The biggest challenge in Peshawar is sticking to the agenda; I’m only here to cover the shifts. I already have more than enough work to do with my project in Chaman and I have many jobs to keep my attention. At the MSF-supported Government health facility in Chaman, we assist the local health authorities to offer a more comprehensive service. We are helping to recruit more staff and upgrade the facility, including repainting, rewiring, restocking and resupplying. But the Peshawar project is also not without needs. Although I am only in Peshawar to help ease the clinical strain of a short-term gap in staffing, they could really use my help with some human resources and training issues that mirror those we’ve experienced in Chaman. I just don’t have enough hours in the day to do both.
I am being stretched and challenged. I can feel my patience wearing thin. I may have a quiet night on-call, but a busy day on the phone to Chaman means that I have no time for project work with Peshawar. At other times, a busy night and a quiet day allows me to catch up on sleep.
I have noticed a big difference in the patients from the two sites, but there are still many similarities. Again, I am being pushed to do a caesarean for a woman who has no good indications for needing one. In resource-poor settings, you cannot guarantee that if you do a caesarean this time, the mother will have access to medical care next time she is in labour. This results in a very high rate of uterine rupture – a complication that is quite lethal and unfortunately quite common in this part of the world. A caesarean hysterectomy is the only way to save such a woman from bleeding to death. In a society where women are expected to have child after child, year after year, a hysterectomy has huge ramifications for her social position within the household. A second or third wife is likely to be brought into the home if the first can no longer bear children.
Consequently, most obstetricians are reluctant to do a caesarean unless there is a really solid indication that it is needed. Yet the staff and the patients are challenging me: wouldn’t it be easier to just give her the caesarean that she wants? Theoretically yes, but technically no; it opens a Pandora’s box of complications. Once I learn the baby has in fact passed away, a caesarean is even more difficult to justify. I want to monitor the mother’s progress and commence oxytocin (the drug that everyone here wants to bring on a quick labour) if things don’t develop naturally. She is in spontaneous labour and there is no medical reason to intervene. But they insist on a caesarean, threaten to leave against medical advice, saying they will just go to another hospital and pay for a caesar. I’m frustrated beyond belief. They won’t listen when we try to educate them about the risks, and of course this is their right. But are they really going to indebt themselves in order to get into a higher risk situation? Or could they afford it in the first place? Does the money really matter? Should I give in, do the operation? But if I relent once, will I have to relent to everyone who demands a caesarean? That is far from feasible. We don’t have the staff, facilities or finances to perform a caesarean on so many women. I worry. I worry that she will re-present with an obstructed labour and a ruptured uterus. If she gets it done elsewhere, will she re-present with a terrible wound infection a week later, and as a result of the convoluted process, will it be my fault? I worry that my stubbornness in sticking to the rules will cause financial ruin for her family if they pay for the caesarean at another hospital. I worry what this will mean for her future children, and how they are birthed into the world. It’s an impossible situation, and as the patient has just left the compound, the decision is taken from me. I’m left with the stress and concern all the same. Part of my brain knows that I am being ridiculous in worrying so much about it, and another part of my head thinks this is all completely valid. A smaller part of my brain is realising that I am getting worn out and need a break.
One of the strangest parts of life here is that we often hear the music of an ice cream van driving the streets of the city. Having grown up in a small rural town in Australia, I have never heard the music of an ice cream van before. This is something out of an American movie: a dream-like world with manicured suburban houses, perfect families with 2.4 children, and summertime innocence. It is hard for me to reconcile the idyllic Hollywood image that this music evokes with what is outside my current four walls.
As the Peshawar roster issue is resolved, I am no longer required. Chaman continues to supply an endless stream of stories and dramas, and I know that I will be busy enough working remotely from the capital. I head back to Islamabad with the knowledge that I am about to have my first two days off-call in six weeks. I am relieved beyond belief.