The first day: everything went quiet

I had settled into my room at the expat house, unpacked and was having a cup of tea. The next day was to be my first at the hospital. It was a pleasant afternoon and I sat on the verandah, watching the hoopoe birds on the lawn.

Suddenly Lisa, the head nurse, put her head out the front door. “You are wanted at the hospital,” she says, and by her tone, I know it is urgent.

I duck back into the house to grab a headscarf, and then we go speeding in the van to the hospital – a trip of about five minutes. It is all new to me, but I don’t think the driver realises this. The high gates of the hospital open as we approach, and we drive into the yard.  We stop at an open door at one of the buildings, and I deduce that this is the place I am wanted. I enter the short corridor and at first see no-one. But, like maternity units all over the world, it is a case of ‘follow your ears’ to the labour room, which I find at the end of the corridor.

I walk in, everyone looks up and immediately they know who I must be. There is a drama at one of the delivery beds, on which lies a young woman, struggling to give birth to her baby. The attendants around are loudly encouraging her efforts, and one nurse is frantically pushing on the woman’s abdomen to try to help expel the baby, while a second nurse has cut an episiotomy, also to aid delivery as quickly as possible.

I am given a rapid outline of the case. She has travelled three hours from an outlying unit where she had been in labour for a day. On arrival at MSF Peshawar, she was finally close to delivery, but now the baby’s heartbeat could no longer be heard. Just as I was about to apply forceps, the baby suddenly delivered. A perfect baby boy was born dead. Everything went quiet.

The woman’s mother-in-law, who was at the bedside, was distressed and wept. The baby’s mother, in contrast, was calm, seemingly indifferent, turned her head away and closed her eyes, too exhausted from the trauma of the labour and birth to care about anything but that the pain was over. I couldn’t speak her language. I held her hand briefly, and patted her shoulder.

I gave the mother-in-law a hug; our eyes met and we both shook our heads. We understood each other. My mission had started with loss of life.

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Tiny patients and the need for patience

We are given Pashto lessons once a week by a very obliging, and very patient, MSF staff member from Pakistan. I am proud of my new linguistic skills: I can now use basic pleasantries such as “Hello” and “How are you?”, and count to ten.
The most useful phrase I have learned so far is “Mashoom charta dey?” which translates as “Where is the baby?” Although this sounds funny, it underlines the reason I am here. Because most often the answer to this question is unfortunately, “Ma’am, the baby has expired.”

This is a culture where the death of an infant is not unexpected, or is even anticipated. It is an accepted part of childbirth and pregnancy. Which is very upsetting to me as a paediatrician. Yes, babies die. Some babies were never meant to survive — whether it is due to an overwhelming infection or a malformation or abnormality that is simply not compatible with life. These babies, no matter what level of care or treatment they receive and where they receive it, won’t make it. But these should be the minority. The vast majority of these deaths are preventable with basic intervention and care.

Many women leave the hospital with their newborns as early as two hours after childbirth, unless they had a caesarean section or are very unwell. If the mother cannot be discharged, the babies are still often taken home by a relative — against medical advice. This can include premature babies, babies weighing less than two kilos at birth, or babies who needed to be resuscitated at birth. Leaving the hospital puts the babies at risk of developing an infection or having issues with feeding.

Some survive, but some die at home and others are brought back to the emergency room (ER). The mortality rate of babies aged less than 27 days who are brought in to the ER is 50%. One in two babies die. There are many factors contributing to this, including an overcrowded ER, doctors overwhelmed with patients who have little or no experience with sick infants, and a lack of facilities. But the inescapable truth is that by the time these babies come back, they are too sick and no treatment or intervention will make a difference.

Babies that do stabilise in the ER are transferred to the nursery – a baby ward run and staffed by the Ministry of Health. At present MSF doesn’t have a role in this ward (or room, as it is more accurately described). This room has space for seven or eight babies. There are, in fact, three more rooms, purpose-built over the last year to create a neonatal unit with a room for premature infants, one for jaundiced babies, and one for sick babies needing intensive care. The problem? There is no generator supply. Incubators stand in their packing, unused. Phototherapy beds for jaundiced babies are gathering dust.

The one room in use is filthy. The power is cut several times a day and the nurse relies on a gas heater (which is a fire hazard, given these babies are sometimes on oxygen). There is one bin, often overflowing, used needles left on the beds, and a dirty sink that doesn’t work. You can imagine that if a sick baby stabilises long enough to make it to this “nursery” it is still fighting against the odds. Twice already, I have lifted a blanket and found a dead baby underneath, unnoticed by parents and staff. The babies that don’t improve in a day or two are transferred to a hospital in Peshawar, which is around three or four hours away, depending on the weather. These babies are often dependant on oxygen, have difficulty breathing and need regular fluids and intravenous antibiotics. Yet they are transferred in whatever vehicle the parents can obtain, with no medical support. I have no idea how many of these babies actually make it to Peshawar, but I can’t imagine it is many.

This is the situation at present and this is why MSF has a paediatrician in Timurgara. I have big ideas about what can and should be done. But the biggest thing I have had to accept over the last three weeks is that change must be slow, if it is to be sustainable. Bit-by-bit, attitudes and practices need to be altered and for that I need to be patient. Friends and family will tell you that patience is not something that comes naturally to me. But this is a town in northern Pakistan, with little money or resources and we have to do what we can with what we have. Hopefully we will soon start to see a difference.


Aoibhinn Walsh is a paediatrician from Dublin, Ireland, working with MSF in Timurgara, Pakistan.

Find out more about Aoibhinn and the MSF Pakistan blogging team.

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Goodbye Australia – Hello Pakistan

A lifelong dream has come true and I am in Pakistan to work as an expat gynaecologist at the MSF Women’s Hospital in Peshawar. As I left for Pakistan, my family and friends wished me well. One kind friend even gave me some ‘shalwar kameez’—the traditional outfit of baggy pants and a long, loose overshirt worn by Pakistanis which has become my new working uniform. Some were admiring of my mission, some envious, some incredulous, but all expressed concern. “Stay safe,” was the parting comment from almost everyone. So far, while I am aware that there are dangers all around, I have never felt unsafe.

After a couple of days of orientation and briefing in Islamabad, I am off by car to Peshawar, near the north-west frontier with Afghanistan. I am surprised at first by the width of the highway—at least four lanes each way—but then the differences to home become apparent. Mostly, there are no lane markings, and where they do exist, little notice seems to be taken of them. The vehicles, large and small, move from left to right, overtaking or being overtaken in a way that is haphazard yet finds its own order; they glide like skaters on an oversized ice rink.

We approach the dusty city of Peshawar. It’s usually dusty, I’m told, but worse in recent weeks as there has been no rain.

My driver takes me on the ‘short cut’ (so he tells me) to the MSF expat house. We pass through the older part of the city, the narrow backstreets, and I feel I am going back in time. The road itself is bitumen (mostly) but the verges and footpaths, right up to the front of the shops and businesses, are just bare earth. The pedestrian traffic is mostly male—the few women are always walking at least in pairs, and always wearing shawls or burkas, partly in respectful concealment, partly for wise protection from the dust. It is so dusty this season that I even see some men wearing surgical masks. Vehicles of all shapes and sizes are crazily overloaded, as anyone who has visited this region will recall. Every surface of the buses, trucks and auto-rickshaws is decorated with colourful paintings of flowers, birds, animals, each surrounded by a patterned frieze. Art on wheels! Great pride in ownership, no matter how old or humble the vehicle.

It happens to be the end of the school day and as we are driving through suburbia, some schoolchildren are walking home (I can’t believe their uniforms can look so clean!), but most are transported. There is clearly no law (or none that’s followed) limiting the capacity of passenger transport. I see a tiny auto-rickshaw packed with more than a dozen children, where there is seating for three. Limbs and smiling faces stick out. The tray of a small truck carries a pyramid of schoolboys. Miraculously they stay on, even as the truck lurches as it hits potholes or swerves to avoid other vehicles. I am fascinated by what I see; I could drive around all day watching this real-life documentary.

We arrive at the big gates of the expat house. The driver toots and the watchman comes down from his sentry box to open them. We enter the high-walled compound – a necessary security measure for many NGOs in Pakistan. Everyone is smiling and greeting me, opening doors, carrying luggage, and chorusing how lovely it is to see me here. The reason, I discover later, is that there had been no expat gynaecologist at the hospital for the last couple of months, which had placed stress on the project.

I had braced myself for very basic living conditions, so I am pleasantly surprised by the house, which was clean and comfortable, with large rooms. Seven of us are sharing the house. Security is tight, yet I do not feel afraid at all. I am keen to start work at the hospital.

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Wheels keep turning

I am happy to report that, after a long stay in our inpatient ward, all of the children with burns from the tent fire were discharged home and are doing well. Unfortunately their mother, who we had transferred to a hospital in Quetta, passed away. The family is holding together, with uncles and aunties all helping them move forward. We provided them with a tent and various non-food items and collected some donations for food supplies that should last several weeks. It was great to see their smiling faces as they left the ward. We couldn’t speak to each other due to the language barrier but the simple gestures and smiles were all that was required.

I sit down to write my final blog and it is proving to be more difficult than I imagined. My time in Pakistan is almost up, however the wheels will keep turning. I arrived full of anticipation about a world that was foreign and uncertain to me. It has been a challenging experience and without a doubt one that I wouldn’t have gotten through without one thing: my team.

Stories of loss, tales of terror, another bomb blast, another kidnapping, children literally starving to death, all of these things would have taken their toll on me and sometimes it was difficult to see even a glimmer of hope. However I found it through the dedication of my national staff. They live with these struggles every day yet they still come to work and play their part in making a difference. I found hope in their faces as we would stay back after hours working on whatever needed to be finished by the next day. I found hope through them when they would challenge ideas and attempt to improve their practice and the inequalities that are ever-present.

I found hope in their dedication to their work. Many of them are working away from their families, for less money than they might be able to get somewhere else but they are there to help the people who need it. They are standing together to work for what they believe in and I have been lucky to work with them. I have been a mere page in a chapter of the book that is MSF in Pakistan and it reassures me to know that these people will continue to work for the people in need.

One question people often ask me is: “If you knew how it was going to be and what you were going to see, would you still have come?”  My answer is definitely yes. Though there have been challenges, both expected and unexpected, the work being done here is valuable and the impact it has on people is undeniable.

During my final days in the field I became acutely aware of all the differences with life back home. I was walking from the hospital to the house and before I left the grounds there were two young boys filling up 20 litre jerrycans from a tap and loading them onto a rusty old wheelbarrow to take home. At the gates, a young girl aged about 4 years stopped in her tracks to stare at me – possibly the first person with white skin she had seen. Across the dusty street one goat jumped another to reach a higher perch on a low-lying mud wall which apparently served no purpose anymore.

A few more steps down the street and I have to dodge the donkey carts laden with people or produce. I jump over the open drain but as a cart goes through, the drain’s contents are splashed on my colleague’s leg; he doesn’t flinch. Almost home now and I pass a man butchering a chicken on the side of a street with a blunt cleaver.

I round the final corner and the call to prayer starts, from one direction then another and again another. I step through my door from what is a benign, uneventful walk for a local, but an experience that is far from home for me.


David is an Australian nurse working with MSF in Pakistan remotely managing obstetric projects.

Find out more about David and the MSF Pakistan blogging team.

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Coats for goats: adjusting to a new life

I arrived in Pakistan one month ago – hard to believe! So much has happened but at the moment I’m stuck in Islamabad waiting for my passport to be released from the passport office and I think that it speaks volumes that I really want to get back to Timurgara.

Timurgara is definitely the biggest culture shock that I’ve ever experienced. As a young woman who lives away from my family and is very much used to doing my own thing, it’s an adjustment to live in a society where I must be completely covered—with only my eyes showing—when I’m outside of our expat house and the MSF office. Although, to be honest, I prefer to be completely covered. I think I would feel incredibly uncomfortable going around uncovered, not only because I would be the only one doing it, but because it would make everyone else uncomfortable. Even though it’s worlds away from what I’m used to, I have to remember that it’s just as normal for these people as it is for me to wear jeans and a t-shirt. It has led to some funny situations, most often when I am examining a baby in the emergency room but can’t use my stethoscope for about ten minutes because I can’t find my ears under all the layers.

I happily spend most of my time outside the house in the mother and child health unit—the maternity unit run and staffed by MSF, where men are not permitted. This means that as soon as we’re in the door all scarves, face covers and burquas are removed and suddenly the atmosphere is like any other hospital I have worked in with chatting, laughter and of course gossip. All the women working there are amazed that I have had a boyfriend for four years and have not yet become engaged or been married. I have had plenty of well-intentioned, but concerned warnings that he might escape if I don’t tie the knot. Every person I have met here has been so polite, friendly and welcoming, it’s very hard to reconcile with the view of Pakistan in the media.

In terms of expat life, thankfully our house is big enough to accommodate everyone. The walls are very high, but we can see the peaks of the mountains that run along the border with Afghanistan about 30km away, and it’s absolutely beautiful, especially when the sun sets. So far, my favourite part of the local scenery (glimpsed through our scarves on our brief drives to and from the hospital) are the goats wearing coats. Yes, in the cold, rainy winter season the majority of goats are dressed in sweatshirts (or coats as I call them because it rhymes). I don’t think that will fail to bring a smile to my face in the six months that I’m here.

Fortunately I am living with a lovely group of people. Being here has made me appreciate the importance of team dynamics, particularly when you can’t leave the house. So far it has been great fun, with birthday celebrations, people happy to make cakes and also cook lots of their national food. We have had dinners of mixed Afghan, Chinese and Filipino dishes. MSF is above all an international organisation.

As for the main reason that I’m here: the babies. That will need a whole other blog post. What I have encountered in my short time here has made me so sad but has also given me hope that the care of babies and small infants is something MSF can have a big impact on, here in Timurgara. At present there is little—if any—basic quality healthcare for the smallest and most vulnerable patients.

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Today I am grateful

I am tired of hearing about bomb blasts, hand grenades and shootings. I’m annoyed. I’m tired. I’m frustrated. I’m angry. I’m disappointed.

People are dying.

It is so normal here that people don’t even blink when they hear about another attack.

I’m also becoming like that. Complacent? Desensitised? Not today though. Today I felt nauseous thinking about people dying.

I’m supposed to be strong. Some days I don’t feel it.

Today I spent the day in the office. Many have said it before me, and I will say it again: remote management is a complete drag. I wasn’t built to sit in front of a computer all day.

Yesterday I was out at the clinic. There were more stories of grief and loss and trauma and sadness. More stories of bravery and resilience and faith.

Imagine making the decision to leave your home country, the place of your birth, your childhood, your people, your land. Imagine leaving your home locked but fully furnished, with boxes and suitcases of your things that you can’t carry with you.

You can’t carry them with you because you are leaving on foot. You can’t travel across the mountains by car. The roads aren’t good, and even if they were, you might get stopped. Imagine that you are leaving because you are scared. Scared you will be killed. Scared your sister will be raped. Scared your brother will be shot. Imagine that before you left, you saw the dead bodies of multiple family members. Imagine these bodies weren’t intact. They were in pieces. A leg, metres away from the body it belongs to. An arm in the other direction. Imagine the fear you would have if you were to stay behind. Imagine the guilt you feel about leaving. Imagine that on your month-long trek across the mountain to safety, you have little food and water.

You have blisters on your feet from your shoes at the start; you have cuts on your feet from walking barefoot at the end. Imagine walking through the snow, up a steep incline, hiding in the shrubbery when you hear a blast. Just imagine that as you walk, you see small children along the way who have been abandoned by their parents because it was impossible to carry them any longer through such rough terrain and in such harsh conditions. I tried to imagine how these parents felt. But I stopped myself. It’s too painful to think about their pain.

The woman who told this story spoke of many more things. She is probably one of the bravest women I have ever met. Every day she wakes up and puts a smile on her face. She doesn’t want people to see her pain. But as she sat in front of me, she wept and said, “Every day I pretend to be happy, so that no-one sees the ache that has been sitting on my heart for the last 30 years.”

The story sounds dramatic. But the story is real. For many people, telling the story is half the healing. We can’t take the pain away completely. But we can be there for people. Be there in their sadness, their guilt and their fear.

Things have been tough recently. So I have decided to wake up every morning and write down something I am grateful for. It’s an attempt to keep things in perspective. I share my gratitude with the expat nurse, who has become an incredible source of support. This week I have been grateful for my health, for blankets and a warm bed, for a wonderful family, for lazy Sunday mornings in bed, for all the good people in the world. Today I am less philosophical, but equally grateful. Today I am grateful for pakoras. There is something quite comforting about the taste of spicy, battered, fried potato.

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Helpless

It has already been six weeks since my arrival in Pakistan. Although I feel I am well and truly in the swing of things now, I know that I still have so much to learn. I treasure the time I get to spend with the counsellors, as they also have their own stories to tell.

They spend every day listening to the trauma and sadness that comes to them. They listen to stories of poverty. Women who talk about not being able to feed their children or wash their clothes. Proud women who are ashamed that their life has come to this – women who say, “I am not a dirty person, but look at my daughter’s dress. I don’t have any way of washing it.” Women who say, “I am living in a house with no windows and no doors. It is cold, and I am scared for myself and my children.”

Hearing this, I feel helpless. The counsellors feel helpless. All we can do is listen. I’m not sure there is any amount of training that helps you deal with the sadness of seeing people who have nothing.

I’m also not sure that any of my previous experiences prepared me for how to respond when I met a woman who had not a cent to her name, who could not even afford to buy bread for her seven children, who had to send her 12-year-old son to start work and who was considering (with much heartache) having her 13-year-old daughter marry so they could obtain a dowry to feed the other children. She invited me to her home, saying with such sincerity that I am a guest in her country, and it would be her joy and honour to host me at her house. She did not once ask for money during our multiple interactions. She taught me a generosity and kindness of spirit I hope I will never forget.

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The strength of children

In just two days the rain has turned the dusty street into a mudslide. This short walk to the hospital usually only takes me five minutes but after the rain it takes at least twice as long, as I slip and get stuck in the mud on my way into the clinic. The poor conditions prevent people travelling on foot, which means there will be less malnourished patients in the feeding centre today. Not only does the rain make it difficult to move around, it also cools the temperature down again, which is where today’s incident begins.

Early this morning I received word that there had been a fire in a tent and we had several burns victims in the hospital. They had been treated by our doctors and their condition was under control. But I wasn’t prepared for what I would see when I arrived. The first thing I saw was a boy of about 12 years, the skin on one side of his face completely burned off. One eye was swollen shut and his head was tilted right back so that he could see through the small slit which was once his second eye. His hands and feet were bandaged and he hobbled from one end of his bed to the other, felt for his pillow and laid down to rest without even a grimace. He wore only the tattered remains of his pants.

His older sister’s face was black and blistered, her hair burnt. She bent forward slightly and looked 40 years old. She was 14. Six children in total came to the paediatric ward; their mother was in the female ward and I was told her burns were the worst. The youngest child was only one year old. Her little body was burnt on her chest, back and feet with small blisters on her face.

I called in extra staff and we spent all day tending to these patients, cleaning their wounds, giving them painkillers and monitoring their condition. We had to send the mother and one child to Quetta (six hours by car) for further treatment. The lady’s husband accompanied them to the hospital in the back of the ambulance. I gave him a blanket to keep his son warm on the trip. He was very thankful. As he walked to the vehicle I saw he was holding on to the blanket like it was the only possession he had left. Unfortunately it was.

Of all the children we cleaned and dressed, the one that caused the most heartache was the baby; she was so helpless and completely dependent on what we did. She couldn’t say if one area hurt more than another and couldn’t be comforted by her mother. No matter which way we moved her, she was in pain. After cleaning the 14-year-old girl and dressing her burns, she started to look like a child her own age again. All the children were remarkably tough and hardly let out a single tear, despite all the cleaning and dressing. These children are not out of danger and they will be closely monitored over the next few days.

I tried to compare what it would have been like if we received these seven burns victims in a busy emergency ward back home. Here in Pakistan, we were managing these seven new admissions with only one-quarter of the number of staff, one-tenth of the resources and materials, not enough space and very limited referral options. Back home, it would have been chaos. But, as I have seen on many occasions, the MSF staff worked through these difficulties together and committed themselves to the patients to help achieve the best outcomes.

The family had been living in a tent for several years, since one of the recent floods in Pakistan. There were six children and at least three adults sharing a tent. They had never had enough money to rebuild their home. From what I could gather, their tent had been covered and had provided shelter from the worst of the rain. Unfortunately, it did not keep out the cold. The family had gone to sleep with some candles burning for light and warmth as they had no electricity. During the night the tent had caught fire and they woke engulfed in flames. The ones who made it to the hospital were lucky to escape. Another female relative wasn’t so lucky.

The scene was like something out of a war zone; something you would expect to see if an area had been fire-bombed. But this was no war. This was just poor people who had been pushed into a bad environment because of circumstances and suffered terribly when they were just trying to keep warm.


David is an Australian nurse working with MSF in Pakistan remotely managing obstetric projects.

Find out more about David and the MSF Pakistan blogging team.

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Colours

The colours of Balochistan brighten any bad day. In Australia, in the middle of winter, the cities are filled with greys, blacks and dark blues. It is the middle of winter here in Quetta, and I am in one of the driest, dustiest places I have ever been. But women are seen in fabrics of every colour. Reds and greens and blues and oranges and every colour in between.

I am not sure why, but somehow these colours help soften the blow of all the saddening statistics that I am learning. For example, Pakistan has one of the highest infant mortality rates in the region. It is one of only three countries to remain polio endemic in 2013, and has one of the lowest rates of breastfeeding in South Asia. These statistics puzzle me.

Attachment between mother and child is so imperative to the psychological and physical health of both. Breastfeeding has such a major impact on this. Yet there is a resistance in some areas that is very hard to break. The nurses, paediatricians, health educators, midwives and counsellors (expat and national) are doing much to try and improve the rates of breastfeeding. Progress is slow, but it is most certainly progress. It is wonderful to see the direct benefits of this work in the hospital.

In between the work, I have enjoyed spending time occasionally on the roof of the house, where we have an open area with some chairs. I lie on a yoga mat, watching kites fly in the clear, blue sky, with the sun shining. We’re not able to walk around the town because of the security situation, so this is one of the only opportunities we have to be outside. Kite flying is a popular pastime here and I wish I could see what was happening below on the ground. But our view is blocked by screens. In fact, I often I wish I was down there flying a kite too! Instead I just imagine the kite fliers running and twisting and turning and laughing. The weather is getting colder though, so I’m not sure how much longer the sun will shine and the sky will remain cloudless.

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Renovating from a distance

Too many piles of paper on my desk and my technical logistician is on vacation. In the top drawer there is an approved project form. These forms are used as a checklist for starting larger logistics activities within the project. With this form approved, everything is ready to start with some renovations.

One of the most important parts of this form is the budget. How much does it cost in Quetta to purchase the various components, how much it will cost to install a new waterline? When I call the logistician of our clinic in Kuchlak and ask if he can get some quotations from contractors, he tells me that it’s not necessary to do so beforehand. But we need to have a decent budget. Two days later, he walks into the office and after drinking tea, and chatting about his family, he gives me a stack of bills. For each part of the renovation project, he has requested a price from three contractors. The quality of all three is good and they are reliable; they have often worked for us. After this, we discuss the plan and the budget with the project coordinator. When can we start? Soon.

While the town becomes quiet in the evening, I call the “log” (logistician) and tell him that the contractors can start tomorrow. He has come up with a scheme to avoid delaying or interfering with the medical activities. While there are some non-medical activities at the clinic, and activities that are only the responsibility of the logistician, he always keeps the medical activities in mind to ensure that they are not hindered.

In the next two days, a new surgical dressing room will be built, facilities will be provided in a number of rooms that can also be used in the warm weather and we will move the fridge holding the ‘cold chain’ medication to another location. (Cold chain contains the medication that needs to be stored in a cold environment.)

After two days, the logistician comes to the office with photos on his mobile phone of the progress that has been made. The surgical dressing room floor has been tiled, water pipes have been installed and the electrical system has been extended. From the pictures it all looks good. Good work completed. The only thing still missing is the curtains in the surgical dressing room. The dimensions he gives me—8 by 15—seems a bit odd; the room seems much smaller than that. For a moment I start to sweat. Were we talking about different rooms? Did we mix up some of the activities? Then his eyes widen and he starts laughing loud about some British history. He had expressed the dimensions in feet, not metres.

After another day the work has been finalised. I’m still a bit sceptical because I can’t believe that it’s all been finished this quickly. However, the medical staff that come to the office after seeing the work are very excited.

The next stage of renovation work in the clinic is to repair an underground water tank holding five cubic metres of water. After this first project I am looking forward to the next.

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