Saira, Pakistan and Washington

Saira is a senior President’s Scholar and member of the University Honors Program who is majoring in biology and anthropology in Dedman College. She received a Richter Fellowship to travel to Peshawar, Pakistan, during winter break 2012 to research the health of Afghani refugee children. Then, during spring 2012, she will intern with the U.S. Department of State.

The visit

Giggles filled the air in the bright, naturally lighted room. I put myself in their shoes and realized I’d be laughing, too, at what seemed to be ridiculous questions. I was visiting my first patient’s home, Tahira, to interview her and her family in a more familiar setting and observe their living conditions. Of course, most of my questions regarded diarrhea.

I had wanted to visit their home so that Nasreen, Tahira’s mother, would be more comfortable. I was hoping she would be able to go about her work, as I merely observed and asked questions about how and why she did things. I soon found out this would be impossible.

As I stepped into Nasreen’s home, I was surrounded by the 15 curious faces of sisters-in-law and daughters. Nasreen briefly showed me around her house before her eldest sister-in-law, Tehmina, took over. There was a clear hierarchy in the house, which consisted of the eldest female serving as the speaker of the household (among females, of course). All of questions I initially had prepared for Nasreen were now being directed to her sister-in-law.

As Nasreen moved in and out of the room, checking on her children and situating herself after a one-week stay at the hospital, Tehmina insisted we have chai. She proudly told us about the two fridges they had, one on rent and the other they owned. She explained the living situation and how each nuclear family had their own room. From the corner of my eye, I could see female neighbors peeping over their low-rise walls to see who had come to visit.

I walked around the house and started taking pictures, I soon learned that women and girls over the age of 11 didn’t want their pictures taken. Though I respected their wishes, it became a game to flash my camera out and watch everyone laugh and disperse out of the camera’s view. I would be surrounded on all sides by women and children one minute and confused wide-eyed children the next.

I watched as children took care of younger children, and a girl not older than 10 picked Tahira right out of Nasreen’s hands not two minutes after we walked in the door. I noticed that families raised each other here; an aunt was as likely to act as a child’s mother.

Nasreen’s husband had died not long ago, and she had no source of income. The extended family household made sure, however, that she and her family were taken care of. Though none of them lived in luxury, a contentment pervaded the atmosphere. Children laughed easily and mothers happily washed clothes and cooked in the background.

As we were leaving, Nasreen’s brother attempted to pay for our rickshaw back to the hospital. I was awed. People who barely had enough to feed themselves wanted to make their guests as welcome and comfortable as they could. The Patan hospitality was such that they would feed you before they fed their own. I was humbled. I had fallen in love with the Patan people.

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The value of a life

I shudder every time I think about it. My eyes fill with tears without fail. In the past two weeks, I’d seen more pain and suffering than I had in my entire life.

A bomb went off four days ago on  a main road that we cross every day on our way to the hospital, 30 minutes after we crossed it. The victims were all rushed to the Mass Emergency Unit, my unit. I had left the hospital by then, but the next day I was filled in on the situation. Twelve were injured and six killed. The head nurse said the situation was good compared to two years ago. The situation had improved.

To me it didn’t appear so. Today, another bomb went off on the outskirts of Peshawar. This time I was at the hospital.

The doctors were on their first day of strike due to the killing of another doctor. They worked with a fraction of their already short staff, and then it began. I heard shots commanding people to make way as stretchers were rushed into the Mass Emergency Unit. I sat unaware in the doctor’s office discussing diarrhea patients (whom he was refusing to see) when a nurse came to inform us of the bomb that had just gone off. The doctors remained unfazed. Unlike me, they had learned to detach themselves from the situation. I didn’t know how to react – whether I should rush out and see the bomb patients or stay protected in the doctor’s office. I decided to take the middle road, and slowly went out to observe the almost peaceful chaos that had taken over the ward. I grabbed a colleague and told her she had to go into the Emergency Room with me – I wanted to see it for myself.

The doctors had started temporarily bandaging patients. Patients came in two or three at a time, but nurses, doctors, families and media were beginning to fill the room. The patients were stabilized and then sent to the surgery ward one after the other.

I had been taught that every life was valuable. The horror right before my eyes spoke to the suffering of the country of Pakistan. People need to know about Pakistan. Here’s a news story about the bombing.

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Making a difference

I walked into a wall of human warmth. The stench of spit-up, human refuse and sweat filled the air. I almost vomited.  I swallowed hard and entered.

Though I had already properly interviewed 20 patients, winter wasn’t the “season” for acute gastroenteritis, and I wandered into Children’s A Ward to see what else I could find. I found myself in a small, side laboratory that catered to the children’s ward. Its rudimentary setup consisted of a single microscope, sulfur, methanol and other testing chemicals. Children’s stool, urine and blood samples were brought in to be tested. Across the hall were a pharmacy tech room, several side chambers for more stable patients, a Higher Disease Unit and a neonatal and pediatric Intensive Care Unit.

The lack of privacy and structure was evident even to an untrained eye. Mothers openly breastfed, and patients’ siblings ran around half-naked and often unsupervised. For the duration of their stay, patients lived in close quarters, their families occupying all parts of the hospital. Families ate, prayed and slept where their children lay ill, and I often wondered whether patients could get sick from all the chaos around them.

Two-month-old Wajeeha was on an intravenous saline and dextrose solution because she was unable to keep down the Oral Rehydration Solution (ORS) that was necessary to rehydrate her. Her mother fed her often, but every few minutes Wajeeha threw up and the stench of diarrhea filled the air. Many mothers were unable to afford diapers, and instead swaddled their babies in cloth diapers that were unable to contain defecation. This increased the contact with the refuse most likely caused by rotavirus, which was spread via fecal to oral transmission. Even when they washed their hands, they used the same hand to turn off the tap that was turned on with a previously dirty hand, possibly reinfecting themselves. That is, if they even washed their hands.

Due to the culture of  scrimping, I knew that even if disposable diapers were made available, they would be used multiple times to their maximum capacity, and in turn could harm the child. But what if a washable, plastic sealed diaper was made available to these mothers? Would the spread of fecal-to-oral disease greatly decrease? I began to truly realize the importance of educating these mothers.

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UNICEF’S presence

His face was sunken; his eyes bulged and twitched. He could barely hold up his head on the Dora-the-Explorer bed sheets. His mother looked exhausted and defeated. It was old man’s syndrome. I thought he wouldn’t make it.

We were receiving a tour of a third hospital. I was particularly interested in the Children’s Ward, which was crowded with children and their families. Families stuck together – patients would make the journey here, some all the way from Kabul, with mothers, grandmothers, aunts and uncles – a full support system. Though it was crowded, sometimes with three patients to a bed, I was impressed with the efficiency and determination of the young, overworked doctors. Unfortunately, I can’t say the same about all the doctors I met there.

A doctor led us around Children’s B ward, which consisted of two admit patient rooms, a rehydration unit and a recently built malnutrition unit. A nutritionist within proudly informed us that UNICEF had funded and built the malnutrition unit in 2009. And athough it was built as a part of the government-run hospital, its nurses, staff and doctors were funded by UNICEF. It was small and well run, with our childhood cartoons lining the walls. A mini playground of sorts occupied a corner of the ward, with a swing and slide for the many children who went in and out of the ward.

Our tour finished with a show of the large outdoor lawn, which held a few chairs and benches. I couldn’t stop thinking about the old child. The next day I began my work in the Emergency Patient Services unit – a five-minute walk from the Children’s Ward. Three days later I found myself back at UNICEF’s malnutrition unit. I had to see what had become of the child. Expecting the worst, I braced myself. The marasmus, or protein and calorie deficient child, was alive and being discharged that day. The pure joy that follows relief could be seen and felt in the mother’s presence; a smile lit up her face as the child laughed on cue at her tickles. She called me over,  encouraging me to take pictures of her saved child. The $50,000 malnutrition unit had saved her child and many before. UNICEF had made yet another difference.

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A different world

A heart-wrenching wailing filled the ward.  Screams were followed by soothing words, deep breaths and wails anew. It filled every corner in a stifling fog of sorrow.

I was at a large government hospital for the past week enrolling patients in my gastroenteritis study. I recently expanded my access from Emergency Pediatric Services (EPS), which deals with acute gastroenteritis patients, to the Children’s Ward, which deals with more severe diarrhea patients. There is a world of difference between the two wards, and I like the upbeat, somewhat chaotic nature of the Children’s Ward.

The past week was filled with incidents. A doctor was robbed and killed, and doctors all over Peshawar went on strike. They appealed to the government to arrange for greater safety measures for doctors. For the past three days, I have watched patient after patient turned away at the hospital door. I was torn between wanting to make the government recognize the horror of the doctor’s murder and the helpless faces of the poor. They crowded the outdoor gravel entry to the EPS waiting to be seen, while within an eerie silence settled over the EPS unit. The usually crowded beds, two and sometimes three to one, now held but a few patients. Nurses held light conversations behind the registration desk, and the lone doctor fluttered in and out, refusing to see patients and sending them to the already crowded Children’s Ward.

I was interviewing a 15-year-old mother on the last bed of the four-bed ward about hygiene practices, breastfeeding, water sanitation and various other diarrhea causal factors in Children’s B ward. I had seen a few doctors run in and out of our room and what appeared to be an attempt at CPR from the corner of my eye, but I stayed focused on my patient until the crying began.

The mother I had interviewed the day before was crying and attempting to comfort a sobbing woman in her arms. Some mothers wept along with the now childless mother, while others stared ahead dry-eyed, devoid of emotion, rejecting their fears that their child could be next. Tears filled my eyes and began to blur my vision as I leaned over to ask Mariam what the wailing mother was saying.  She stared ahead and in a barely audible whisper said: “God help me, God help me – what will I tell my family?”

While we worry about our children going to college and making the right friends, these mothers worry about their children surviving to their first birthday and then each one after that. It doesn’t seem fair.

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Day 4: My research begins

Children could be heard crying from every direction. In one room, a child was receiving a shot; in another, an IV was being started. My heart broke for them. I wondered how long it would take for me to become desensitized to their crying.

Attempting to battle jet lag, I decided to take my host up on her offer to visit the hospitals where she was beginning her rotations. We were expected to wait as final-year medical students were being taken on rounds. Of course, for a group of ten 21-year-old girls, that means explore.

An organized chaos filled the hospital, one you couldn’t understand unless you were groomed in their system. We split up and wandered from room to room. As we were inspecting the female ward, an excited student informed us that a birth was happening downstairs. We rushed to (thankfully) find out that the child had been born a few hours before. The proud grandmother held her grandson in the post-maternity ward, where we all gushed over how handsome and healthy he is. This led to my first introduction to the children’s ward at one of the three hospitals in which I would be conducting my research.

Two stark rooms were filled with only the bare necessities. Peeling walls surrounded eight rusted metal hospital beds; patient files lay on metal desks attached to the beds. We accessed the patient files (no HIPAA here) and assessed how many patients had acute gastroenteritis and whom we would be able to interview later. We learned that three patients had indeed been admitted for diarrhea.

Before we could start our interviews, though, the medical students were called down to the head doctor’s office, where they were being taught how to check the thyroid. Again, chaos filled the air. Patients filed in and out waiting to be seen by the doctor (who was teaching us), a child was receiving a rectal exam behind a sheet-like curtain, and students crowded around a patient with an enlarged thyroid. I took it all in from my bench in the corner of the room.

It is in this environment that I would come to learn the importance of effectiveness over privacy. These refugees, displaced people and Patans had been thrown into a world where the little things we value in America don’t matter. They wanted to get better, and they were willing to forgo a privacy they never knew in order to receive it. It was this openness that allowed me to begin my research.

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Landing in Pakistan

The first thing that hit me was the smell. The pungent smell of dirt, dust and human sweat was a familiar one and alerted another one of my senses that I was in Pakistan.  The sight confirmed my nose’s insight- a fog of dirt and dust hung in the air, preventing one from seeing far ahead of the airport platform. Pashto surrounded me, and although it was Pakistan, I felt like I was truly in a foreign country. I couldn’t understand much beyond the passionate gestures of the Farsi-derived language.

I had donned the hijab in the airplane and kept thanking my dad for reminding me to do so. I was one of four women on the airplane from Doha to Peshawar, and even with the traditional garb I could feel eyes curiously looking at me in Peshawar’s baggage claim. I kept my gaze lowered and allowed my brain to go into overgear, creating absurd abduction stories. I only occasionally glanced up and caught sight of the beautiful people around me. Some wore the ­­­keffiyeh, indicating that they had recently come from Saudi Arabia, while others wore the intricately patterned white prayer cap.

After receiving our luggage we were greeted by our driver at the airport, Walee, who was lovingly called Chacha, meaning uncle. His weathered, tan skin and fist-length beard made him appear experienced and older, but his eyes told another story. They seemed knowing, but young and vibrant. It was later that I found out he indeed wasn’t very old; he had two children under the age of 10. He informed us (thankfully in Urdu) that we had a long ride ahead to the house. Being from Texas, we expected our ride to be at least an hour and a half, and I comfortably settled into the back seat with our piles of luggage.

From the safety of the car, I finally allowed myself to openly look at the people around me. The cold weather had caused many of the men to also wear the chaddar that women typically wear for warmth. Their distinct features – piercing green eyes, chestnut-colored hair and light skin – marked them as Afghani immigrants. After leaving the airport, I took in Peshawar’s scenery. Its dusty roads and lack of road rules were all too familiar. Within 30 minutes we had reached home; I soon learned that more than a ten-minute drive in the small city of Peshawar was considered a long trip.  My dad and I settled into our room and allowed our exhausted bodies to rest.

Not more than an hour and a half later, I awoke to the sound of azan, the call to prayer, filling the house. The beautiful Arabic language resonated in the city. One could hear azan from one mosque start and then another and another, so that one could hear the typically five-minute azan for fifteen minutes if they tried hard enough. I got out of bed and thanked God for a safe journey and prayed for a successful project; we had arrived in Peshawar.

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Preparations for Pakistan

She told me they were beautiful people. Kind, respectful, hospitable. This was a first for me.

My last two weeks have been security meetings, warnings, and updates about the perils of Peshawar, Pakistan. For the first time, someone wasn’t lecturing me about the dangers of Peshawar, but rather was telling me about what it had to offer.

I am traveling to Peshawar in two days to research the prevalence and prevention of acute gastroenteritis (yup, diarrhea) in Afghan refugee children. The past six months have been filled with research, proposals, countless revisions, review board submissions, creating questionnaires, information searches (not to mention the innumerable Wikipedia searches) and, finally, attaining the Richter Fellowship.

When I first began to look into the history of Afghan refugees and their personal migration stories, I did not think to look to the natives and ask about their perspectives. My meeting with the Peshawar-American immigrant made me realize that many Peshawarites viewed Afghanis the way many Americans view illegal immigrants. The description of the beauties of Peshawar and its people was followed by a slight tone of negativity. The struggles faced by these refugees are well known – they were exposed to armed combat, they were witnesses of extreme violence, they were often separated from or watched the death of loved ones. I realized that perhaps the refugees were a burden to the people.

The warnings began to resurface. Religious extremism, political unrest, the overall instability – were they a result of the influx of Afghan refugees? A new story unraveled – could the refugees’ lowly status be attributed not merely to their financial status, but also to their ethnic background? How did this affect the spread of disease? The analytical, research-oriented part of my brain pulled me one way as my emotions pulled me another.

I was pulled back to the present as she offered me chai. She wrapped up her accounts with a story of her father. I could sense the nostalgia of home that she felt, and that’s when I realized this place is home for some, not merely my “project.”

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