Dear All,

The news came through on the 3rd June, but the details were sketchy. Five staff, travelling in an MSF vehicle in Badghis, Afghanistan failed to make their scheduled contact. They were found, executed, several hours later.

I can’t go into details as I don’t know them yet, but the implications of this targeted attack have hit everyone hard. Badghis was widely believed to be a safe operating environment. The team were accepted by the local community and had been working there successfully and safely for a significant amount of time. What happened has sent shockwaves through MSF and the entire NGO community.

I keep thinking back to how we were welcomed “to the MSF family’ at the end of my mandatory MSF pre-departure course. That’s what it felt like then, and it feels even more so now. The mood is sombre, and everyone’s thoughts are with the families, friends and colleagues of Pim, Egil, Hélène, Ahmed and Besmillah.

The implications for MSF’s projects are also severe. The decision about when safe operation in troublesome areas is no longer safe is always a question of balance. An acceptable level of risk is determined, security indicators are identified and the situation is monitored continuously. Each identified risk is then mitigated where possible through procedures, travel restrictions and communication protocols with evacuation of staff resting as the final stage of each projects security plan. The decision is complicated - healthcare provision saves lives - withdraw it and people die.

In light of what has happened an immediate decision was taken. All expat project staff in Afghanistan and Pakistan were recalled to main accommodation points and projects in both countries have been suspended. ‘Assessment’, ‘investigation’, ‘discussion’, and ‘way forward’ are amongst the words being used to describe what will happen in the forthcoming weeks.

What does this mean for Shasho Hospital? When the call came through for us to leave Mark was doing his surgical rounds, Maria was 40kms up the road in Parachinar in a meeting with the Political Agent and I was sweeping out the room I was in the process of commissioning for an office. We had the first of our new Afghan Doctors, Walliullah, settling into his paediatric inpatient rounds and outpatients consultancy. I had plumbers, painters, carpenters, and an electrician (who smiles endlessly even when being shouted at for his inefficiency) working on the accommodation for the eight nurses we are in the process of recruiting.

Countless other loose ends concerning telephones, hospital mattresses, pre-arranged meetings with local NGO’s, discussions with the levy co-ordinators and meetings with local landowners were scheduled. Suffice to say leaving, without any idea of when we were to return, was complicated and felt wrong.

I’m also still unsure why it was that I found myself looking over my shoulder at every crossroads; why I walked that bit closer to the guards; why I gave in to the fraudulent demand for an extra Rs/20 at the road toll (although I do have the satisfaction of writing a receipt for the accounts with “theft” as the expense) and above all why I cast my eyes around as we drove down the road, looking suspiciously at all those I’d passed for the previous weeks with a greeting and a smile. Distrust breeds distrust – it’ll be hard to overcome!

The last week in the hospital had been productive. By spending more time there we are at last beginning to understand how it operates, and any remaining doubt I may have had about the need for MSF’s assistance were gone. Like everything, it’s when you look at the detail that you find the problems.

There had been reluctance to show us the waste disposal pit for reasons then unclear - it was the smoke rising from some waste ground across the road that gave it away. By following the path down through the low scrub bushes towards the river, a sea of discarded waste came into view. There was a hole – how deep I have no idea - into which incinerated waste should be emptied, but it was almost full. The surrounding area was a mix of needles, syringes, soiled dressings, assorted and unidentifiable clinical waste and countless small glass vials with the remains of the injectable medicines in them. There’s only so much incineration afforded by 4 litres of diesel daily, the remains were just scattered, smouldering, with the ashes blowing around in the afternoon breeze.

The hospital toilet facilities were also found and investigated. A row of filthy stinking pit latrines in a room additionally used as patient clothes washing area (on the floor naturally), rubbish dumping area and seemingly a children’s play area if the three kids splashing round their mothers were anything to go by. Poor drainage, slimy floors, no latrine flushing facilities and used by sick patients and their healthy family members alike. I believe there’s a shower block as well, but it’s locked and the green smelly open drain that runs round the compound wall doesn’t give me much confidence in its existing utility.

These are just some of the issues facing this hospital, but fortunately things can be done to change them. Sharps disposal systems, incinerators, maintenance of drainage systems, improved hygiene procedures….it’s all possible over time and will be hugely rewarding to see such systems functional.

It’s here in my thoughts that I have to be careful. A hospital challenge such as this can easily be treated by a non-medic such as myself as a simple matter of a bit of building, fixing and organising. I don’t do it intentionally but have found I sometimes think of the patients as someone else’s responsibility. To try and counter this I’ve taken to joining the ward round in the mornings when I can. This helps to gives me a sense of why I’m here without which I could easily get caught up in the excitement and specific achievement of the peripheral activities.

Standing at the bedside of a tiny child struggling to take four breaths a minute with his sunken eyes closed and his legs flaccid is sobering. Diagnosis is still uncertain, but as I understand it the decision sits somewhere between pneumonia and cerebral malaria. “Referred” written on his medical notes at the end of his bed doesn’t offer any hope in this case….it means ‘we’ve done all we can – we suggest you take him to a different hospital’- this will change, but probably too late for this child.

Burns seem to be another issue. The three kids with facial, leg and back burns are a depiction of misery. Infection is ever present and with the ceiling fans circulating the air in wards where infectious and non-infectious patients lie side by side, antibiotics are the only defence. Significant facial scaring for any young teenage female must be traumatic, but in a country where the role of women is so markedly different from that which I understand, I can’t help but feel pessimistic about the future of the fourteen year old girl in Shasho who had an accident with a pan of boiling milk.

Burns are common as local housing is cramped and over crowded, cooking is done inside on wood fires or erratic stoves and the perception of danger (or I suppose the value of human life) is much lower. Quite what happens to the incidence of burns in winter, when the frost and snow comes to the NWFP and fires are necessary to keep people warm remains to be seen. I can’t imagine it will be better.

Walking around the hospital seeing the patients certainly doesn’t make me feel good. I’m invariably horrified, outraged, sorrowful or angry, but I can see that things are beginning to happen. The satisfaction of identifying what elements can be put in place to ensure better functioning of the hospital does give me a rewarding glow, but it is not the sole source of my positivity about what we’re doing.

Mark and his subtle questioning of the existing medical staff has achieved a fantastic amount even at this early stage. On enquiring of the nurses (a team of four women, dressed in the ubiquitous Shalwar Kameeze with dark heavily made up eyes) about how often the sheets get changed, the response “never, but in our old hospital we used to change them daily” wasn’t a surprise. The sight of ten sheets on the washing line the next day was.

Maybe our enthusiasm is infectious, maybe our presence is giving a shared sense of purpose to improve things, or maybe there’s the (false) perception that a ‘rich’ NGO will provide cash hand-outs to anyone who helps. It’s too early to say for sure but small, self-introduced changes such as this is where the future for this hospital lies.

That’s always assuming there is a future.

Concluding this letter now, with our remaining colleagues from Afghanistan on their planes home and the entire Pakistan mission in Islamabad I feel helpless and angry. Our doctor is sitting in the hospital, with strict instructions not to practice. The four nurses we’d arranged to visit Shasho in our absence with a view to accepting positions were asked by us not to go. I have Hashim, my local purchaser, sitting in Peshawar with a car full of furniture ready to complete the staff compounds in my absence. Everything (except for the essential medical supply and administration of TB drugs to specific programmes) has been frozen by head office.

Partly this is in sympathy and solidarity for our dead colleagues, partly for assessment of Why? and How? Partly for fear that this could happen again and partly to make a political statement about the unacceptability of actions such as these towards humanitarian workers. It is the last statement that I think says most. How can humanitarian aid be provided when those without any humanity act in this way?

The freeze of operations means our work at the moment is fairly light. We are developing plans for remote operation; for occasional and random visits to the area; for work that can be planned and instigated by the existing hospital administration under our direction and mechanisms by which we can assess the safety and security of our local staff. We have identified where we want to be now, next week, next month….. for such a new project this is likely to be inaccurate and is certainly complex.

Without an established infrastructure, contacts network or understanding of the true functioning of the area in which we work my biggest fear is that the MSF management, who take overarching responsibility for all MSF projects, will view our continued operation at Shasho in the context of the Badghis tragedy. The losses may continue to grow: Pim, Egil, Hélène, Ahmed and Besmillah, their families, the Afghans they served in Badghis, the populations whose healthcare was provided by other MSF projects in Afghanistan, continued operations in Pakistan…?

All of this is supposition on my behalf but I am aware of one thing: Continued support to Shasho Hospital may require a fight.