, I suppose you too need things of no practical value, and I cannot murder you or steal from you with all these people looking, so therefore I will have to give you some money. I would like this decorative plastic model of a waterfall, and I will give you one rupee for it.

Bartering ensues.

Shopkeeper: “Although I am dissatisfied at the deal just brokered, I can see we have reached an impasse. Therefore, I would be showered in blessings if we are to make this exchange in the hope that one day you will return to my humble place of trade.”

Customer: “I too feel peculiarly unfulfilled by this transaction. My culture and society told me I wanted this decorative plastic model of a waterfall (which I now see to be poorly crafted and somewhat garish), so I bought it. Nonetheless, I’m not going to let a touch of buyer’s remorse spoil my day – I’ve still got a little to spend on things of practical value, like food, and besides – it is festival season. As for my return, I promise it with a smile, which unfortunately for you, means nothing of any value whatsoever.

Value does not solely lie in practicality of course. Through the miracle of trade, all of Biraul gets a bit richer, and with money comes development. But when going into work in the morning to see the malnourished kids, it’s still strange to walk past the mass sale of things they cannot eat. Maybe this is the point of festivals – a time of hope when you allow yourself to throw caution to the wind and do a few things in the name of fun rather than function. I am in no way criticizing (it would make me a terrible hypocrite!) – in this month of celebrations our programme helped families of 169 children to cure their severe acute malnutrition.

Not everyone is celebrating though. One of our patients, a seven month old we can call Sam, finally left the Stabilisation Centre after almost six weeks as an inpatient. She had had a stormy ride. Eventually we cured her sepsis and stopped her diarrhoea. My last memory of her is with a smile on her little face, happily shaking a rattle. A day later her mother took her home against medical advice: earlier than we would have liked, but in a good condition. The diarrhoea and the fevers stayed away, as did any other medical complaint. We asked her mother to at least come back to the next clinic, three days hence. She turned up after five days, by which time Sam had somehow managed to lose 700 grams. Small change if you are privileged enough to have a few extra pounds around the waist, but a mortal blow if you only weighed 3600 grams to start off with. Sam died the next day.

Her mother claimed that over those five days, she had given Sam food and fluids just as we had been doing while she was in the Stabilisation Centre, but if this is true, Sam’s fate is completely baffling. Can all our health education messages to her really have failed? Did we not give her the tools she needed to properly look after Sam? Or, to think the unthinkable, could Sam’s family really not have cared that much for the well-being of their youngest daughter?

Accepting this would, for me at least, be paramount to giving up hope – laying down and accepting that these tiny little humans are not entitled to a life. MSF reject this. Where there is no hope, they create it. Sometimes it is not cheap to do, and just occasionally the main result is the creation of hope rather than its fulfilment. What value you give to hope itself… well, I suppose that is subjective. I don’t know what our hypothetical shopkeeper would charge for it, even in festival season. The more I see, the more I believe it is priceless.

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Malnutrition part II: George’s story

Not everyone in India views malnutrition in the same light. There exists a pervasive idea that the kids are just thin. As one official callously implied,

I was skinny when I was growing up, and it never did me any harm’.

You can understand why there has been inertia to seeing malnutrition as a disease. For one thing it means India must start to take responsibility for the eight million children who suffer from it, not a cheap thing to do. Also it draws unwanted attention to why there is such a massive problem in a country with (mostly) no acute crises and 8 mobile phones for every 10 people. It is a politically sensitive subject.

MSF first noticed the problem in Bihar during an emergency intervention during the floods of 2007. Some preliminary surveys revealed the baseline severe acute malnutrition prevalence in under 5s to be roughly 5%, which may in some contexts qualify as a humanitarian emergency and be dealt with as such in, for example, parts of sub-Saharan Africa. This is how our project kicked off, and MSF have been treating children in Biraul ever since. However, there are about 300,000 people in Biraul block (about 20 Roystons), and it is only one of eighteen blocks in the Darbhanga district (population 3.9 million). And there are 38 districts in Bihar state (population 104 million). And in all of Bihar state, all of India even, there is only one nutrition program such as the one MSF conducts. Why then, are MSF in Biraul and not anywhere else?

The main reasons can be boiled down to a combination of opportunistic luck, MSF’s capacity to negotiate access and then generate results, and the political willingness to address the issue on the part of the Bihar State government. What MSF are trying to do here – in Rising India, one day to be the world’s largest economy – is show the government that malnutrition can be treated cost-effectively on a large scale.  Inside this contradiction, MSF performs a tight-rope walk, balancing results-oriented, life-saving medical operations and diplomatic negotiations with the government.

So here I am in the Stabilisation Centre, supervising the national staff doctors as they treat the malnourished kids. One two year old, let’s call him George, has that flavour of malnutrition that causes children to start swelling with excess fluid. It is a common cause of those swollen bellies I remember so clearly from the television as a child. I am finally clear as to the cause of the swelling, and contrary to what many sources would have you believe, it is not ascites (an abnormal accumulation of fluid in the abdomen), but in fact a combination of an enlarged liver and overgrowth of bacteria in the intestine, compounded by weak abdominal muscles.

The pathophysiology matters little to George. His skin is flaking off, leaving a mosaic of sores over his swollen body. His mouth is so cracked and infected that he can barely eat. He exudes misery. George does well on treatment though, and within a couple of weeks, he is healing up nicely and I even spot him smiling. He is discharged for follow up in the out-patient clinics.

The day-to-day purpose of the project here is to heal kids like George of their severe acute malnutrition, so that they avoid stunting or, worse, death, and you could no more quantify this benefit than you could put a price on a human life. But MSF are here with an additional, even more ambitious goal: if we can help kids like George with a model of community based nutritional care tailor made specifically for the Bihar State, Indian setting, then we might just be able to convince the government to adopt this model of care, scale it up and then help every sick kid like George.

And that would be quite an achievement!

Read Luke’s post Maluntrition matters

Luke’s blog post was first published in Spanish in 20minutos.es

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Malnutrition matters: part I

We’ve all seen the pictures. I vividly remember my mother telling me to “think of the starving Ethiopians” whenever I left food on my plate as a child. And I did think of the starving Ethiopians I had seen on the television, mostly with pity but also some curiosity as to why their bellies looked so rounded. Whether the cause is war, famine or natural disaster, it is these acute nutritional crises that tend to make it onto the television. Good for ratings I expect.

India has no “acute” crisis. As my boss astutely observed on the week he arrived, this is a nation capable of space travel and nuclear warfare. The rate at which the economy is growing makes the West envious and fearful in equal measure (although we’re a bit coy about the fearful bit). Naturally you might ask why is malnutrition a problem in a country such as this? A simple question which, unfortunately, does not yield a simple answer. Suffice it to say that there are multiple historical factors and geosociopolitical variables interacting in a complex fashion to produce dramatic inequalities of wealth and food security. That just came off the top of my head, so I would take it with a pinch of salt. I don’t think “geosociopolitical” is even a real word.

Whatever the causes, in practical terms, there is no quick fix for malnutrition in India. Neither I nor MSF nor anyone else can just click their fingers and make everything suddenly all better. I am optimistic for change, and things are changing, but in the interim, children are dying. So, if you can’t treat the cause, you are left with treating the consequence, which put simply, is really thin kids that can die if untreated.

But can you ‘treat’ malnutrition? You can’t really say it’s a disease in the same way that malaria or schistosomiasis are diseases, right? And maybe there is something strange about putting illnesses which are directly caused by very specific parasites in the same bracket as one with “geosociopolitical” causes. The facts are plain though. Malnutrition is associated with increased mortality and morbidity. It has diagnostic criteria. And it has evidence-based treatment. So whether you choose to label it as a disease or not (and MSF does), you can do something about it, and that is what really matters.

Malnutrition matters, part II: George’s story

Luke’s blog post was first published in Spanish in 20minutos.es

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Bureaucracy – part two

The next point of order:

“As I’m sure you all know, our security guards are not empowered to deal with internal security threats.” Internal security threats? This sounded serious. Images of armed men wearing balaclavas surfaced in my mind. “I am of course, referring to the mangoes.”

Mangoes? Really? Dear reader, please do not judge me harshly for what happened to me next, which was a bad case of the giggles. I was not laughing at anyone, nor was I belittling the importance of comfortable bottoms or threatening mangoes, I just had a surreal moment. To my credit, I don’t think anyone noticed. If you had looked very closely, you may have noticed my pursed lips, a very slight shudder of my shoulders or bobbing of my Adam’s apple. Apparently the mangoes, along with all the other fruit, legally belong to the landlord of the property we rent, and our security guards are not employed to stop other staff members from eating them.

Before leaving that evening, still smiling, I notice a fallen fruit on the ground in the MSF compound.

“I’m not afraid of you,” I whisper to it playfully. The next day I tripped over that very same fruit, sustaining a small laceration to my left knee. Karma, presumably, telling me not to be a smart-arse.

A fortnight or so later, I was tasked with conducting the performance evaluation of a member of staff under my supervision, a man I had recently met and knew little about. Kevin is a register. His job is to enter all the information for each child onto their record card and into the register books. This includes the week-by-week weight of the children, from which he draws a nice clear graph in the notes.  As I have often told the registers, their job is really just as important as the doctors:

Correct data + bad doctor  =   bad clinical decision

Incorrect data + good doctor = bad clinical decision

As we went through his evaluation, it transpired my predecessor had noticed a few areas in need of improvement in Kevin’s work. The evaluation system we use gives a kind of final score, and Kevin’s was somewhat low. The evaluation process is fairly new to him, and he expressed a fear for his job. The look on his face said this was quite genuine. After a moment’s hesitation, I sigh and give in to perhaps not the most professional course of action.

“Kevin, I’m going to let you into a little secret. Don’t worry too much about this score. You’re not going to get fired.” Visible relief washed over him. “The bits you need to focus on are right here.” I pointed to a small table on the back of the form. “These are things you did well – keep doing these and build on them. Here are some things that you didn’t do so well – these are areas you need to concentrate on improving. If you do that successfully, next time your score will improve. Then you can say you are making progress, I can say I supervised you while you made progress, the admin guys can put the evaluations in a drawer somewhere, and we can all go home.” Kevin smiled. I kind of wish someone had explained this to me 10-years ago. It would have saved me a lot of time.

I could go on, and I’m sure anyone who has worked in a large organisation for any amount of time has had moments when they could take bureaucracy, strangle it to death and feast on its entrails. The truth though, is without the bureaucratic process, nothing our project aims to do would get done. We could not keep track of the 700 patients currently in the programme, and we certainly could not have treated the 10,000 or so children since the project began.

So, Bureaucracy, you may become so complicated that you have ended up looking like a cross between a particle accelerator and a combine harvester. You may smell of stale sweat and fresh tears. And you are certainly not popular at parties, perhaps hanging out in a back room somewhere with Inheritance Tax and Celine Dion. But you do have an unenviable and practically impossible job to do, and I think generally, you do it as well as it can possibly be done. Bureaucracy, grudgingly, I salute you.

This post was first published in Spanish in 20minutos.es

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Bureaucracy – part one

Much of what follows may sound disrespectful to, or even critical of the administrative process. But please do not misinterpret me. If bureaucracy is an unwieldy, complicated leviathan of a tool it is because the material it must fashion (us… me in particular) is very complex, contradictory, frequently selfish and sometimes just plain stupid. So please do not think I am mocking it. What I do find funny is the human condition that made bureaucracy necessary in the first place, and if a boy can’t laugh at… well himself basically, then what the hell can he laugh at?

I have almost 15 years experience with the British National Health Service (the world’s fifth largest employer, slightly behind McDonald’s) so I am no stranger to bureaucracy at its most cumbersome. And MSF isn’t small-fry either, so I don’t know why it surprised me to have such a fine example of the subject so early on in my mission. It was a swelteringly hot afternoon in Biraul (you know you’re in trouble when even the locals declare a heat wave), and the team supervisors had gathered for their weekly meeting.

From beneath the layers of perspiration, I became vaguely aware that we had been talking about chairs for some time. One of the supervisors felt his team would benefit from a new office chair, to replace the medieval-looking devices that were currently in use.

“Is there the necessary budget?” asked one.

“What about health and safety aspects?” considered another.

“And what about upkeep and repair costs?” chimed in a third.

Some while had been spent discussing these matters, when yet another interested party pointed out that if one department was getting a new chair, perhaps all of them should get one. In terms of debate, the cat was truly set among the pigeons. With 20 minutes already lost to comfortable office chairs, the rounds of queries and counter-queries began afresh.

Now it might seem strange that office chairs are even on the table, as it were. I myself sometimes send a little cash MSF’s way (yes, my accountant hates me), and long in the past, I had some naive idea that every last penny was being spent directly on medicines or food. It turns out that someone at MSF much cleverer than I has had a bit of a think about this, and arrived at two important conclusions. Firstly, if you are going to provide care, it needs to be of as high a quality as possible – anything short of this would be at best unethical, and at worst downright harmful. Secondly, to deliver quality care, you don’t just blow your budget on antibiotics or therapeutic food and randomly wander around giving it to people who look a bit thin.

To use donors’ money effectively, you need also to invest heavily in human resources, logistics, administration, equipment, support teams, managers, analysts and so forth. Without this investment, the whole system falls apart and little gets done. For those members of staff who spend all day in front of a computer screen, comfortable office chairs are part of this effectiveness, and I for one am very happy that some fraction of my donation is being spent on bottom padding.

Nonetheless, after almost 40 minutes of chair-related discussion (outcome: we need some), I found myself having to suppress a big, childish grin.

Next week, I’ll tell you about the second point of order: mangoes as a security threat.

This post was first published in Spanish in 20minutos.es

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Reena* is a four-and-a-half year old girl, who in her younger days was partial to eating a bit of soil. Her parents have brought her to us out of simple desperation. She has been very sick for about three weeks prior to arriving at the MSF Stabilisation Centre.

To say she is “not in a good way” would be an understatement which even the English would be uncomfortable with. She is barely conscious, almost completely unable to move her body, more skeleton than flesh. Vomiting, fever and diarrhoea are her main symptoms. Her father, a carpenter, has spent large amounts of money on local doctors (well, about £40, but it works out as many weeks salary for him). They have prescribed for her the usual mix of placebos and domestos-strength antibiotics, all to no avail. They think she might have typhoid fever. Now the doctors refuse to see Reena, saying there is nothing more to do, and that she will die. They advised the parents to take her to the district hospital, about 1½ hours from Biraul.

Just a bit of background for this hospital. It is very overcrowded – it acts as a referral centre for as far away as Nepal, 60 paediatric beds for too many millions of people – so the level of care there varies. And it is far away. In the end, Reena’s father says there is no way he would even consider taking his daughter there.

The first week is rough for Reena. Despite her pitiful moans whenever we have to examine her, the defiance in her eyes says she is a fighter. We rehydrate her intravenously, which is a start. Anything we try to put into her stomach via the nasogastric tube just comes straight back out of her mouth – this makes her nutritional treatment tricky. We load her with antibiotics, but if anything the fevers get worse. We examine and re-examine her stool, which is reported as normal. On the third or fourth day, now too weak to move, she develops bed sores, something familiar to me only in patients at least 60 years older than this poor creature.

Over the weekend, blood and mucous start to appear in her diarrhoea – dysentery. We have no lab technician on a Sunday, so I decide to have a look under the microscope myself. I’ve not picked one up for about three years since my tropical medicine training and I feel quite pleased with myself when I find the ‘on’ switch. I prepare a very poor slide of her stool, and immediately notice large numbers of something that to me looks like a worm egg.

The next 48 hours are spent discussing this finding and pouring through text books trying to identify it. The lab technician initially tells me it is a food particle, but after showing him enough of them, I convince him otherwise. Besides, the poor girl hasn’t even managed to keep any milk down since she got here, let alone food. Eventually we decide it is a trematode worm egg, which would fit with many of her symptoms. We give her a dose of the standard deworming treatment, and low and behold, she passes a number of fat, half-centimetre little worms in the next few stools. These particular worms do not always respond well to the standard treatments though, and our very kind logistician spends a morning in Darbhanga doing a pharmacy-crawl, trying to source a slightly more targeted treatment. His hard work is rewarded with Reena passing hundreds if not thousands of the little parasites over the next couple of days. We never got a precise diagnosis for this worm, although we narrowed it down to the genus at least – Echinostoma. I suspect the number of them had something to do with the soil-rich diet.

For the next few days things go well. Her fevers start to subside, the vomiting stops, and after almost a week of watching her waste away, we finally start to get some milk into her. Even the diarrhoea improves. The lethargy turns into irritability, which we all have to try hard to remind ourselves is a good sign.

More than anything, I wish I could say there was a happy ending to this story. But the improvement is only short-lived, and after more than two weeks with us, Reena starts to deteriorate again. The fevers return, and the domestos-strength antibiotics are wheeled out once more, but to no avail. I see the fight go out of her eyes, and at this point I have an incredibly bad feeling as to how this is going to turn out. At the limit of what we can do for her, we take her to the district hospital for some outpatient tests and to see a specialist. He advises her to be admitted to the hospital, but again the parents refuse. Unhelpfully, the tests come back pretty much normal.

Late the next evening, I get the phone call I was both expecting and dreading. Reena, the little fighter who ate soil, has passed away. I ask after the parents – there are no tears shed. I think they had resigned themselves to this outcome weeks ago. I ask after the staff (we have all grown very attached to Reena during her time with us). Everyone is very sad, but again, for the last few days we have all had a sense of the probable outcome.

Sepsis got the better of poor Reena. Whether things would have turned out differently had she not been malnourished… no one can say for sure, but at least she would have stood a better chance. So it is for many diseases. If a young child gets severe malaria, pneumonia or diarrhoea, they might be in trouble even at the peak of physical health. To start from a point of malnourishment is to start on a very disadvantageous playing field indeed.

Young or old, no one should have to face this uphill struggle, due to a simple lack of nutrition. As for the team, there is no consolation in words. We are all professionals, and we do our best to separate the human tragedy we have just witnessed from the actions we must now take – picking up the pieces, learning whatever lessons that can be learnt, and continuing to treat the malnourished with renewed determination.

*Name changed to protect anonymity

This post was first published in Spanish in 20minutos.es

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The “Biraul Block” (Darbhanga District, Bihar State, India) has a population of about 300,000 people, many of whom are not wealthy. Biraul town centre is bustling to say the least. It’s a bit like someone has siphoned off a couple of lanes of the M25 to run through the middle of Oxford Street, sucked out every last iota of material wealth, then finally added a large number of agricultural vehicles and domestic animals for decoration. The smell is dominated by sulphur, smoke and… stool. The MSF ex-pat house is located on the outskirts of the town, suburbia if you will, but even here the concept of noise-pollution is but a twinkle in the eye of the local kill-joy. The default state of the lorry klaxons, day or night, is set to “on”. Occasionally, if there are no other vehicles or people or cows or goats in sight, a driver may desist from using it for a passing moment. This overnight cacophony is a small challenge.

On arrival, I had a very strong sense of familiarity from the area. Presently I realised that this was because it is very flat, very fertile and very wet, reminding me strongly of the fens of East Anglia. Here the similarity ends though, Norfolk being about 20 degrees colder and about 80 times richer than Biraul. It is this humid, still heat that presents a bit more of a challenge. Giving up any hope of ever being free from perspiration again, I take the only sensible way out and decide to take up sweating as a hobby.

The other MSF ex-pats have had some time to get use to these things. They have been through quite a lot together over the last six months, and my new colleagues are close knit like siblings. I have initial concerns that the social group is going to be about as easy to crack as the average Brazil nut is with the average plastic coffee spoon. But they are special people (in the flattering sense) and they give me enough openings to fumble my way into the dynamic. The outgoing doctor, an animated Greek girl of exceedingly good nature, shows me the ropes at work. She seems so good at her job and good with her staff… how am I going to get to where she is now in six short months? She tells me what I suspect is a white lie:

“You’ll be fine.”

That said, I pick up the bare bones of the clinical care, a nuanced blend of nutrition and paediatrics, fairly quickly. The staff management is clearly going to take a lot longer to get a grip on, psychology being more complicated than physiology and all.

Given it is diarrhoea season, the number of patients in the stabilisation centre is low during my first week. About seven of the sixteen beds are occupied, depending on the day. The malnourished kids we are treating are aged between six months and five years. Some of the sicker ones have drips or nasogastric tubes hanging out of their emaciated bodies. They sit or lie on their beds, looking understandably miserable. The time between them starting to smile and being discharged is brief by necessity – every extra day is another chance to pick up a hospital-acquired infection. Next to the children sit their mothers in their colourful saris, eyeing the goings on with a certain suspicious resilience.

It’s not easy being a Mum in Biraul. Juggling the childcare, domestic work and agricultural labour, often while pregnant, is no mean feat. There is tremendous pressure on a mother’s time, and sometimes impossible decisions have to be made.

Her malnourished child becomes sick, for example. Does she stay with her child in our stabilisation centre, sacrificing irreplaceable harvest days and the care of her other children? Or does she continue her (literally) vital roles at home and hope her child gets better? If you were to forget that the decision was impossible to begin with, you might judge her decision either way harshly. It is perhaps one of the reasons that previously we were seeing the phrase “careless mother” written in the medical notes. MSF have since worked hard to change this mentality among the staff. I ask our head doctor, my right hand (and probably my left hand too for the first few weeks at least), about careless mothers.

“There’s no such thing,” he says, quick as a shot. No flies on this doctor. The same cannot be said of Biraul, unfortunately.

The day after I arrive in Biraul, a child on the ward dies, ravaged by kala azar (or visceral leishmaniasis) which is even more unpleasant than it sounds. Horrible as it is, it does not kill as many each year as malaria or diarrhoea, and has slipped quietly into the category of a neglected disease. The people who suffer from it are generally poor, and drug companies have little incentive to develop new treatments (many of the drugs currently available have severe side effects – you would think long and hard before giving them to your dog). Since July 2007, MSF’s other project in Bihar State has treated over 10,000 patients with this killer disease, as well as trying to raise awareness in local communities about it. Tragically, this one poor four-year-old didn’t quite get to us in time to be saved.

By the end of my first week, several other sick children have been taken from the ward against medical advice, by parents (who are definitely not careless) having to take a calculated risk on the health of one child such that they can avoid running out of food for the whole family. At night, it is still as noisy as an illegal rave (and twice as sweaty) but my sleep is much better. It somehow seems childish to let little things like this bother you. There are bigger challenges to think about in Biraul.

Women working the fields in Biraul © Luke Chapman/MSF

This post was first published in Spanish in 20minutos.es

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Journey to Biraul

I admit it, despite having a good couple of months to prepare, I have left some of my shopping for Heathrow Airport. I still need a sun hat. But I arrive in the departure lounge, secure in the knowledge that there is always a little traveller’s shop to be found in these places.

It turns out I am somewhat misguided. Should I have wanted Beluga caviar, a Rolex watch, or anything from the vast Harrod’s outlet, I would have been alright. The Prada, Gucci and Tiffany & Co shops all sit in a row, completely devoid of customers (for some reason this makes me feel just a little bit smug). After my second circuit of the duty-free shopping area, I give up and get a pint in the pub. I can find a hat in Delhi.

The flight is comfortable but sleepless. The obligatory 30 minute delay is in effect, and combined with apathetic Delhi baggage handlers, I am almost two hours later than my poor taxi driver anticipated. He takes it in good humour though, as you would hope from a man who regularly braved the traffic “system” of Delhi.

He drops me at an unexpectedly nice flat, which I have all to myself for the next few days. It is next door to the main MSF guesthouse, and after a much-needed shower, I meet some of the people working in the capital. MSF is big on acronyms. The pre-departure course I have just attended barely let a sentence go by without mentioning a TESACO, FinCo or IMO. In the classroom, it was bewildering, but now the acronyms start to crystallise into real life. For example I meet the FinCo (Financial Coordinator, nothing to do with sharks or aqua sports) who turns out to be a lovely lady from the Phillipines bearing a homemade blueberry cheesecake.

The cheesecake and I are escorted to the Head of Mission’s place, where he is hosting a Sunday brunch. I have tried to be careful not to develop expectations for this trip. But I would have been surprised to say the least if someone had told me that on Day One I would be eating French toast topped with maple syrup, while playing with some of the MSF employee’s toddlers. Everyone is incredibly nice (as is the cheesecake and French toast), but sleep deprivation has taken a big bite out of my social skills, so I am glad to get back to the flat for a little nap.

The next few days pass in a flurry of briefings, registrations, hat shopping and particularly fine currys. Before long I find myself on a plane to Patna, the capital of Bihar state. Depending on exactly what you read, if Bihar were a country in its own right, its per capita income would be the third lowest in the world. About 30% of the population live below India’s poverty line, which means they earn something  like 12 pence per day or less. The population is a little over 100 million, with 58% of these below the age of 25.

From Patna, it takes no less than three MSF vehicles and seven hours to get me to Biraul, my final destination. As the journey progresses, the roads get progressively bumpier, and the children get progressively thinner. Eventually, myself and a large refridgerator with which I have shared most of the journey, are dropped off at the ex-pat’s house on the outskirts of town. I am greeted with a smile, a wave and a paradoxical “bye bye” from a little gaggle of children who cannot be more than five years old. I get a pang of the very familiar “what the bloody hell am I doing here?” feeling. I suppose the next six months will tell.

This post was first published in Spanish in 20minutos.es

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