Timergara is in the region of Lower Dir in Pakistan, close to the Afghan border and on the banks of the Panjkora River. Médecins Sans Frontières (MSF) has been working here for over 12 years, and at the end of January 2021 handed over the last of our activities in the district headquarter (DHQ) hospital to the Ministry of Health.

MSF’s work in this corner of Pakistan demonstrates the changing landscape of the country over the past decade, with activities evolving from mobile clinics and emergency surgery, to training sessions on misuse of labour-inducing drugs and COVID-19 triage.

Over the years, rehabilitation work and upgrades of the newborn unit, the maternity ward and the hospital waste zone were completed, amongst others, and an x-ray unit was installed in the emergency room. During the time we supported the project, over 96,800 deliveries were assisted, more than 9,000 newborn babies needing further medical follow-up were admitted to our newborn unit, and more than 1 million patients were seen in the emergency room. But there is so much more to this project than the figures.

“MSF adapted its interventions to respond to the needs of the most vulnerable people in almost the whole area,” said Ijaz Zarin, deputy project coordinator for MSF in Lower Dir, who had been working in the project since it began. “We successfully managed to help those in need when the health services in the outer areas of Lower Dir were almost non-existent.”

Conflict and displacement

Back in 2008, local health services and host families were under strain due to massive displacement in what was then known as Pakistan's North West Frontier Province (NWFP) and is now Khyber Pakhtunkhwa. Conflict had forced over 2.1 million people from their homes and most found refuge in small camps or with host families. MSF supported local health structures, including the Timergara hospital, to help them cope with the new and increasing needs, and provided relief items such as tents and blankets to displaced families.

As well as treating those wounded in the conflict, MSF teams worked with Department of Health personnel on how to manage influxes of wounded. In 2010 there was an explosion in the city, roughly 600 metres from the hospital, and doctors and medical staff treated 88 people injured in the blast. This was the third time in six months that MSF had to initiate a mass casualty plan in the hospital’s emergency room.

Natural disasters

But it wasn’t only conflict that posed a challenge in the area. In July 2010, severe flooding hit Pakistan and caused widespread destruction to both houses and infrastructure. Timergara project was for a while inaccessible, as all the access bridges had been destroyed, but the staff continued treating trauma cases. At this point, more than 1,300 patients were being seen each week in the hospital’s emergency room and approximately 100 surgeries were being conducted each month in our emergency operating theatre.

In October 2015, an earthquake rocked parts of northeastern Afghanistan and northwestern Pakistan, and Timergara hospital was faced with an influx of seriously wounded in the first few hours. Over 200 patients were triaged, stabilised and treated in the emergency room, and MSF continued to support those seriously injured who were moved to other wards in the hospital.

“I was on duty in the emergency room when the earthquake jolted the whole region”, said Javed Iqbal, who worked for MSF as a nurse in the Emergency Room at that time. “Within moments, we had to activate our mass casualty plan as a heavy influx of patients started arriving at the hospital.”

Mother and child health

Pakistan has one of the highest newborn mortality rates in the world, with one in 17 babies dying during the first month of life. In response to the needs in Lower Dir, in 2012 MSF built an extension to our existing mother and child facility, and in 2017 the neonatal unit grew from 18 to 34 beds and included an eight-bed ‘kangaroo mother care’ room. As of 2020, up to 1,100 babies were being delivered every month at the DHQ hospital in Timergara, and 20 per cent of the pregnant women were arriving with complications; 14 per cent requiring a caesarean section.

In addition to supporting the care being given to pregnant women and newborns, MSF also conducted awareness-raising sessions with healthcare workers on the use and misuse of oxytocin. Common in Pakistan, unregulated use of oxytocin to speed up labour can lead to complications such as uterine rupture and put babies at a significantly higher risk of suffering severe birth asphyxia and stillbirth. The unregulated use of oxytocin also puts the mother’s life at risk.

Outbreaks of disease

Annually during MSF’s time in Timergara hospital, teams have helped manage seasonal outbreaks of disease such as dengue, measles and acute diarrhoea by setting up isolation wards and treating the sick. During an acute watery diarrhoea outbreak in 2019, MSF treated over 2,000 patients.

The most recent challenge, however, has been COVID-19. On 3 April 2020, MSF installed a COVID-19 screening system at the entrance of the DHQ hospital, to help protect against the virus and prevent it from spreading inside the facility to healthcare workers, patients and their caretakers. An isolation ward within the hospital was also set up, which at the peak of COVID cases in June had 30 beds. Over the course of the six-month intervention, nearly 21,000 people were screened, over 3,300 COVID-19 consultations were undertaken, 106 were transferred to a facility with a high level of care, and 187 patients were managed by the MSF team in the isolation ward.

Moving forward

MSF first started supporting the DHQ hospital in 2009. By 2010 a new operating theatre, a post-operative unit, and a sterilization and waste management system for the hospital had all been established. The following year, MSF was also supporting the delivery room in the mother-and-child healthcare ward, as well as the hospital’s blood bank and laboratory service. And over time activities expanded further to include mental health counselling and other health promotion activities.

But MSF is an emergency medical organisation that responds to urgent needs in an area for a certain period. Over the years, the capacity of the hospital and its staff have been enhanced and after more than a decade of support, it was decided in 2019 to gradually hand activities back the Department of Health. This started with the emergency room in March 2020, followed by the neonatal unit in August and the remaining activities in early 2021. The needs in the area have not disappeared, particularly with regards to mother and child health, but the Department of Health is in a much better position today to run all the services in the hospital than it was previously when the area was still in conflict.

“The handover of MSF medical activities in Timergara DHQ hospital does not mean the end of our relationship with the area or with Khyber Pakhtunkhwa province,” said Aymen Abdullah, MSF’s country representative in Pakistan. “MSF remains committed to the people in the region, and we continue to investigate what future medical activities could be possible, with a lighter and more mobile approach.”