Health promotion in Pakistan: Patchwork
How can you plan to serve a community if you don't know how many people live there? Nance is in Pakistan, where she's working for Médecins Sans Frontières / Doctors Without Borders (MSF) as a health promoter. Today, she explains why Google Maps, sticky tape, and a lot of patience has been crucial to the team's work...
Machar Colony might be described in many ways. An informal settlement, encroached land, a slum, a patchwork of construction on the edge of Karachi, Pakistan, between a disused railway line and the sea. 
How patched? 
I once saw part of a roof made of an uncut rubber sheet of hiking-boot soles.
A boy floats on a make-shift raft in a flooded area of Machar Colony, Pakistan

A boy floats on a make-shift raft in Machar Colony, Pakistan. Photo: Sa’adia Khan

It was once called “Macharay” or “Fisherman’s” Colony, as it grew up between a port and a mangrove swamp. The people who moved there might speak Bangla, Pashto, Balochi, Punjabi, Sindhi, Kashmiri, Hindi, Burmi, or another language, and the name of their home was reduced to Machar "Mosquito" Colony over the years.
MSF first went to Machar Colony in 2010 to offer medical aid after the area was flooded. Finding marginalised people with limited access to healthcare, MSF stayed on, partnering with a local group to open a free clinic. 
Among the health issues faced by patients at the clinic was Hepatitis C. As well as offering free-of-cost treatment for Hepatitis C, MSF showed that a simplified treatment was highly effective. 
With a drop in the price of hepatitis C treatment (one of the targets of MSF's Access campaign), and MSF's treatment shown to cure almost 95% of patients, it was time to think about scaling up — to start measuring the impact not only in how many individuals were treated, but also in the effect on the population. 
That is when I arrived. 
I'm what’s known as a "Flying HP": a health promoter who is overseeing multiple projects. Machar Colony being the first. 
To start with, I wanted to know how many people lived in Machar Colony. The last published census data was from 1998. A place like Machar Colony will have changed a lot since then. Different sources suggested populations which ranged in size from 100,000 to 1,000,000 people!
So, determined to get an accurate figure, I got the number of children under the age of five. I looked up the urban age distribution and extrapolated, coming up with a total population of about 120,000. But was it the correct number of children? 
My colleagues were doubtful.
Next I got the details from MSF's measles vaccination campaign a few years earlier, which reached virtually all children aged 6 months to 10 years. Again, I took the age structure of urban Pakistan and estimated the total population: about 135,000. 
Colleagues were still not convinced. One looked up the reported population density of a slum in another country, and applied it to the area of Machar Colony, and came up with over 700,000. 
Litter clogs the side of the road in Machar Colony, Pakistan

  A street in Machar Colony, Pakistan. Photo: Sa’adia Khan 

Every time we discussed the future, these large population figures came up, and we felt we could not have an impact on such a large population with our resources.
We had a lot of things we did not know, and not even a detailed map of the place. 
I realised that I was not going to be able to find out how many people lived in Machar Colony. 
But I thought I could show how many people did not live there.
Nance sits on the floor, in front of a patchwork of print-outs

Nance begins the work of assembling a map of the area. Photo: MSF.

One morning I zoomed into Google maps, moved carefully through it, and printed out the whole place on about 50 A4 sheets. In the next days, after most of my colleagues left for the day, I lined up the streets and landmarks and started pasting and taping them together on a big table. Some others joined in on the giant puzzle.
A few days later, we had a workable map. Then it was simple: I divided the built area in the map into polygons, measured their sides, calculated the surface area, divided it into equal plots, selected a random sample of the plots, counted and marked every rooftop in the sample plots on the map, and multiplied to get the total. 
Then I calculated: if there were 1,000,000 people in Machar Colony, there would have to be 94 people under each roof — nothing like the 10-15 we usually saw. We could be confident of an estimate of 120-150,000 persons. 
The map is stuck to the wall, reaching far above the height of the doorframe

The map in pride of place! Photo: Nance Cunningham / MSF.

With one aspect of Machar Colony's description settled, we would be able to plan better, and have a good idea of the difference we make. 
Although the map has gaps, smudges, tears, and irregularities, we hung it up on the office wall. As one of the team said, in a lot of ways that patchwork madness represents us at MSF. Chaotic, untidy, struggling to keep the parts sticking together, yet extremely effective, and striving to fulfil a purpose.