Young British Engineer on His First Mission with MSF in Pakistan

22nd May 2004

All,

I am now in the town of Sadda, in the middle of the Tribal Areas of the North Western Frontier Province (NWFP) on the border with Afghanistan. I made it to the Shasho hospital for the first time yesterday and finally saw the nature of my work for the next nine months. Wards to re-commission, incinerators to build, water to chlorinate, accommodation to find, generators to service…. and that doesn’t even consider the medical aspects of the programme, from referral ambulance service to pharmacy to patient record keeping system……it goes on and on, and I’m still not aware of even the half of it!

The hospital is situated in an “interesting” area. The tribal regions are a set of locally administered states, 7 in total I think, and each governed by a group of tribal elders. The elders are “influenced” by the government in Islamabad through a complex set of grants, payments and permissions, all negotiated through a Political Agent with responsibility for each agency’s security and stability. As I understand it at the moment, the road system in the tribal areas is owned by the government (a purchase made by the British before Partition in the 50’s in an effort then to limit the taxes on trade each tribal area placed) and there is a complex set of permissions needed to travel…all of them involving armed escorts!

As things stand at the moment, getting to Sadda involves the collection of three armed guards (Levies) in Peshawar that enable us to travel into the NWFP. At the entrance to the Kurram Agency (in which Sadda lies) we change the Levies for some others, locals this time (and again with Kalashnikovs) and from that point on we’re escorted everywhere we go. Unsurprisingly MSF (and us) aren’t great fans of this arrangement so we have separate cars for the guards, and are trying to limit their role to one of “the further away from us you are the better”. They don’t come into any compounds with us and spend most of the time drinking tea in the shade.

Initial impressions are that the guards are simply a formality. Everywhere we’ve been so far seems friendly and welcoming. Very few westerners are about in this area so certainly the locals are curious, and unsurprisingly there’s the immediate assumption that we’re American with all the ill-feeling that provokes. I’m doing lots of patient explaining as to our intentions, where we’re working, what nationalities we are, what MSF’s charter is and all of the other good things! We are forever being invited to sit for tea and talk, and while we’ve made a security policy that’s fairly strict at present, I’m sure we’ll be able to work here safely and effectively – especially once more widely known in the area.

Surprisingly for many MSF destinations this area is actually quite beautiful. The surrounding land is predominantly brown with short scrubby trees, (temperature is mid thirties during the day so unsurprising really) but the wide stony river at the base of the valley means there’s sufficient water for paddy fields and fields so the area is fairly fertile.

Sadda sits at 1300m above sea level and the land rises from the river in low foothills leading to 4-5000m mountains (some still with snow on the tops) on the Afghan border – probably 10km away as the crow flies. There is one road through Sadda onto Parochinar and the Afghan border, where there’s a pass (for locals) but no official border crossing. This area has long served as the buffer zone between Afghanistan and Pakistan and the free movement of populations has been ongoing for decades.

Although we don’t have a permanent place to stay yet (house hunting is one of my early responsibilities) we’ve been put up by the UNHCR in a large spacious compound with a garden and all mod cons. As the team will be spending large amounts of time in wherever we finally end up MSF believe very firmly on not pressuring their staff unduly through poor living conditions so I’m currently hunting for a compound for Mark (the Doctor), Maria (the project co-ordinator) and I. The only available one I’ve found so far has 14 rooms. Excessive it may seem but at about $150 per month an affordable luxury…..!

We don’t have permission to stay in the area for more than 4 days a week at present so are based in Peshawar, a 4 hr drive away where MSF maintains a house and we have our main medicine store (186 cartons delivered 3 days ago in a large truck decorated in true Pakistani style – beautiful colours, ornate metalwork and a fantastic array of dangling chimes).

Back to Sadda and the real reason we’re here: In terms of health needs and what we’ll be providing my understanding is still limited – indeed we’re still to agree some of it. The hospital is the only almost-free healthcare in the area (a token consultation and dispensary charge is levied) and it is currently funded by a Pakistani relief agency – PIMA. PIMA’s suffering a shortage of funds at the moment so they are closing areas of the hospital. First to be hit (and our primary purpose here) is the mother and child healthcare unit – 2 wards, 20 beds, outpatient’s consultancy and all of the paediatric surgery. Shortages of staff, poorly maintained infrastructure and lack of basic training all characterise the remainder of the hospital and although not specifically our remit, we hope to positively influence the other departments as much as possible.

What’s the hospital like? When I had my first visit yesterday I poked my head round the door of one of the paediatric wards. The kids had a bed each, but the mothers and invariably brothers and sisters shared it – where can the rest of the family go if the mother needs to be with one sick child? The place was being cleaned when we arrived and a slurry of dirty dressings, used needles, syringes, bits of food and general dirt was being sluiced through the ward and out into the corridor, where other barefooted kids splashed about round the needles. The floor was concrete, mattresses dirty and collapsing, walls filthy and a fairly strong smell of compost.

The area is almost exclusively Muslim, so the segregation of males and females is everywhere. Walking into a ward full of women is a certain way of feeling unwelcome - scarves cover heads, talking stops, everyone looks at the floor – in reality it’s not unwelcoming, just cultural! Women don’t talk to men, can’t be seen by men and can’t be effectively be treated by men…. an interesting challenge in a hospital with 5 male doctors. (…we have already begun the recruitment process for a female doctor in case you were wondering how we were getting round that one!)

The patients come from the local area….Pakistanis from Sadda, Afghan refugees from the numerous camps up and down the valley and a small population of nomadic Kutchi people from their encampments wherever they are. Without this hospital there would be no affordable healthcare for these people – something serious in this area with its rising malaria infections, leishmanisis problems, TB, malnutrition and countless other nasties I’m only now beginning to find out about…..”Haemorrhagic Fever” in particular is a new one on me!

In summary so far I have my feet about 15 feet off the ground. Day 1 I arrived in Islamabad and drank tea. Day 2 I was buying second hand cars for the project in Islamabad (sadly a couple of white Toyota’s instead of the black Range Rover I had my eyes on.) Day 3 was spent driving to Peshawar. Day 4 involved organising the office, setting up the filling system and medicine store. Day 5 was spent shopping in the bazaars for everything needed for an effective office (including furniture, mosquito nets, and lots of insect repellant!). Day 6 in Kurram Agency inspecting the hospital, hunting for houses with armed guards and drinking tea with the local head of the UNHCR and today, …..well it’s now midnight, I’ve had a chance to reflect on my first week here by writing this and I have still to worry about how I’m going to build a 1000 degree incinerator, how much the re-commissioning of 2 accommodation blocks should cost before next weeks tradesman’s meeting (and no doubt animated price haggling) that I arranged today, I have 20 mattresses to find, offices to identify, a food store to build, generator to service, and the small matter of a compound to find……it’s certainly a challenge, but I’m loving every minute of it.

Bye for now

Tom

Since this letter was written, the brutal murder of five MSF staff in neighbouring Afghanistan has had major implications for Tom and his project.