BBC Health Matters interview with Maureen van Rossun du Chattel

Transcript from the BBC World Service Health Matters, Dialogues November 2001.

Many of us remember where we were and exactly what we were doing on September 11th, the day of the terrorist attack on New York City. Dr Maureen van Rossun du Chattel was in Afghanistan. She was there working as a children's doctor with the medical charity Medecins Sans Frontieres. She had been in Afghanistan for three months and was due to be there for another six months. She was needed then, as she is needed now, but she has been evacuated along with most other foreign aid workers. She's back home in Holland and she joins me today on the line from Hilversum.

Maureen, can you remember exactly where you were when the news broke? Just by chance I was already on my way back to Peshawar. Every few weeks we get a break from our jobs and I was just being flown back to Peshawar in Pakistan for a couple of days' leave from my job in Herat. Just after I arrived I heard what had happened in the United States and immediately knew that it would have major consequences on our work in Afghanistan, so that was the end of my break.

So you were pulled out straight away?

I was already on my way back to Peshawar so that was quite easy but three or four people, a skeleton team, stayed back in Herat. The majority of the people were pulled back on the 13th .

How did you feel about that? You say that as soon as you heard the news you realised that there would be tremendous implications. How did you react to know that you would not be able to go back to work with the children in the hospital in Herat?

It's quite devastating to know that you can't return to the place where your presence is so much needed. The humanitarian crisis was already huge and the rate of malnutrition among the children was increasing tremendously before September 11th so just knowing that you can't go back is really difficult.

So you had been working in the hospital in Herat for, what, three months, before this? Tell me about your arrival in Afghanistan. Why were you in Afghanistan, why through the organisation Medecins Sans Frontieres, and why had you been sent in the first place?

I'm a paediatrician and I'm interested in tropical paediatrics. In Herat in Western Afghanistan MSF is supporting the paediatric ward of the hospital. So with my background it was a really interesting position because I could support the local doctors in Afghanistan and I could also see a lot of tropical paediatrics.

Did you have any choice in where you were being asked to work? If I didn't want to go to Afghanistan I could have told them so, yes. But for me it was a really interesting place, not many people get the chance to see a country like that from the inside and it was quite appealing.

Clearly it's very important for a doctor to be able to communicate with a patient and their families. I wonder how you were able to do that in the ward there and indeed in the refugee camps. Clearly the local language is not one I presume you have a mastery of.

Not really, I was learning Dari when I was there but I'm definitely not fluent. I could just ask about diarrhoea or something. Thank God I had a very good female translator and I had to completely rely on her translations completely. This is sometimes quite difficult because you can't ask questions as easily or naturally as you would when you talk the language yourself. In Angola I spoke Portuguese and it's a lot easier and you can just talk to the patients yourself.

So when you arrived, then, what was your impression?

It's a very interesting town to work in. Herat is quite large, about 200,000 inhabitants with quite a large hospital. What was good for me was that there were 15 local doctors whom I could train. When I worked in Angola in 94-95, I was the only doctor there. The humanitarian situation was very bad, however, and the malnutrition rate especially was going up very quickly.

You've mentioned malnutrition twice. Presumably that was what struck you more than anything. You were seeing children who were desperately undernourished and sick as a result.

Yes, what was surprising was that malnutrition was found not only in the refugee camps because you expect that. People come from the local villages to the refugee camps because there was a drought for the last three years. There were also some malnourished children from Herat City and the surrounding villages. MSF has feeding centres in two refugee camps surrounding Heart and in the time that I was there we opened a regional TFC (Therapeutic Feeding Centre) near the hospital.

So what can you do for these severely malnourished children?

It depends very much on the degree of malnutrition. Children who are not very severely malnourished go to a supplementary feeding centre and they can stay at home and they get food supplies every two weeks. Children who are more severely malnourished come to a day care centre so they stay there from morning till evening and they get five feeds a day. And children who are very severely malnourished need special 24-hour care in hospital because they have severe hypoglycaemia -- their blood sugar can drop quite dramatically -- and they can become very hypothermic as well.

What food is given to the ones who come to be fed five times a day?

We give them high energy milk, special fortified milks, and porridge, several times a day, so they get a mixture of very high energy nutrition.

And when you see these children is it entirely obvious that malnutrition is their main problem? What do they look like? What medical problems result from this?

It's very often a combination. It's not only malnutrition but also severe dehydration and severe infections that occur at the same time so you have to be careful what to diagnose, but normally you can see if a child is severely malnourished. We measure the weight and height. The child should be a certain weight for its height. If it's 80 per cent below the weight for height average then you can immediately diagnose severe malnourishment. The most striking example that I remember was a seven month-old baby who weighed only 1.9 kg. I just couldn't believe it when I saw the baby because that weight is not even a birth weight in Europe. But the mother said that it was born when there was snow so she must have been right. And at 1.9 kg it was born prematurely but it never had a chance to catch up. It was also severely dehydrated. Unfortunately it didn't make it, but you can't believe the weight of some of the children that you see.

He didn't make it, but you're saying that that if it's done in time some of these children, perhaps even the majority, can survive as a result of the feeding programme?

Yes, if you intervene in time, if you give them proper care, if you treat infections in time, if you treat worm infections in time, then you can save many of these children. It's quite frustrating that our therapeutic feeding programmes can't function at the moment. However, our local staff in Herat are still working at the regional feeding centre and also in the paediatric ward: they are still doing a great job.

It must be frustrating all round though, if these children are helped through a crisis and are fed in the camps and they then go back to a home where there isn't any food available. Do they then come back to you in due course?

This is why you can never have a feeding programme if there's not a general food distribution programme at the same time. This is why the food that the World Food Programme distributes is so essential. As you say, if you do not have food in the house you just wait for the children to return to your feeding centre.

And all this of course was before September 11th and before what will be perhaps a very long hard winter with air attacks and people being displaced, or people having to leave the country. Can you even begin to imagine what is happening to those children who you helped in the past and who are now facing what kind of future?

Yes, well it's very difficult because you know that without even one bomb being dropped lots of children will die because all the aid organisations have left the country. Also the general food distribution and aid programmes have stopped and so a very large proportion of the already severely affected population will die. What I am also afraid of is that we had quite a large number of cholera cases on the paediatric wards just before I left. The majority of these cases were from Herat City and surrounding villages. Quite a lot of cholera cases came from Maslat (?) camp which is the large refugee camp next to Herat . If a cholera outbreak occurs in a large refugee camp it's really devastating.

You will have to explain a little because many people in the West do not see cholera and do not know the implications of this disease. What does it mean for those who catch cholera? And for those, like yourself, who may try to treat this disease?

Cholera is a diarrhoeal disease and it causes very severe watery diarrhoea. Someone can die extremely quickly from it and in a large refugee camp it can very easily spread from one person to the other. It's faecal/oral transmission, that means that the febria cholera (?), the bacteria which causes the cholera, is excreted in the diarrhoea . Just by bad hygiene you can get it on your hands and someone else can swallow it and can catch cholera. You need lots and lots of intravenous fluids to save these patients. Sometimes they can also be saved by oral rehydration solution but in any event they certainly need medical attention.

It is a very grim picture that you're painting. Cholera is just one of the diseases that presumably flourish when all the systems are upset, when there's no good hygiene, when food is in short supply, when people have to move from one area to another. What are the sorts of diseases that struck the young children that you nursed and treated in the hospital in Herat?

It depends very much on the time of year. I was there mostly in summertime, the diarrhoeal season. Cholera is more October/November which is now, more or less. In winter you see more pneumonia cases. While I was there we had something like 160/180 kids on the ward and many of them were malnourished, many had diarrhoeal diseases, we had quite some severe pneumonia and we had some children with meningitis, mostly viral meningitis. And tuberculosis a very big problem in the whole of Afghanistan and is very difficult to treat, certainly in a country at war.

You talked about encountering illnesses, diseases, that you wouldn't come across normally and perhaps wouldn't want to. I gather that one of those in Afghanistan that you came across was rabies.

Yes, that's true, I had one boy with rabies, though I also came across rabies cases in Angola. It's the most horrible disease imaginable, people die a horrible death. The 8 year -old boy in Afghanistan had full-blown rabies.

And this was as a result of a dog bite?

Yes, it can occur weeks after the dog bite, but as soon as you have symptoms you can't cure it any more.

But if it's such a rare disease in the West and you haven't seen it before, how did you know it was rabies, what were the symptoms?

Once you've seen one rabies case it's not very difficult to diagnose. It was really a text book case. It was impossible for him to drink water and he had extreme fear of water. He was also very frightened and very afraid of air or wind being blown into his face or wind, and this is quite typical and unmistakable.

So when you have something like that and you know there is nothing you can do, how do you cope with that?

You realise that you can make the death more humane, so we sedated the child so at least he was not conscious of such a horrible death, and you help the Afghan doctors to realise it, too.

Did you have the supplies before September 11th to treat these children?

We were quite well stocked with drugs. MSF has a very good logistical system and the drug supplies were good, although you can't compare working in a country like that to working in a Western hospital. You don't have any monitors, you don't have any equipment to resuscitate the children.

Indeed you make the point you really cannot compare situations. I wonder then how you as a Western doctor can make the kind of mental adjustments you need to make from working in a well stocked, well equipped hospital with children who are in many ways sick but not desperate, to a hospital where there are some drug supplies missing, you have perhaps large numbers of very sick children from families where if they go home there is nothing for them. How do you make that adjustment?

Yes that's quite difficult, you have to sort of make a sort of mental switch. I remember the first time when I worked in Angola I walked on the ward in a third world country and I thought oh my God I can never do this, I can never work here, all these children need to be in the intensive care unit, I can't do this, I'm not trained enough to do this. In Europe you always have your back-up, if you can't solve it yourself you call a colleague. But if you're in a country like Angola you can't do that so you have to sort of make do with what you have. And although it's quite difficult it's also very rewarding to know that with limited means you can save about 80 per cent of the children and you have to learn not to be too frustrated about the 20 per cent that you can't save. I remember in Angola a girl who died in an asthma attack. You think of all the nebulisers that you have in Holland and you don't have any equipment like that over there. So it is frustrating every now and then but you have to learn to deal with that otherwise you can't work there at all.

Who helps you learn? Does the organisation MSF train you so that when you arrive in a country, whether it's Angola or Afghanistan, you can work from day one and you can be effective in this new environment?

MSF does give you a course before you go out for the first time but I don't think that any course can prepare you for it completely. You have to be able to do that mentally yourself. But it's the same thing back working in Holland. I worked in the north of Angola for the last month before I left starting up a hospital, which was really basic and then a few weeks later I started working in a neonatal intensive care unit in Rotterdam. It was a complete culture shock. You have to be able to adapt both ways.

What is it about you that can do this whereas many others, while admiring what you're doing, simply couldn't do it for themselves, and wouldn't want to even have a go?

I don't know, it's a very good job, it's really very challenging and very exciting work. For me it's a blessing that I can work in both worlds.

But what about the personal hardships? These countries very often do not provide many comforts of the sort you might be used to, and in fact might even be dangerous. I'm thinking not least of the kind of infections you might be susceptible to as an incomer. Does that ever concern you, or if not you, perhaps your family?

You're quite right about the last part! I do take precautions of course, I do take my malaria prophylactics and I'm extra careful. MSF is quite well stocked with emergency medicine and if something happens healthwise you will be evacuated to a well-stocked hospital nearby. So for myself I'm not particularly worried about the medical aspect. You have to take holidays in Indonesia or wherever. Being single and not having a family makes it possible to do this. If I had children of my own I would think twice about taking risks. I don't think it's impossible, however, you can go on short missions, or for shorter periods of time.

Is it something then that you would encourage other young single doctors to do, at least as part of their training and development?

Yes. You don't have to be young and single to do it but it is quite a challenging job and you encounter diseases and problems that you would never see in Europe. You also have management and organisational responsibilities. In Afghanistan I started a regional therapeutic feeding centre which meant that I and my colleague, an English nurse, had to train the staff, which I would never have been able to do in Europe.

So now you're back in Holland, what happens next? None of us knows how things will change in Afghanistan over the coming weeks and months. Do you have any idea yourself as to what will happen? Will you have the opportunity to go back or will be sent on another mission elsewhere?

I'm not sure myself yet. I'm looking at different options at the moment. I would really like to go back to the same region because I feel really connected with them, I have unfinished business. I was only there for three months and I've seen so many people that really need help. MSF is present in the surrounding countries with quite a large staff, and refugees have not yet crossed the borders which are in effect still closed. I don't think it's going to be possible for me to go there very soon. So I think I might go on a different mission.

Well, you have our great admiration and our good wishes for wherever you may end up. Thank you very much indeed, Maureen.