Highs, lows and the perks of perseverance



So blogging about what I’m doing here in Pakistan is definitely harder than I first thought it would be, and for completely different reasons. Initially I thought it would be difficult to find things to write about (and yeah that has happened) but then also I find myself starting a blog only to re-read it later and find it is not as upbeat as I would hope to make it (to be honest some of them have been fairly depressing). So please hear my apologies for not writing more frequently.

To fill you in on what has been happening in the last two (nearly three) months I first want to try and explain how difficult this mission has been for myself and others in my mission.

Remote management as I wrote before is challenging, but I think the most challenging thing about it is you don’t know how challenging it will be until you are in the middle of it. A lot of my colleagues and myself included have really struggled. The highs have been high and the lows have been low… Questions like: what am I doing here; When will I get visa’s; When will I get a travel permit; And should I just go home; have been frequent discussions and questions that we have all asked ourselves. A few of my colleagues have gone home early and for various reasons – each and everyone I understand and empathise with. I myself have decided I want to stick it out.

Even though I’m on call 24/7 and am functioning on very little sleep and even though restrictions on movement about town were still in place with the upcoming elections (now been and gone). Even though I wait every day for news on my chances of travelling to the field.

OK, so to fill you in on the more exciting stuff…Last time I wrote, all my team went to my project site on my birthday. Since then a number of expats arrived in the capital and all managed to get out to the field for various periods of time. But for some reason unknown to all I was not given a visa or travel permit. I think about 10-12 expats for the field arrived since the beginning of the year and I have been the only one to miss going to my project site! Imagine this. It has meant that in team meeting discussions a suggestion I make can be explained away as being unsuitable by a colleague who has only been in Pakistan for a few weeks because they know the reality, they have seen the hospital and I remain blind. Was I jealous of their experiences – ABSOLUTELY!

Luckily I am a person who is fairly optimistic and kept trying to believe that one day my turn would come too (trust me though this optimism has been well tested). But I also strongly believe in our project – what we are doing and what we are achieving. And luckily again, my team is incredibly supportive, and supported me going to the city closest to our project site to help facilitate ETAT training (emergency triage assessment and treatment).

This meant a week away to a complete change of scenery and believe it or not but even tighter security rules. Movement there is only permitted between the airport to the house/office and hospital. But most importantly it gave me an opportunity to meet two of my junior nurses and for the first time see the babies in the neonatal nursery, children in the inpatient paediatric ward and babies and children in the nutrition program.

Initially I was excited about this opportunity but then when it came down to actually going I was fairly nervous. I was headed to an area that is often in international headlines for bombings, shootings and attacks by various groups. I was the only foreigner on the plane and felt surprisingly emotional going into this setting on my own. For the first time I was required to cover my head with the long scarf (dupatta) and I needed to be on high alert of my surroundings.

Instantly, from landing in the airport, I felt the frustration of not being able to take photographs. I was in a ruggedly beautiful flat valley surrounded by high-pitched mountains (some with snow still on their peaks) with low lying clay houses as far as the eye could see. There were the beautiful trucks decorated with ‘truck art’ that were incredibly overloaded and carefully balanced with all kinds of supplies from bundles of hay to meticulously stacked bricks. On the outskirts of the city I could see tent cities with houses made up of what looked like any scrap of material that could be found and has since been subjected to the harsh weather conditions. Children were walking along the sides of the road or scouring through the rubbish piles for anything that could be used or sold. Men were sitting outside the shops lining the main road. And women were few and far between.

Visiting the hospital gave me some wonderful albeit brief experiences. It was my first time in the clinical environment in Pakistan and I was able to see the layout of this nursery, see how the feeds were given for the premature babies, see how mothers were supported to breastfeed and how the patient files and doctor’s prescriptions were documented. Most interestingly in the nursery I was able to see babies that had been referred by our team a few days earlier. These were 28-week twins that weighed only a little more than 1kg. We had to refer them from our hospital because our nine-bed department needed to accommodate 12 babies. These babies were doing well but I learned that when they arrived they were hypothermic – not difficult for a premature baby and these babies had to spend around three hours being transported from city to city without an incubator. As a result of seeing this we were able to put in place a new system for ensuring our referrals were made in a safer way. Tubular bandage was ordered to be used as a hat and emergency foil blankets cut in quarters are now used to keep the babies bodies warm.

I also spent some time in the ATFC (ambulatory therapeutic feeding program) where I had the phenomenal experience of talking to two mother’s without a translator. These women were from Afghanistan originally and were wearing the customary blue burqua. When I approached them both ladies lifted their burqua right up and I was faced with a beautiful young woman with clear green eyes, and her mother. In my project last year I learned to speak Tajik which is close enough to Farsi that we were able to speak about how the two small babies were doing on the feeding program and to discover that her five-year-old daughter was having vomiting and diarrhea and no appetite for one week. I was possibly sitting there having this relatively serious conversation with a big stupid grin on my face because all I was thinking was “finally… this is why I am here….”.

I also saw some very sad cases. One in particular stays with me. It was a one-and-a-half-month-old baby who weighted only 1.1kgs (almost the same weight as the premature babies we referred from my project). This baby was obviously extremely malnourished and skeletal in appearance. It had what the staff here call monkey face (aka old person face) – where the skin is so tight across the bones of the face that it take on the appearance of a monkey (or older person). It was unclear why the baby was so malnourished but most likely the mother did not have a good enough milk supply to feed her baby and unfortunately it took this long for the baby to receive medical care. We were all asking ourselves – will this baby survive? And if it does what quality of life will it have? This degree of malnutrition, especially in such a young baby will no doubt have devastating effects on brain development.

Naturally this week I spent hours on the phone to my MTL (medical team leader) who happened to be in our project site at the same time, discussing thoughts, concerns and plans. We have as a result resurrected mortality reviews; debated bottle feeding over cup/spoon feeding for infants; debated over resuscitation policies; implemented paediatric assessment tools and planned future ETAT trainings.

All in all it was a great week. The ETAT training went very well with huge thanks to all the national staff involved, and I was very proud to see that my two staff participating had some of the highest test scores in the group.

Now just to wait until I can get exposure to the field environment again.