"There are new doctors in the hospital" - setting up a programme in Pakistan

For several years MSF teams in Pakistan have been running clinics and health centres in the regions bordering Afghanistan, where insecurity has had a serious impact on healthcare. But it has become clear that there are other rural areas in Pakistan where many people are finding it hard or impossible to get medical treatment that they can afford. This is particularly true of eastern Balochistan province, which has some of the most neglected healthcare in the country. Life here is harsh, with cold winters and dry, blistering hot summers. There are steep barren mountains in the north of the province and desert plains in the south that slope down to the Indus valley. "We have been trying to work in East Balochistan on a permanent basis for several years now," says Chris LOCKYEAR, MSF's head of mission in Pakistan.  "Our new programme in Jaffarabad district hopes to address some of the very great needs"

In June last year, cyclone Yemyin brought widespread flooding to Balochistan. "I was part of a big MSF team that came here to the town of Usta Muhammad," says Dr. Ahmed BILAL. "We started working in an area that was very hard to reach, and when we got there we saw how terrible the conditions were. Whole villages were destroyed and we started up treatment centres under the open sky. We treated about 3,000 people in two weeks. When we heard that in one area children were dying of diarrhoea, we very quickly did some 'rapid tests', which confirmed that it was cholera. The MSF base in Islamabad immediately sent down cholera kits and logistical materials and we set up six cholera treatment centres. We treated more than 300 children. Before our arrival four children had died of cholera, but after we set up the treatment centres there were no deaths.

"I remember the conditions being very, very bad - nothing to drink, nothing to eat. We covered the whole of that difficult area and the regional officials really appreciated the work of MSF - they said that MSF were right on the frontline, the first to get there in these terrible conditions.

"Working in the floods, we saw how bad the general health situation is here. I have been working with MSF for more than three years and I have seen many places, and I really think that east Balochistan is an area in great need. The land is some of the richest in Balochistan, but most of it is owned by landlords and the majority of people work as daily labourers. They often cannot pay for good food for themselves or their children. The mothers are often very malnourished and when they are breastfeeding, they have no proper food to give their babies. And sewage gets into the drinking water channels, which people are using for drinking, for cooking, for everything. The number of cases of diarrhoea, typhoid and hepatitis is very high and when they get diarrhoea, the children quickly become malnourished.

"In July this year we did a rapid nutritional survey and we found high rates of malnutrition in this district. So we agreed with the authorities that we should start a nutrition programme. We are working in the main regional hospital, an old 40-bed hospital that was built in 1944. It is in very bad condition, and we have been offered a separate ward that we are repairing. It is always busy and people come from far away, from all over the region. They know that there are new doctors in the hospital, 'doctors for weak children' they call us, and if people have a malnourished child at home they bring them to our programme."

The team is seeing increasing numbers of patients by the day and one of the biggest challenges is making sure that patients continue their treatment after the first visit to the hospital. "Having outreach workers who can visit people at home is very important because some people find it hard to come back for check-ups and to collect their next ration of therapeutic food," says Aleem SHAH, MSF's programmes officer for this region of Pakistan.  "People here are very poor and most cannot pay for transport. 90 percent of mothers in this area work as daily labourers, mostly in the brick kilns, mixing clay to make mud-bricks, or in the rice fields. They have to work 8 to 10 hours, in temperatures up to 50 degrees in July, and if they do not work a full day they do not get paid. So it is very hard to find the time to come to the hospital. They want to come, and they do come when they can, but often it is simply impossible, so we need to go out to their homes."

Gaining acceptance is also a challenge when starting to work in a new area. "A mother had brought her 2-year-old baby from a long way away by donkey cart," continues Shah. "The baby was severely malnourished so we had to give the child special therapeutic food rich in vitamins and minerals.  The first time the mother had come alone, but when she brought her baby back for a check-up, her mother and mother-in-law came as well. The baby was doing much better already, and there were tears in all their eyes. The baby had vitamin A deficiency, probably since birth, and was blind. They explained that he used to just lie there limp, but now he is getting a bit more active, showing signs of liveliness. I saw tears of joy and happiness running down the mother's face. This is the best thing, better than words, and it makes me feel that what we are doing is really worthwhile. Since this family went back to their village, we have had thirty more patients from this area, so it is clear that MSF is getting well known".

For now MSF has started with a nutrition programme, but Dr. Bilal suggests that MSF will need to do more in the future: "Tuberculosis is common; there is a lot of hepatitis; people's general health condition is very bad; there's almost no awareness about health education; maternal mortality is very high; and there are no c-sections in this district – women who have a complicated pregnancy are referred to a hospital 200km away, but people are too poor to get to other cities. Healthcare in this area is completely neglected. For the people in and around Usta Muhammad I think there is a great need for MSF to do more".