Agra Health Care Project Final Report
January 27, 2014
Dr. Rubina Mumtaz
The calamitous floods of August 2010 in Pakistan affected up to 20 million people in what is now considered one of the country’s worst natural disasters in scale to date. Continuous monsoon rain caused repeated surges of floods along the Indus River and its tributaries in an estimated 70 districts across the country. Damage to 1.2 million homes, livestock, agricultural crops and infrastructure such as roads, railways, bridges, communication systems, health and education facilities rendered an estimated 8 million people displaced (IDP – Internally Displaced Person) and in need of assistance.
One of the worst affected was the Province of Khyber Pakhtunkhwa in terms of not only mortality and morbidity but also destruction of infrastructure and property. In the immediate aftermath of the floods, governmental, local and international agencies swooped down armed with donor funds and worked furiously to address the multitude of problems including health in form of mobile and fixed health service delivery projects. Over the next 2 years, most of these donors slowly closed up projects to move on to another disaster affected area in the world leaving the resources strained government to tie up the loose ends.
RMF actively played a role in providing continuous, high quality health care to flood affected victims in Districts Nowshera and Charsadda for over 3 years from September 2010 to September 2013.
Real Medicine Foundation (RMF), a US and Europe based non-profit public charity founded in May 2005 and currently operating in 15 countries, believes that "real" medicine is focused on the person as a whole by providing medical/physical, emotional, social, and economic support. The RMF Pakistan office was set up with the 2005 earthquake.
True to its mission of providing humanitarian support to people living in disaster and poverty stricken areas, RMF addressed the immediate relief needs of the people in KPK affected by the 2010 floods by conducting 12 free mobile medical camps, funded by Google Inc/Tides Foundation, across several Union Councils of Districts Charsadda and Nowshera from September to November 2010, reaching out to 23,965 people of which 67.8% were female and 21% children below the age of 12 years.
Following that, in response to the continued desperate need, RMF took up the task of setting up a stationary primary health facility, funded by APPNA, in December 2010 in Union Council Sardaryab, one of the many refugee Union Councils that were housing IDPs people in government run tent camps. The location of Gulbella within this Union Council was determined by its strategic location on the main Charsadda-Peshawar road on the bank of Kabul River easily accessible to displaced persons as well as residents from surrounding Union Councils. The Gulbella Health Project closed down in February 2012 after 14 months of service, in response to the KPK Government’s step of revitalizing the local BHU. In the course of this project, quality healthcare services were provided to 15,763 persons of whom 65.4% were women and 10.8% children under 12.
In alignment with our concept of never duplicating services, RMF relocated to Union Council Agra in District Charsadda, an area that was declared as one of the “worst flood affected Union Councils of Charsadda” by UNOCHA (Office for the Coordination of Humanitarian Affairs). For this purpose, RMF joined hands with PHF on 1st March 2012 and set up a healthcare project in Union Council Agra.
Pakistan Health Foundation (PHF) is a non-for-profit UK based organization founded in 2011 by a group of members from the Rotary Club Reading, UK. With its sole mandate to work exclusively on health issues for the poor and vulnerable people of Pakistan, PHF acquired a small plot of land centrally located and easily accessible by public transport, with the aim to construct a 10-bed hospital.
While PHF, in line with their role of the MOU, concentrated their funding in the construction of a hospital building that eventually entailed more than 16 months, RMF began its operations immediately on site in a small makeshift structure to ensure that the community was not devoid of healthcare services for a single day.
RMF-PHF HEALTH PROJECT STRUCTURE
Based on today’s Best Practices Modern Medicine, Real Medicine Foundation has developed a Comprehensive Integrative Primary Health Care Model (CIPHC) that includes three components of high quality primary healthcare services: basic Mother and Child Health Services and Community Outreach Health Education. The CIPHC employs local staff, tailors to local needs and incorporates proven effective holistic methods, all at a minimal cost; this model is implemented in all RMF healthcare projects across the globe. Therefore the RMF CIPHC Model was adopted in Agra.
Project Goal: To improve the health of the people, especially women and children, living in Union Council Agra, one of the Union Councils of District Charsadda worst affected by the floods, thereby contributing to the achievement of the Millennium Development Goals of reducing maternal and infant mortality in Pakistan.
- To provide high quality primary health care services free of cost to the poor and vulnerable.
- To provide MCH services, including antenatal care, gynecological/obstetric care and family planning.
- To develop a strong referral system to secondary and tertiary care facilities for patients needing advanced care.
- To provide a basic pathology laboratory for routine diagnostic investigations to augment both primary healthcare and MCH services.
- To conduct outreach activities focused on preventive health/hygiene education & promotion and capacity building by training community health workers.
- To create a sustainable and scalable model for other NGOs, private investors, and government to apply throughout remote regions of Pakistan.
- The project covers 20,000 persons in Union Council Agra; however, as per our previous experience in similar projects in other parts of the country, it is expected that communities from surrounding Union Councils will also access this health centre.
o The MCH component of the PHC addresses the unmet needs of the women and children of the communities living in UC Agra and neighbouring Union Councils. At an average, 29% of the female population is in childbearing age and 18% is pregnant or lactating. These women of childbearing age and children under 5 were the direct target population of the MCH Centre.
CONSOLIDATED 19-MONTH MORBIDITY REPORT
During the 19 months of operation in RMF-PHF Hospital Agra, we saw a total of 25,766 patients of which 14.2% were children and 85.8% were adults. Among the total patients the gender distribution was 37% male to 63% female. The breakdown is as follows:
During the 19 months at RMF-PHF Hospital the most common presentation at the hospital were acute respiratory tract infections (ARI). Other cases commonly presented and successfully treated were bloody and non-bloody diarrhea (11.7%), dyspepsia (10.7%), gynecological and obstetric cases (15.9%), scabies and other skin diseases (7.3%), urinary tract infections (3.7%) and hypertension (7%).
From March 2012 to September 2013 (19 months), more than 4,000 women in their child bearing age attended the hospital, of these women 1,370 came for antenatal visits, 2,005 women visited the hospital for gynecological problems and 717 women visited to discuss family planning, a total number of 4,085 MCH related consultations, demonstrating the local demand for MCH services and the rapport the hospital established with the local community.
The above graphical representation indicates the flow of patients for the top ten diagnoses (diseases) from March 2012 to September 2013.
A total of 837 cases were referred to secondary and tertiary level hospitals in nearby towns and cities. Details of patient flow during these 19 months are summarized in the table below.
Pakistan is one of three countries (Nigeria and Afghanistan) in the world where Polio has yet to be eradicated. According to the Global Polio Eradication Initiative, Pakistan stepped up its eradication efforts and numbers fell from 173 cases in 2011 to 58 in 2012. Unfortunately, with the advent of 2013, Pakistan became the most hazardous country in the world in terms of Polio where all persons involved in Polio drops distribution from grass root field workers, the organizational employees dealing with EPI as well as the security workers accompanying the polio workers have been killed by terrorists across the country. Beginning in December 2012 where 8 Polio drop workers and 4 aid workers were slain in Karachi and KPK respectively, these horrendous senseless attacks have not ceased or eased even slightly.
The killings are believed to have been the work of radical, extremist Islamic groups who call vaccination programs a Western conspiracy to sterilize Muslim populations. They cite the U.S. operation that led to the 2011 killing of Osama bin Laden in Pakistan as the foundation of their suspicion. It was a Pakistani doctor conducting a fake vaccination program in 2011 to collect DNA samples from residents of Osama bin Laden's compound to verify the Al Qaeda leader's presence there. As a consequence, the seeds of distrust of health campaigns with foreign links germinated.
Our Agra Health Center located bang in the center of this storm, 20 km away from the organization whose aid workers were killed on New Year’s Day 2013 did not deter from its Polio drop drive. Security measures were put into place to protect the staff but our Polio drive that began in January 2013 at our health center continued unabated. A Polio Awareness session was held before the start of the vaccination with parents of children. The attendants and participants were mostly women, men and children, who were informed about the importance of Polio eradication. It was also stressed that all children less than five years of age should be brought to the clinic for Polio drops.
Over a period of 9 months from January 2013 to September 2013,, in conjunction with the KPK Health Department and the Rotary Club Renaissance of Islamabad, a total of 1,704 children under the age of 5 years from not only UC Agra but also from other neighboring Union Councils were administered Polio drops.
Despite the fear and depression that was palpable at every turn, the silver lining was the brave commitment of our staff to continue risking their lives refusing to bow down to extremists’ demands. Based on their beliefs, they argue that the time of birth and death is determined by Allah, hence no mortal can change that; if their death is meant to take place in the hands of a terrorist attack, so be it. Meanwhile they are not going to allow a handful of twisted men change the way they live the life meant in their ‘kismet’ roughly translated as fate. This fatalistic view to life is perhaps the strongest weapon against the terror of extremist militants. It can easily be said that this view characterizes the resilience of the Pakistani people, a fact that has undermined all the efforts of the Taliban so far.
THE LIVES WE TOUCHED
One of our first patients to frequent our Agra Health Center, fifth born son of his parents, Parvaiz was born severely physically handicapped, affecting his speech and facial expression as well. Unable to communicate, the family always treated Parvaiz as mentally challenged as well and hence he had lived his 7 years socially ignored by his kith and kin except his mother who insisted that he communicated with her with his eyes. Attributing this to maternal instinct, the family cast aside the mother’s insistence that he was not mentally challenged, only physically handicapped. RMF’s Health Center was the first time the family had a doctor at a walking distance from their poverty stricken makeshift home. Parvaiz was brought to the clinic for his first ever evaluation by a doctor. On examination, RMF’s doctor came to the conclusion that his mother was right all along, Parvaiz was mentally as fit and aware as any other 7-year-old. Lacking the physical capacity of contracting and relaxing his facial and oral muscles, he was unable to speak or change his expression but could understand all that was happening around him. The expression of delight on his mother’s face was priceless; the family was instructed to keep Parvaiz fully involved in the family and all should talk to him as a normal person and given time and perhaps proper therapy, he might eventually grow to live a semi-normal life. A private citizen from Peshawar had donated the wheelchair, depicted below, to the family.
Spogmai, which means “Moon” was 20 months old when she came to our clinic with a presentation of a severe chest infection that, according to her mother, had plagued her on and off at varying intensities since her birth. The mother never understood that Spogmai was an asthmatic child and would turn to traditional healers for her repeated episodes of breathlessness and frequent chest infections. With RMF’s Health Center a 5-minute walk from the family’s house, Spogmai received a simple antibiotic course for her chest infection, diagnosed as pneumonia and recovered completely. The family was educated about asthma and instructed on how to prevent and/or deal with mild asthmatic attacks at home.
Mashal (which means “Light"), a 12-month-old girl, was brought to our clinic in UC Agra, Charsadda by her panic-stricken parents. Shepresented with respiratory distress, extremely high fever and a full body rash.
Mashal was born premature and her weakened state was exaggerated by the fact that she was not breastfed by her mother who had been misled into believing that bottled milk was a better option. A weak baby, at nearly a year of age, she looked 6-7 months old and could not sit unsupported. Mashal had contracted measles from her older siblings and cousins living in the extended family set-up and within a few days of spots erupting over her body, she rapidly slipped into respiratory complications and pneumonia. She came to us with very high fever, her breathing was rapid and shallow, and her skin color had a bluish pallor. The child immediately received urgent medical care and within a few days was on the road to recovery. Even in previously healthy children, measles can be a serious illness and as many as 1 out of 20 children under five with measles develop pneumonia. In developing countries where malnutrition and Vitamin A deficiency are common, measles can kill 1 out of 5 children. Mashal with her weak nutritional status, stood a reduced chance of recovery but it is because of our clinic that she was lucky to have survived this episode.
Mashal is the youngest of 6 children born to Sakeena and Amjad whose only source of income comes from Amjad’s daily laborer wages and, according to her mother, had not had any vaccinations since her birth (Sakeena delivered all her children at home at the hands of traditional birth attendants called 'dais'). Mashal was registered with our EPI team and we ensured that her vaccinations are up-to-date as her mother was educated on the importance of this aspect of all her children’s health.
Razia Bibi, a 70-year-old widow living alone whilst her two sons work in Karachi, 3,000 miles away, was plagued with several medical issues attributed to her advanced age. Quoting her:
“I am sick and can’t go to the hospital in Peshawar because I am alone and can’t afford the transportation. This hospital and your medicines gave me hope for life. Now I am not dependent on my children to come home on holidays and take me to the doctor.”
The Children of Agra
Private philanthropists from the UK donated a boxful of Teddy Bears to PHF who had them shipped to the Agra Health Center. About 25 Teddy Bears were distributed to children visiting the hospital and other children who poured in once the word was out that little furry toys were being given to each child, for no reason other than being a child, with the only return being asked was the pleasure of their delighted smiles. A light happy day where we hope the new furry friends provided comfort and smiles to the girls and boys, lessening some of the post-tragedy psychological trauma caused by the floods.
Three years after the fateful floods of 2010, in August 2013, District Charsadda was the last to be struck off the list of flood affected areas of KPK and the government announced that the road to recovery was at last present. The Pakistan People’s Health Initiative (PPHI), a semi-government body had signed an MOU with the KPK Health Department to adopt all the BHUs in the main districts of Charsadda, Nowshera and Swabi. In a matter of a few months, the PPHI will revitalize the BHU in Union Council Agra. Given our concept of not duplicating services, RMF decided to close down the primary health care services in the Agra Health Project at that time.