Dr Jonathan Tomlinson's First Mission with MSF, in Western Afghanistan

Herat November 27, 2003

It’s a spectacularly starry night again. The icy air stings my nose as I tip my head back to admire the heavens. As I look up at the night sky, so dense with distant planets, I am reminded that I too am no more than a speck among billions. Coated with dust like everything out here, I’m trying to live amongst, understand and work with the Afghan people in Kushk-e-Khona.

Winter has come quickly. When I arrived less than 4 weeks ago we had to shelter from the heat of the day. Now we huddle around kerosene heaters, assembled by Heath, Robinson and sons, they shake and rumble and smell vile and asphyxiate you as fast as warm you. Last week we were caught in a snowstorm on the road from Herat to Kushk. Driving along with the windows down, cheeks flushed in the cold, dry wind, but warmed by the bright sun, we began to climb up to the first mountain pass. As we turned a bend we left the sunshine and entered, all of a sudden, a black cloud and sleet swirled around and through the open windows before we could wind them up. Within minutes the sleet had turned to snow and was settling on the road in front and behind us. We slowed to a crawl as the visibility reduced to a couple of car lengths, and trucks appeared and disappeared out of the gloom. We were all silently debating whether to turn back, when as if to answer our questions, in the eye of the storm we saw a truck rocking silently and seemingly in slow motion over the edge of the road, the valley bottom below lost in the clouds and snow. To add what might have been a surreal touch, but is something I have come to expect in Afghanistan, a cyclist came past, hunched over the bars, wrapped in cloaks, head entirely covered, but somehow sticking to the road. We were luckier in our return to Herat, but Kushk had to wait another day for our weekly visit.

Twenty-four hours later the road was hot and dry, the truck with its bed buckled was on the side of the road and we were on our way again. The road, which takes us halfway to Kushk, is metalled, but has deep cracks every 10 yards or so, so that for 90 minutes there is a steady “thudthudthudthudthudthud……” This has the convenient effect of numbing our buttocks for the second half of the journey along dirt tracks and desiccated riverbeds. On this trip however we were going a lot further, another 90 minutes deep into the countryside to visit the Kutchis, -the traditional nomads- to prepare for a day of immunizations and health education. A few weeks before some Kutchi women had visited Robyn, an Australian midwife, working at the clinic in Kushk. Maternal mortality, the numbers of women dying during or shortly after childbirth, is 170/100 000 in Afghanistan. This is the second highest in the world after Sierra Leone. In the US the rate is about 5/100 000. Nobody knows the rate amongst the Kutchis, but with no access to healthcare and almost no opportunity for education it’s likely to be even higher than the Afghan national average. The road to their tented villages reaffirmed their isolation and inaccessibility. Following paths made by camels and goats, over and around hills, leaning at angles which would have made lesser vehicles roll, along valleys so steep that we straddled the bottom and away from even a trickle of a stream in a stony river bed, we traveled deep into the dusty hills. Soon even the sparse bush disappeared and the soil was blackened and sooty. We remembered stories of a fire that swept over these hills in September during the wild pistachio harvest, destroying the crops and the grazing.
The villages of mud-plastered houses we passed on the road to Kushk had by now disappeared and we were aware of being in a far more desolate place. Craggy outcrops were the only landmarks amongst these monotonous hills. Eventually we saw the dark, sweeping woolen Kutchi tents. Ruined mud buildings crumbled back to dust and newer, better maintained, but empty sheep-pens with mud-brick walls on the hillsides stood in-between the tents and a vicious cold wind churned up the dust everywhere. A few mangy goats and camels gazed at the ground forlornly hoping for some young succulent shoots to appear. Occasionally someone would scuttle from one tent to another, head-down to avoid the dust, ignoring the white landcruisers parked as improbably as a flying saucer in front. Even the fearsome, enormous Kutchi dogs with their docked ears and tails, famous for hanging onto the back of a landcruiser for mile after mile, were strangely subdued.

We were introduced to the Arbab, the village leader and invited into his tent to explain our mission. Our Afghan drivers waited in their vehicles with the engines running. Later they told us that they didn’t trust these savages who shared their tents with their animals and lived in holes under the ground like mice. Far more spacious within than it appeared from the outside, the tent was cold but sheltered from the dust which the wind was chucking around furiously. Roughly butchered meat was hanging from a piece of rope above our heads as we sat on beautifully woven carpets and village elders came to join us. Despite it being one of the last days of Ramadan, we were offered saffron tea, which we gratefully accepted, accepting also the risk that the water had probably come from a filthy stream. We explained that we had come because some of the women from the village had come to ask for our help. The Arbab told us that every year in his village about ten women and many more children die. There is no healthcare, the Kushk clinic takes 6 hours on a donkey or a day on foot, but if anyone is sick enough to go they often choose to stay at home rather than risk dying en-route. A metre of snow can fall overnight in these hills and they can be stranded in their tents for days. The fires in September decimated the grazing and now they are facing a winter without enough food to last until the spring. They have never had any immunizations or education, but they are keen to learn. They list their problems, which are as we expect; respiratory infections in the winter, malaria in the spring, and diarrhoeal diseases including dysentery and typhoid in the summer. Maternal deaths are perennial and happen because of sick and malnourished women having many babies over many years in unsanitary conditions, with obstructed labour, infection and haemorrhage horrifically common. Many babies succumb to tetanus, diarrhoea and vomiting and pneumonia. Every woman is not just aware of, but is actually related to a mother or child who has died.

Over cups of tea we listen to their stories, bearing witness as one of the core values of MSF. We hear of the triumphs as well as the disasters, from these great travelers and ex-fighters, able to eke a living out of these barren hills. They show us their wells over 30 metres deep and dug by hand, and their beautiful hand-woven carpets, made without a loom. They will identify 20 women and prepare a tent for the training day, and will inform all the women and children about the immunizations.

We plan to come back on December 9th.