by Samia Altaf
Mandra health center, outside Islamabad, on this spring morning, without the cacophony and confusion of health centers in the city, was the picture of serenity. An emaciated woman of indeterminate age sits coughing in the corridor, in a chair that bears the logo of the United States Agency for International Development, next to a little girl with dry shoulder length hair and yellow eyes, one bare foot resting upon the other. I make a provisional diagnosis—pulmonary tuberculosis for the woman, viral hepatitis for the girl, both diseases endemic in Pakistan.
In a room cluttered with furniture and people, its walls lined with the ubiquitous portrait of the Quaid-e-Azam, a map of district Gujjar Khan and a couple of framed certificates whose writing is mostly illegible except for the USAID logo, the Medical Officer is examining patients. He nods to me while still attached to his stethoscope the other end of which rests on the chest of a skinny young man sitting on a stool holding up his shirt to expose his protruding Christ-like ribs. A man and a woman stand waiting calmly for their turn on the stool.
Mandra center, part of the government’s health service system that caters to the medical needs of almost 75 percent of Pakistan’s population, is one of the 32 hospitals upgraded by USAID for a total of $92 million to improve emergency maternal neonatal and child health services under a project called PAIMAN (Pakistan Initiative for Mothers and Newborns). John Snow Inc. implemented it from 2005 to 2011.
USAID funded repairs, provided surgical equipment, trained staff, and built a vaccination room with refrigerator to store vaccines. It provided benches and white boards for the meeting room where visiting US CODELS (Congressional Delegations) and USAID officials were briefed about the project. Mrs. Munter, the US ambassador’s wife, “sat here” said the medical officer pointing to a chair. “That was such a good time,” he remarks as we walk around. “See this corridor,“ he says, pointing up and down, “renovated by USAID. The walls, the floor, the tiles , the furniture, these chairs. They also equipped the operating room for C-sections and other obstetrical surgeries.” He begins to count off the equipment on his fingers—“special operating table, shadow-less lights, sonogram, sterilizer…and a special vaccination room. Come I will show you.”
We walk past the yellow eyes and a feeling of cognitive dissonance begins to germinate growing as the day progresses. Given the population density of the area and the disease burden, this center on a weekday should be full of people—pregnant women crowding corridors, children milling around, noises of groans, moans and coughs, staff herding folks in one room or the other, giving orders, keeping order. None of that existed except for health center staff standing aimlessly and trying to look alert.
The Vaccination Room is locked. “To prevent unnecessary activity,” says Sister H, the senior midwife accompanying us. She unlocks it. A pleasant room painted in primary colors, Winnie-the-Pooh posters, a rug, chairs, a wall mounted TV (an unheard-of luxury in Pakistani health centers) and a refrigerator, “to store vaccines…” says Sister H, “all given by USAID.” The room is tidy but a thin coat of dust covers everything. I open the refrigerator door; it whirrs encouragingly revealing its sole occupant—a large bottle of 7–up. “Well, you see madam, we have not received the vaccines from health department and the refrigerator is running anyway so the staff sometimes use it to store drinks. Why waste a fridge?”
In another small room, seventeen-year-old Rubina, a new mother with a baby in her lap, sits across the table from a community health worker writing in a register. “Did the baby get these? I ask. “No,” says the CHW, for there is no vaccine at the center. Rubina is to wait for the vaccination teams that will visit her village next month. What is the CHW writing in the register? It is a list of all the infants given vaccinations today. This information is sent to the district head office and then onto the provincial headquarters where it forms part of the statistical reporting for vaccination coverage. This “reporting” causes more problems than mere inflation of numbers for it is based on such reports that the supply of subsequent doses of vaccines is sent to the health center. “No wonder they run out of stock or there is a deluge,” the provincial manager lamented when I alerted him to the fact.
The Medical Officer is anxious to show the operating room, the jewel in Mandra’s crown. It is also locked. A peon is sent to find a chowkidar who has the key. Once located, the key turns the lock, the bolt is pulled back, and “Here it is…” says the MO, with a dramatic flourish.
The first things that I see are chairs lined up against the wall,with laundry spread on them. Just as the MO had said, the room contains equipment bearing the USAID logo. To the right is a sonogram covered with a green dust-protective cloth. In the center is the operating table with the shadow-less lights the MO has been raving about. In the far corner, close to ceiling, hangs a huge spider web, its silky gossamer lighted by the bright sun streaming in through a window. Below it, on a gurney, sits the autoclave, its connecting wires trailing to the floor. Beside the autoclave is a bag of potato chips and a plastic bottle of 7-up, both empty.
Even to someone not familiar with the inside of an operating room it would be clear that this room is not used for obstetrical surgeries. The empty bag of chips and 7-up bottle I can forgive; it is the drying laundry that gets me. The culprit is the chowkidar’s wife. She is produced from her quarters in the rear of the compound. Looking rushed, wiping her red and sweaty face with the edge of her chador, a chubby no- nonsense kind of woman in colorful shalwar-kameez. She has been called away from cooking the family lunch and is not amused. O yes, she nods energetically, this is her laundry. What to do? With the cold and damp outside and no space inside her small apartment with five children—this room is always empty so why not put it to good use? She would have removed it had she had known there was going to be a visitor… She rushes to gather the lot, then thinks the better of it, shrugs, and leaves them in place—and hurries off to see to her cooking. I have visions of this resourceful women pulling up the chairs around the operating table to serve dinner—why not put it to use? She’d say, a nice sturdy table, and the chairs are here anyway. Thrown in is the excellent lighting, the electricity supplied by the USAID generator while the rest of the town is plunged into darkness because of power outages.
The labor room is quiet, empty of delivering women, a fine coating of dust on the delivery table. When was the last time a baby was delivered here? A few days ago, I am told. Posters, giving instructions in English to manage the third stage of labor and treating convulsions in newborns, line the walls. They provide detailed instructions about ergotamine injections and Mesoptrol, an oral medication, to prevent postpartum hemorrhage, a frequent cause of maternal mortality in Pakistan.The PAIMAN Annual Report for 2006-2007 records that “Meticulously developed protocols for dealing with MNH emergencies have also been developed and displayed in all PAIMAN facilities for the ready reference of trained personnel.”
Whether these meticulous protocols are put to any use is another matter. I ask Sister H if she knows what the posters say. Yes madam, she replies, she can deal with the third stage of labor as she can with all other stages. International experts from Johns Hopkins University have trained her. “The training took place in Islamabad, we stayed in a hotel for a week. I learnt a lot. I even went for two refresher courses after the training.” So, has she used that knowledge here?
“No, Madam. That is not possible because we have no supplies.”
There is commotion in the corridor. A young man, visibly exhausted from carrying it, deposits a big bundle on the floor. A moan escapes from the bundle and one realizes that swaddled in all those clothes, tied up in a grimy bed-sheet, is a woman. Seventeen-year-old Nasreen—who has been in labor for the past two days. Nasreen, already having lost a newborn last year, consulted a trained midwife this time following all her instructions about eating meat and eggs even though difficult to afford. Two days ago, when Nasreen went into labor, the midwife was not available—her family said she had gone for training. Since Nasreen is bleeding, her husband, Mehmood has brought her here. Mehmood knows this health center. Some months ago, he was one of the many lucky laborers hired to paint and fix the building because the big doctors—including lady doctors and foreigners from the city—came for the opening. There were speeches, photos, and a sumptuous tea.
Sister H shakes her head and without touching the bundle tells Mahmood this hospital is not equipped to deal with problems like Nasreen’s. She needs an operation to deliver the baby. And quickly, otherwise…. He should take Nasreen to the “big” city hospital.
How? ask Mehmood’s eyes, his hand in his empty pockets. He has already spent all his money on transportation—a donkey cart followed by a Suzuki van, a total of 13 hours—to get here. He is hopeful. He had seen many lady doctors—women wearing white coats who spoke in English to foreigners—that day months ago. Surely there will be one today. He leaves Nasreen in the corridor and moves out—to find himself something to eat, mostly to get away from Nasreen’s feverish moans, and the yellow eyes.
Nasreen waits, half-dead already, curled up on a hard bench, watched by the unblinking yellow eyes. She waits to die or, if she survives, to develop a fistula, a hole that forms between the urinary bladder and vagina, leaking urine, or a pelvic organ prolapse, making her ‘useless’ for the rest of her life. “In such a state, what use is she to me?” one man told me as his wife stood by crying inconsolably. “It is better that I die,” she had said, “for where can I go? What can I do?” In a country where women have no status without a husband, she had assessed her situation correctly.
“Well, as you can see madam, this is the problem we have,” says sister H. “Now she will be here for hours, the baby is probably already dead… it is a question of saving her own life.”
But there is an operating room equipped to perform just the operation this woman needs, I say. This is exactly the emergency obstetric surgery for which USAID upgraded the health center. The MO and the LHW look blankly at me— yes, equipment is there, but, madam, there is no obstetrician or anesthesia or anesthetist. So what good is equipment?
Surely at some point his operating room must have functioned? USAID has been involved with the center to improve services here for six years. Its monitoring was being conducted all this while to ensure availability of exactly this service. As has been reported in all PAIMAN reports, there is “increased utilization of EmONC services 24/7 in all the centers” supported by USAID.
“No, madam. There has not been a single C-section conducted in this operating room, ever.”
“What is the room for then?” They think it a rhetorical question and look strangely at me.
“What do you do then with a woman like her? One who is bleeding?”
“We just pack her and send her to the city.” Why not take her blood pressure? Arrange a blood transfusion? Or even intravenous fluids?
“There are no arrangements here for any intravenous fluids or blood transfusion so why bother with blood pressure and pulse?”
“Madam, we know about these things, but supplies and gynecologists are not available here… and she is too complicated.”
Well then instead of depending on her husband why not send this woman in the ambulance—after all this was the purpose of the specially equipped ambulance provided by USAID. Unfortunately, the ambulance cannot be made available.
“Why not? It is parked outside, sleek and shining, in its makeshift shed.”
“Because there is no petrol and no driver.” The donors do not fund POL (petrol, oil and lubricant) for donor-supplied vehicles nor do they supply drivers. These are the responsibility of the provincial government, and “we have not received the required funds from them for these items.”
The Government of Pakistan approves its program budget through a Planning Commission document, the PC-1. The MNCH (National Maternal and Child Health Program) PC-1 sanctions staff of 25 to 30 for all health centers that are designated as Comprehensive Emergency Obstetrical Neonatal and Child (EmONC) centers, as is this one. The sanctioned staff includes a lady medical officer, an obstetrician, and a driver.
“Yes madam,” the MO’s patience is running out, “but we have not received the funds for the same”. They seem angry with USAID for “abandoning the project. They should increase the funds and provide a driver. How difficult is that for USAID?”
I see myself down the rabbit hole again in this aid world, a world where things are not what they are supposed to be. An operating room is not an operating room, an ambulance is only to stand in a shed, and staff is trained to shake their heads. The story is not unique to this center. In most other hospitals supported by USAID, the situation is not much better. I saw incubators for newborn resuscitation sitting unplugged in the district hospital in Khanewal long after the PAIMAN project was over. Yet USAID continues to fund such projects.
Annual reports and evaluations present a glowingly positive picture. The Population Council monitored PAIMAN’s activities. Its Routine Monitoring and Output Indicators from the 2007-2010 Project Completion Report show a “75% increase in admissions for obstetrical complications and a 40% increase in emergency Cesarean sections performed.” In the end-of-project evaluation document “PAIMAN achieved all its established benchmarks”.
Something is terribly wrong somewhere. The US Government paid with citizens’ taxes for obstetric services not for expensive equipment to sit unused or for reports that cannot be taken seriously.
“What can we say, Madam. It is the higher-ups who make the decisions. ” says the midwife fixing her head covering which has come loose. I try to extricate myself from the rabbit hole. It is a different world with a different reality—this world of aid, with USAID at its center. In this world, all the actors in this project — USAID, JSI, JSI’s partners—Aga Khan University, Save the Children Fund, the Government of Pakistan—and their technical experts, they all live and work by this reality which works only for them. Its rules are peculiar , known only to those who live in this world, one that has no connection to the reality of the country, its people, and its problems.
I am relieved to come out into the real world and the dusty street. Outside, in the sparkling sunshine,skinny and shoeless boys are playing cricket with makeshift wooden paddles. A couple of girls, around 10 to12 years old, their heads covered with grimy dupattas, stand by with snotty little ones on their hips. The girls point surreptitiously at me, their hands covering their mouths, they whisper to each other, and giggle.
I can’t help thinking, dead girls giggling. Their turn is coming, for in spite of the millions of dollar worth of assistance to the Government of Pakistan to fix its maternal health services, the situation remains stark and grim—the 2018 maternal mortality rate (deaths per 100,000 live births) was 178 compared to 30 in Sri Lanka. Future Nasreens, these giggling girls.