New role, new challenges

"It’s interesting how the buildup of an event is often a period of far greater stress than the event itself."

Doctor Daan speaks about mission nerves, finding a home in Quetta, and improving neonatal health services in Pakistan. 

I arrived in Pakistan just over two months ago. Prior to leaving home, I faced a multitude of anxieties. Am I experienced enough to do this kind of capacity building? Will I cope with the pressure of being in such a confined and restrictive environment for nine months? Given the security context, movements are very restricted in Balochistan.

Surprisingly, as soon as I arrived in Quetta, the fears dissolved. It’s interesting how the buildup of an event is often a period of far greater stress than the event itself. The nice expat team and very welcoming national staff colleagues make my new 'home' in Quetta a fairly pleasant place to stay, although this may sound a bit strange.

Health services in Pakistan are often unaffordable or inaccessible for certain population groups and in many regions, conflict and insecurity further restrict access.

You might ask yourself why MSF is present in an urban area like Quetta. One million people live in this city, nothing like a refugee camp or a remote African village hundreds of kilometers from the nearest town, settings where MSF usually works. It is true that there are enough hospitals in the city, but paediatric inpatient care – especially neonatal care – provided by government and private hospitals is insufficient to meet the population’s needs and many people cannot afford the fees charged.

The biggest gaps in the health care provided in the city of Quetta are a proper malnutrition program, neonatal care and reproductive health care. MSF fills this gap by running ‘Quetta Paediatric Hospital’ (QPH), a 65 bed children’s hospital (including 20 neonatal beds) and a mother and child health centre in nearby Kuchlak.

Malnutrition and lack of care for low birth weight or premature babies heavily contribute to the morbidity and mortality rates in children under five years old in resource-limited countries. Besides not being properly addressed by the private clinics, both conditions (malnutrition and vulnerable newborns) have a very high prevalence in Pakistan. The fact that the decline in mortality in the under fives is slower than expected in Pakistan comes as no surprise. In the last years, Pakistan was the country with the highest number of admissions in the therapeutic feeding centres in MSF's Holland section.

The mother and child health centre we run in Kuchlak offers outpatient treatment, including nutritional support for children under five, and vaccination. There is a birthing unit, and a system to refer complicated emergency obstetric cases to Quetta.

In Kuchlak and Marriabad Basic Health Unit, we also screen and treat for cutaneous leishmaniasis. This disease mostly affects children, causing large ulcerating sores usually on their face or hands. The ulcers can be quite large and disfiguring, and usually leave scars when they do heal. Leishmaniasis is caused by a parasite transmitted by the bite of a tiny sand-fly.

The treatment is difficult and painful, and often involves mostly injecting the treatment drugs directly into the ulcers on a daily basis for seven days. The wounds on these children’s faces are often horrible to see, but the treatment usually does work quite well and over 95% of the patients in our program are cured.

paediatrics, doctor, MSF, Doctors Without Borders, healthcare, Pakistan

My role here with MSF is more the role of teacher and coordinator than being a full time clinician. After the ward round with the local doctors in QPH, I start sending emails about certain medicines that we need urgently from Islamabad or even Amsterdam, we organize training for doctors and nurses, we talk to people from the national TB programme to improve the cooperation for diagnosis and treatment of children with TB, in the mean time doctors call for some advice about a patient on the ward…

And before you know it, it’s already late at night. Time goes by very quickly. Sometimes it’s a bit frustrating that I can’t be in the wards right next to the sick children we work for all the time, but at the end of the day I actually like my role as a ‘medical activity manager’.

The challenges of working in a country like Pakistan are immense and it is a country of many contradictions. But I have been struck by the warmth of people here – from the doctors and nurses I work with every day, to my lovely fellow expats, to the water resources engineer (father of a patient we admitted) I met one night in the hospital, who thanked me extensively for coming to a remote and 'dangerous' city like Quetta.

It’s this warmth from all these different people that gives you the energy and strength to keep going!