Hangu is a tough place to be when you're little. 800 grams to be precise.
Nicknamed Spartacus and later Queen Sheba this little twin had it rough from the start. Delivered at home, as is all too common here, the first of the two girls weighing in at 2.3 kilos, the second a mere third of her sister's weight. With virtually no antenatal care, also a common problem here, the growth restriction of the second twin went undiagnosed, leaving one twin with everything and the other with almost none. The girls were however, both reportedly robust on their entry into this world. And a credit to the family, given the very small size of the second twin, they brought her to the hospital. On arrival she was a little cold and her blood sugar low - neither findings surprising given she had been unable to feed and had no subcutaneous tissue to keep her warm, thus utilising what little energy stores she had in a metabolic race to maintain her temperature. She did however have a strong heart, and a good set of lungs. She responded well to a boost of glucose and being placed under the warmer and soon enough was demonstrating that she was a little fighter.
However, one had to ask the un-askable question. What chance does a baby like this little one have here? She doesn't meet our admission criteria, but where can we send her? Unfortunately our sister MSF hospital in Peshawar, our nearest city centre and primary referral hospital for women and neonates, were full at their inn... Would any of the other public hospitals really provide for a neonate this small? It was going to take time for her to grow. It was going to be a long admission.
"Where is the mother?" I asked. "At home, with the other twin, of course." "What you need to understand Rhiannon, is that here, the mother is only for the feeding. The whole family is bonded to the children and will care for them. So if the baby cannot feed, there is no need for the mother to be here." This was a scenario I had become all too familiar with in the New Born Unit, as it was rarely the mother by the baby's bedside, rather the mother-in-law or an aunt. In this case, like most cases, I most certainly wanted this baby on breast milk, knowing it was the only chance she would have. Furthermore, I needed to know that the mother was committed to feeding both twins, otherwise there was little we would be able to achieve. So, I informed the team there was every need in the world for the mother to be by this baby's side, and to her credit, she came, bringing the other twin with her. And she proceeded to demonstrate not only love for both of her beautiful daughters, but a sincere commitment to providing and nourishing them both.
Day by day, we were able to increase the small amounts of milk we were giving Queen Sheba, and day by day she was winning the hearts of those who passed by her cot. We once again began discussing, where can we send this little baby who was trying her hardest to prove to us she deserved a chance. The MSF hospital said they would try if we could wait a few more days until they had some discharges, stating they needed assurance from the family that they understood the likely longevity of their admission to Peshawar. Much to my surprise, given the daily challenge we face with families refusing referral and transfer, and many leaving against medical advise on these grounds, this family were very agreeable not only to the referral, but were totally dedicated to providing what ever their daughter needed in order to survive.
Devastatingly however, this little Queen Sheba, unlike her namesake, was not to reign in this world. "Ina lillahi, wa ina ilihi rajooun" - "It was His will. You are gone, we are coming".
I tell you this tale not as one of sadness, even though of course that is what I felt. But also one of joy. Through my experience with this family, I have seen love, dedication and commitment. I have continued to learn, and to be increasingly amazed by the Pashtun people and their culture. Whilst battling to understand a society in which girls are prized less than boys, I am reminded that out of necessity, survival is a privilege often reserved only for the fittest in the mere struggle of life.
At times my own lack of insight has led me to mistake pride for a lack of feeling. And yet, these people who are so incredibly resilient, bearing their burdens privately, and keeping their emotions veiled, have demonstrated to me that whatever social customs prevail, and no matter how challenging life is, the soul will feel and the heart will love.