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.