A Belated Eid Mubarak

I have to say that what has most impressed me about the Pakistanis, is their devotion to Islam.

I arrived during the period of Ramadan (or Ramazan as we say here) when our national employees were fasting during the hours of sunlight. Neither water nor food passed their lips during the entire day, they continued to plod along in their work without complaint in heat of up to 40°C. I would hear them rising at 4am to feed under the moonlight and regularly see them heads bowed in prayer, sometimes in the most peculiar of circumstances - on the side of the motorway or guards facing east during their break at a checkpoint.

I tried myself to fast for one day. I allowed myself sweet chai and water so effectively I was cheating, and it was still difficult! Admittedly tempers began to fray towards the end of the period, as everyone looked up optimistically for sightings of the moon in order to break the fast, but the strength of their belief must be incredible to endure such a test for a whole month. I have enormous respect for anyone who can manage this based solely on their love for Allah.

The Shalwar Kameez

Almost all women in Pakistan, including us expatriates, wear the Shalwar Kameez daily. Consisting of a tunic dress worn over baggy trousers, it is complimented by a long shawl-type scarf that can be draped over the upper body in a variety of fashions. (Photos to follow shortly, I promise).
It is quite a pretty garment, despite being designed to conceal our feminine curves and can come adorned with all sorts of beads and decorative embellishments. It has the added benefit of being comfortable and I do not have any problems wearing it…

…Aside from the technical problems it can cause. The scarf, usually several metres long, can be quite a tricky obstacle to manoeuvre in and I find myself constantly flicking it back over my shoulder or head from where it has slipped. I have had to learn how to perform a range of daily functions while wearing it. Not only have I almost strangled myself by getting it caught underneath the wheeled chair at my desk, or trapping it in the door of a moving car, it also very easy to trip over just while walking. Not to mention the challenge of avoiding dipping it in the toilet bowl every day!

Old Versus New

Islamabad is a modern city. Apart from the power cuts, of which I don't feel the pain due to the generator, one tends to feel that life here is of a modern age. Urban planning has been well thought out, and when driving along the roads armoured jeeps and other new cars imported from Japan are common sights. There is not so much to see out of the window that will tell you that you are in South Asia.

The town of Islamabad has an older sister called Rawalpindi that is what I would consider as much more authentic, only a few kilometres away. Going there is forbidden for us and this makes us even more curious to visit but sometimes we do get to see the traffic headed in that direction from the Margalla hills.

Tonight on our way home, we passed a donkey driven cart doing just that. With a family of seven on the cart travelling somewhere with what looked like almost all of their wordly possessions, it made me aware of where I was. A small but pleasant reminder that I am in South Asia after all and that not everything has been lost to modernism!

Insecurity Increases...

Bad news. The Taliban are supposedly united and strengthening; they are looking to cause trouble. And trouble they have caused. In just two weeks they have shook the country with daily bombings, five of which cannot be considered insignificant. Two with a direct impact on us.

The first, in Peshawar, led to the loss of one of our drivers who was off-duty that day and happened to be in the wrong place at the wrong time. I need not write much about the huge dent in the morale of the team, and his wife left with two children to feed.

The third in Islamabad occurred today in my neighbourhood, all too close for comfort. We felt the blast through our upstairs windows and heard the sirens wailing past at full speed. It was the first time that I knew of something that wasn't yet on the BBC website, and our team crowded round the radio operator's desk to watch footage and listen to the local news.

Never before have I felt so close to danger than today, despite my being safe and not in much personal danger at all. During the rest of the afternoon I had difficulty concentrating, and my heart did beat a little faster than usual. The strikes continue, we expect explosions at any moment, but thankfully we are not considered a target.

However, business as usual for our team, while keeping our heads down we avoid taking any additional risk, and continue in our work as always.

How The Hail Took Us By Surprise

I cannot lie and say that it is not hot in Pakistan. It is more than hot, it is extremely humid. I am now used to sitting at my desk with both a manual and automatic fan simultaneously, still damp in my clothes. It is supposed to be the monsoon season here right now, but we haven't had any rain to cool us for about three weeks.

This Saturday we were forecasted rain. The sky appeared doubtful and I sat outside during the evening. Little by little, the temperature rose to a near-painful level. It was finally going to rain. It must have been about 35° but it felt like 50°. Suddenly the winds picked up; fresh air blew our way as we sat back to enjoy the storm. The rain fell down hard. And pounded harder still. Leaves and bins span around, the iron gates swung open and the noise on the roof became deafening. The air cooled but the wind and rain did not relent; only picking up momentum. Never have I seen anything like it before in my life. It began to hail. But not the hail I know. Huge golf-ball sized chunks of ice literally fell from the sky in their masses. The kind of snowball that could knock someone to death! Everyone blinked in amazement, at the strength of the elements. Impressively powerful, oh-so violent, and very refreshing...

The Soundtrack To My Mission

Aside from listening to the regular calls to prayer, I keep my ears pricked for sounds of danger, especially when on the field. Explosions can't be the prettiest of noises, and I already know that gun shots aren't. However, music really does come to my ears late at night when, after inspecting my mosquito net for any unwlecome buzzing guests, I get into bed, turn out the lights and listen.

An array of tunes, tweets and songs can be heard. I don't know what insects and birds are out there beyond my windowpane - they certainly don't exist in my home country, but together their choir produces a veritable melody. In the dark when I can't sleep I try to pick out the different calls one by one as they chant to each other. It is one of the calmest moments of my day, and I relish it quietly.

Budgeting For Our Projects

My predecessor has flown home. I have my computer and keys to the office and safe. I guess it is time to get working as that is what I have come here for. Essentially my job is to manage the finance teams in the field, ensuring that they have enough cash to do what they need to do and that for every rupee spent there is reasonable justification and a correct accounting record. My days are punctuated with cheque signing and authorising payments and a large part of my work is relationship management down at the local bank. Nothing new there then. Except that things do not quite work in the same way here in Pakistan as in Europe. It is quite a wonder to work mostly in cash. I have to deal with large physical transfers of money that literally burst out of my backpack there are so many bundles and wads.

In order to draw up the budget, it is crucial that I understand the project and our operations. We have eight different cost centres that fund several activites:

MSF France returned to Pakistan after a previous evacuation to act following the earthquake in 2008. Since then we currently have a project in the Masehra district, where we are treating patients for Cutaneous Leshmaniasis, a skin infection transmitted by sandflies. Due to increasing security risks, we have evacuated all expatriates from the town and are running this project by remote control from a large city several hours away called Abbottabad.

We have another activity in the North Western Frontier Province (NWFP). Here we are running a cholera treatment centre and have a presence in the in patient department and emergency room of a local hospital. We are very successful in this region as people are are travelling for miles passing public hospitals just to attend our basic clinics for accurate diagnosis and referral.

Coordinated from Peshawar we are running basic health units and mobile clinics to allow free access to health care to those in need, in addition to revamping operating theatres in local hospitals. Non-food item distribution is another activity that we are fond of, providing blankets, temporary housing and soaps to fleeing refugees. The area was home to many internally displaced persons (IDP) who fled the recent military operation in Swat Valley and previously we were running some IDP camps in the region. These camps closed for two reasons, firstly the army wanted to assist in their management whereas we do not condone any military or political associations, nor do we accept arms in our places of work, and secondly because most IDPs preferred to stay in local homes. The Pakistani culture of privacy for their women is such that life living in camps all in the same tent is not easily accepted, thus they choose to find shelter with other families in a house. This can mean many families under one roof, with hygiene conditions that encourage the spreading of disease.

We also have further activity in the Kurram Agency, in the Federally Administered Tribal Areas (FATA) bordering Afghanistan. Again managed by remote control, we have activities in a region that is plagued by sectarian Shiite-Sunni conflict. The road into FATA is too dangerous to cross with a high risk of kidnapping, even for locals, as the area is under Taliban control. Our medical activities support local hospitals, and are run out of two towns, one Shiite and one Sunni.

Our latest project is just in its birth stages. The focus of military attention has shifted from Swat to Warziristan where we expect bloody violence and consequently a new movement of refugees. We had originally intended to take over a disused hospital in the city of Dera Ismail Khan and had obtained permission from the local authorities to do so. During a meeting to finalise this permission, the District Police Officer received a phonecall and then informed us that we had 30 minutes to evacuate the region with a police escort. We are now in the process of setting up a trauma centre and operating theatre from a Punjabi town bordering the Dera Ismail Khan district. We will operate from there and will rely on ambulance shuttles to access the area bringing patients for treatment.

This makes for a lot rupees needed, and a lot of rupees spent. I plan to visit those fields that are accessible to meet the team and enhance my comprehension of the technical operations, as I don't have any medical background whatsoever. During my first week I was responsible for drawing up the budget. This is a task that should normally take about three weeks for one cost centre. In Pakistan we were responsible for producing budgets for eight cost centres in just one week. We worked fifteen hour days for ten days solid. However, this was a great way to understand exactly what we are doing and what it is costing. Not working for profit is very different to working for the private sector. I am used to deciding what can be spent based on an arbitrary budget allowance. Here we are deciding what to do then estimating how much it will cost and thus we have our budget. Completely the other way around but not altogether foolish.

Our cholera treatment centre and staff