MSF activities update Pakistan: October 2008

Overview

Since 1998 Médecins Sans Frontières (MSF) is working in Pakistan to provide medical care for Pakistani nationals and refugees who are suffering from the effects of natural disasters and armed conflict. Pakistan has one of the highest infant and maternal mortality rates in the region. There is poor access to good quality and affordable health services, particularly in remote rural areas, where access to safe drinking water remains scarce and sanitary conditions are poor. Women and children are the most vulnerable members of society and tend to be worst affected by the shortage of healthcare.
MSF is currently carrying out medical activities in the North West Frontier Province (NWFP), Federally Administered Tribal Areas (FATA) and in Balochistan, with 429 national and 23 international staff.

Tribal areas, NWFP: Violence makes access to health care extremely difficult

MSF works in some of the Federally Administered Tribal Areas (FATA) and Northwest Frontier Province (NWFP) in Pakistan. Along the Afghan border fighting for the control of the area broke out a few years ago. Not only has the Afghan conflict spilled across the border, but armed clashes between the Pakistani army and armed opposition groups in the western areas of the country are on the rise, accompanied by a dramatic increase in sectarian violence. MSF teams report that civilians are frequently direct victims of violence in an increasing number of attacks. MSF teams regularly have had to bunker down in the hospitals, ambulances have been attacked and it is increasingly difficult to refer injured patients for surgical care. 

Swat Agency

Regular bombardments, suicide attacks and long curfew hours have drastically reduced movement in the district of Swat and the population is finding access to health centres very difficult. Violence is increasing, and the teams are seeing large numbers of people subjected to violent trauma.

In Saidu, where MSF is supporting the district hospital, the casualty department received 309 patients suffering from war wounds during the month of August alone. Since November 2007, MSF has been providing primary health care, ambulance services and distribution of relief items to the population of the conflict-ridden district of Swat. Until last year, the district was unaffected by the violence, but the conflict has now reached the area and there have been heavy civilian casualties and a severe disruption to normal daily life.

Since fighting began, MSF has donated drugs, medical material and equipment to the emergency room of Mingora hospital. The resources of the emergency rooms of the two main hospitals of the most affected sub-districts of Swat (Kabal and Matta) have been strengthened with extra human resources, medical equipment and medicines. The MSF team also does basic logistical repairs and distributes food, hygiene kits and shelter material to the displaced population.

In conjunction with volunteer doctors from the Swats Doctor Society, a non-governmental association, MSF is running mobile clinics in five different locations in Upper Swat. Around 4,000 consultations are carried out each month, providing medical care to the population, who are often unable to access the city and health structures due to curfews.

As a response to insecurity, MSF has established a clearly identifiable ambulance service, which is able to travel throughout the region and bring patients safely to the hospital. During the prolonged curfew hours imposed by the military, MSF ambulances are the only vehicles allowed to move, apart from a local charity ambulance. Between December 2007 and August 2008, 1,042 referrals took place by ambulance.

Bajaur Agency/Lower Dir District

In August 2008, fighting in Bajaur Agency escalated, forcing more than 350,000 people to flee the area. Of those who fled, 95,000 found refuge in the district of Lower Dir, including 35,000 in Summer Bagh and Munda Union Councils. MSF teams have directly provided hygiene kits and non-food items to more than 11,000 people. In addition, MSF is providing medical services through a fixed team and mobile clinics in the two union councils.

The situation in Dir is volatile and changing rapidly. Because of insecurity, displaced people who had returned home for Ramadan had to flee to temporary camps a few days later. To cope with the increasing numbers MSF started working in the camps setting up tents, latrines, and giving people access to safe drinking water and medical care. As of the third week of September 2008, more than 5000 people were sheltered in a camp in Summer Bagh village near the border of Bajaur. Due to continuing military operations, this number is expected to increase in the coming weeks. MSF will continue to provide medical care as well as water and sanitation support to the displaced people (and their host families) until they can return to their homes.

Charsadda district

Hundreds of families fleeing the violence in Bajaur have been taking refuge in Charsadda. Around 600 families have gathered in Palosa camp, a school on the outskirts of the town. Whilst local authorities and NGOs mobilised rapidly to help the displaced, access to water and lack of a functional sanitation system was one of the main problems in the camp.  53% of consultations were due to watery diarrhoea. MSF intervened to provide access to safe drinking water, provide a functional toilet system, washing area and a sustainable sanitation system. Hygiene kits, blankets and plastic sheeting was distributed.

A diarrhoea treatment unit will be set up in the camp, supporting Charsadda district authorities on case management and disinfection. Though the number of diarrhoea cases is now decreasing following the water and sanitation activities, it still remains a concern for the camp as well as the neighbouring community.

Peshawar area

Near Peshawar, a flash flood hit in August, affecting around 200,000 people. People had to quickly flee their homes, forcing them to leave their belongings behind. Camps have been set up and emergency aid is being provided, but in some areas the provision of water and sanitation materials and sufficient food is a problem. The people affected by the flooding have also been joined by those fleeing the violence in Bajaur.  MSF is working in Kander Kheil, a devastated village, with a mobile medical team, and distribution of Non-Food Items (NFIs).

Kurram Agency

Sectarian violence in Kurram Agency, one of seven agencies in FATA, has meant that providing assistance in the towns of Alizai and Sadda is increasingly difficult. Sectarian tensions are reaching new levels against the backdrop of fighting throughout NWFP and FATA.

MSF’s main activities in Kurram are the provision of mother and child healthcare and paediatric support. Since March 2006, MSF has provided outpatient and inpatient paediatric services in the Alizai hospital. In May 2007, MSF also started work in Sadda Hospital, ensuring reproductive health including emergency obstetric surgery and neonatal services were also provided. The presence of international staff is limited, so the project is managed by local staff for extended periods of time. The ongoing violence since the end of 2007 has led to a dramatic drop in patient numbers.  Insecurity means only the most critical patients will risk travelling to reach medical services. In 2007, teams treated an average of 1,800 patients per month, but the number of consultations dropped to less than 600 per month in 2008. Safe travel in and out of Kurram Agency has not been possible for the last few months making it too dangerous to move staff. In Alizai the clinic has not been properly re-supplied for months.

MSF has supplied displaced people living in fields on the outskirts of Sadda with shelter, hygiene and cooking kits. The hospital in Sadda has been provided with clash response kits and supplies to deal with an outbreak of watery diarrhoea.

Malakand District

In October 2006, MSF started working in Malakand supporting five health structures to improve delivery of primary healthcare, with a particular emphasis on maternal health. Malakand is a mountainous area where many health structures are understaffed, particularly with regards to female staff meaning that women’s health needs are not met.

MSF established an emergency room in Dargai Hospital in December 2007 and soon afterwards a Women's Clinic was set up to offer comprehensive emergency obstetric care and an operating theatre. In the first half of 2008 the team did more than 11,283 consultations in the emergency room and conducted about 697 deliveries. The emergency room sees about 500 patients per week, approximately two emergency surgeries every day. In the small hospital of Agra, MSF has converted one of the staff quarters into a women's clinic where reproductive health services such as antenatal and post-natal care and deliveries are conducted. 7,729 general consultations and 56 deliveries were conducted during the same period (first half of 2008).

Kala Dhaka tribal area and Darband Hospital (Mansehra District)
MSF is providing support to the rural hospital of Darband to ensure a functional referral system. A medical team is currently working in the out patient department, hospitalisation wards and supporting with emergency case management. Moderate cases are treated in Darband while very severe ones are referred to an upper level facility in Abbotabad or Mansehara.

In the Kala Dhaka tribal area of the NWFP, MSF is preparing a programme to respond to an outbreak of cutaneous leishmaniasis. In certain villages, our teams estimate that 60 - 70 % of children are infected. The first cases of Leishmaniasis will be treated in Darband hospital.

Assisting Afghans, displaced and neglected in Balochistan

MSF provides care in a rural health centre and supports maternal and childcare in Kuchlak, a largely Afghan refugee settlement just north of Quetta. Over 5,000 medical consultations are conducted monthly, including maternal and mental health support. MSF also runs an ambulatory therapeutic feeding program and has started treatment of cutaneous leishmaniasis.

In the border town of Chaman health actors are struggling to provide care for the residents of the city, in addition to the refugees and patients coming from neighbouring Afghanistan. In May 2007, MSF started assisting the Chaman Hospital with reproductive health, including emergency obstetrics, and neo-natal services and nutrition. The re-establishment of medical services was facilitated by work previously done by MSF in the Afghan refugee camps around Chaman up until the end of 2004.

In September 2008, MSF opened a new project in the eastern districts of Jafarabad and Nasirabad. The region is rich in gas reserves, but poor in health care. An intense internal conflict has been simmering for over 30 years. MSF worked in the region during the floods caused by Cyclone Yemyin in the summer of 2007. MSF surveys also found concerning levels of malnutrition in Jafarabad and Nasirabad. The opening of an emergency feeding programme for children under 5 in Usta Muhammad is the first step, with 68 children admitted in the first week. The programme is planned to incorporate mother and child healthcare

In June 2007, heavy monsoon rains exacerbated by cyclone Yemyin, caused flooding and displaced thousands of people in the western part of Balochistan (Mekran division). MSF responded to the emergency, complementing the activities of the Ministry of Health. In addition, MSF provided water and sanitation support, non-food item distribution including hygiene kits, in addition to shelter material.  During this emergency, MSF teams provided more than 150,000 litres per day of treated drinking water in Ormara District, and in Pasni, assisted in chlorination of trucks coming into the city with water and set up distribution points for safe drinking water. In and around Turbat (Kech District), MSF also distributed mosquito nets for the displaced people. The medical teams treated over 1,000 patients for acute watery diarrhoea in addition to malaria and skin infections during the first weeks of the flooding and set up a cholera treatment centre and five oral re-hydration corners. Doctors and nurses were sent to provide additional support and ran mobile clinics to target isolated communities.

After the initial emergency intervention, MSF stayed in Turbat to support primary health care services. Between 60 and 100 consultations are performed every day in each of the four health Centres (2 rural health centers and 2 basic health units).

In Turbat MSF is also working in treatment and prevention of malaria, being one of the areas in Pakistan with the highest malaria incidence. Since last year, about 7,900 people have been screened with malaria paracheck tests, among which more than 2,800 were positive and have been treated. In August 2008, MSF started an ambulatory therapeutic feeding programme in Turbat. 40 children suffering of severe acute malnutrition have been admitted in the first month of activities.