16th child

Late Thursday afternoon we are given the great news - interim visa granted! We leave the day after next, on a journey that consists of a flight followed by a three-hour drive over desert plains and a steep mountainous pass.

Late Thursday afternoon we are given the great news - interim visa granted! We leave the day after next, on a journey that consists of a flight followed by a three-hour drive over desert plains and a steep mountainous pass. Many meetings consume the remaining time in Islamabad, including briefings for a journey involving ample risk; security protocols, timetables, in-case of emergencies practises, culture & dress advice and of course a large goodbye dinner for three expats finishing their mission.

We leave at 5:30am, so I am in bed early, however I get a nice wake-up call at 5am advising me that our flight has been delayed until 5pm! A painful day passes as I excitedly anticipate getting to the project. Eventually we leave, and I can't help but enjoy the sights outside of the car windows, as we are often indoors and limited to only a few sections of the city. Traffic is entertaining, to say the least. Overladen donkey drawn carts drive in the 'fast lane' of the highway, and a transvestite begs at car windows while we are stopped at traffic lights. We pass a roadside graveyard that can only be described as beautiful as it also resides in a forest. The presence of so many well grown trees shelter the headstones, dappling sunlight patters that elicit a truly peaceful atmosphere. All this I notice as we whizz past on the way to the airport. After having my freedom constricted for a few weeks I hungrily take note of all that I see.

More flight delays ensue at the stiflingly hot airport, resulting in a group of very sweaty expats, yet spirits are still high - nothing stops a group of eager MSF staff! Following a short flight we overnight in our interim location to prepare for a road journey that I have heard much about. Although my security briefings have reminded me that MSF works in some of the worlds most interesting places, I am easily distracted by the feast for my eyes outside of the windows.

As we leave the town, small curiosities remind me that I am a long way from home. A man dragging a washing machine along the side of the road. A flock of four sheep quietly chew grass by the side of the road yet we are in the middle of a town. I notice there is an obvious lack of women out in public. But I am most impressed by the elaborate artwork and techni-colour lights that decorate the trucks we pass. By day you see beautifully hand-painted flowers, patterns, people and animals on every visible surface of the truck. By night you could be forgiven for crashing due to the distractingly entertaining light show and musical horns. The spectacle continues as we move out of town and a hot summer desert landscape is revealed.

Small towns abruptly appear over the dust-filled horizon. I feel like I must have accidentally gotten into the Delorean in Back to the Future as some scenes could fit perfectly in a time at least 50 years ago. Three old men in traditional dress sit outside a shop front with meat hanging from the porch roof. One of the men holds what resembles a shepherds' staff whilst guarding the gate to an animal pen. Men meet and greet each other in the street with a handshake, a big hug and a slap on the back. A truly affectionate greeting is expressed between men, in a society where touching between men and women is strictly forbidden. Old cars of all shapes and sizes loaded so full you can barely see the wheels. As we increase speed and overtake the traffic jam an agile skinny toddler darts hell-for-leather across the road, narrowly escaping sure death from a collision with the oncoming vehicles.

Before I realise, we are almost there. A dry rocky moonscape towers above. We wind up and over, down and around, back and forth. It is a rough dirt road laden heavy with truck traffic, an international highway like I have never travelled before. A one-hundred-year-old steam train powers into view from the side and overtakes us before I can blink. I am astonished to learn that it is actually faster to take the train to our destination. Then on the home stretch but just before we hit flat ground again, we are stopped. Only a dozen vehicles up ahead, two trucks driving head on passed a little too close and have become stuck on the road. Metal touches metal, cargo compresses cargo. No one can move in either direction. Luckily nothing appears to be broken, the precariously overladen cargo remains in place. Many men gesticulate and passionately discuss I can only assume what is how best to resolve the predicament.

Traffic quickly backs up on this busy mountain highway. Impatient drivers in Camrys and 4WDs alike go off-road to attempt to pass the potentially hours long wait. More cars get stuck, people start to emerge from their vehicles and people can be heard yelling orders to other drivers. I begin to wonder how long we are going to be here and if we have enough water to satiate my thirst for a few hours standstill in the hot desert heat. I also start to wish I had a burqa, as there are no other women in sight. Just as my fellow passengers begin to look nervous and we contemplate what sound be done in such a situation, suddenly to trucks move, we are shepherded through an amazingly small gap between two trucks stacked double high, and I can see the road sign naming our project on the horizon! A few more dusty streets later we slip through a gate and the car comes to a sudden stop. Finally, before we have time to realise we are no longer stuck in the desert, we have arrived at the project!

I had been in the project for only a few short minutes when I am called regarding a women who has delivered her 16th child earlier that morning in a private clinic. She presented with on-going heavy bleeding. Profoundly anaemic despite blood transfusion, her blood level is one third of the normal. The midwives were so excited when I announced that I was here, in the project, and would come review the patient. The management for this patient was relatively simple; remove the gauze packing that was preventing the contraction of her uterus, and infuse medications that maintain a strong contraction thus stopping the flow of bleeding. It was so nice to know that despite this woman having had three times the amount of children I was used to a patient having, and therefore much higher risk of a complication, my skills from home were still the skills that would work.

I am very happy to see that the general manner in which patients behave is the same as at home. No one wants to wait hours in the heat for her turn in antenatal clinic. Everyone would like her symptoms to be heard, considered and explained. All women want their privacy respected, not to be exposed and on display where prying eyes can see.

But the differences are minor yet profound. Most of the women I see each day are pregnant for the 10th or 15th time, when at home a large family is considered five. My mind boggles thinking of the number of times each woman has survived the natural risks associated with pregnancy and childbirth. Although I am still in the same country, it feels like a very different one. Most if not all my patients wear a burqa, and as the maternal and child health area is a female only zone, the women walk around with the front lifted and resting on their head. Up close, you can see the detailed embroidery that decorates the veil. Hands and feet are stained with henna. Arms are full of bracelets, noses are studded, ears are laden with rings and eyes are lined with kohl. Shalwar kameez are patterned, sequinned and adorned with bright colour. Underneath the protection of the veil, women take huge pride in their appearance.