I met her at a tri-club event two years ago. Everyone is unique, but she is “more unique” than anyone else I know. A medical resident in Toronto, German born from an Indian family.
She came to Maryland to get a master’s in public health from Johns Hopkins, while here she also got an MBA from Hopkins while training for Ironman Florida. Most of her training rides are done at 4:30 Am on the trainer.
I think the first time I met her she said she was going to be a doctor in a developing nation. Looks like she has already done at least some of that. I’m lucky to know her.
Here’s her story.
I am on my way home from an Emergency Medicine elective in Argentina when I learn about the earthquake in Pakistan. I land in Atlanta and look up at one of the ubiquitous large-screened televisions that bombard you with CNN coverage at every step – and there are the initial images of houses crumbling into rubble, and people being buried, rescued, injured and killed beneath that rubble. I stand open-mouthed as the words envelope me. “Tens of thousands dead…children just starting their school day…soldiers in their barracks…7.6 on the richter scale…” My first thoughts are of my family in northern India, despite reason telling me that the maps indicate they are far from the damage.
I wait in the airport variety store watching children crying, women wailing, workers digging. At a time when media transports information instantaneously, it seems like I am watching a replay of post-tsunami or post-Katrina despair. Yet I am particularly drawn to this event. I claim to support human rights, equality, et cetera, but seeing people so close to my own family in history, race, origin, location, crushes me in a way that the other tragedies had not. The languages spoken and the settings being depicted seem familiar, although I have never traveled to Pakistan.
I pick up a copy of the New York Times, my first written connection to international news in days. The numbers are staggering. Tens of thousand dead with tolls rising rapidly. A desperate race to meet medical needs as the wounds and fractures multiply. A cataclysmic building-shattering eight seconds, followed by eight minutes of continued shifting. In an area accustomed to earthquakes, this was an occurrence with few precedents.
For the remainder of my flight I am haunted by the thoughts of the earthquake. I reach home and verify that my family in India is safe and then I begin seeking organizations that are orchestrating fundraising efforts in Toronto. They range from the Canadian government and large NGOs to local mosques and small group efforts. Within a few days I have signed myself onto numerous listserves and have contacted several people working locally who are collecting money, medication, tents, clothing, blankets, and more.
Approximately one week later I receive an email from the Canadian Relief Foundation seeking volunteers to travel to Pakistan…willing to leave in two days. I reread the email numerous times, thinking “I wish I could go.” Then I remember an Irish woman I had met in Argentina who would ask everyone she met “If you could do anything in the world you wanted to, what would you do?” And when she received a response she would say “Well, why don’t you?”
I quickly decide that any excuse I can make would be laughable…my marathon in a few days, Les Mis tickets in a week, meetings to attend. I have no vacation time left to draw from, so I page my understanding residency programme director in the evening to request an unpaid leave of absence. There is a day of uncertainty while I wait for university permission and arrange a Pakistani visa and plane ticket…but the details fall into place and I am preparing to leave for Pakistan. Tomorrow.
For years I have read about humanitarian crises, learning about them from an academic point of view. I have tried to volunteer for aid organizations but have been thwarted by my lack of experience. I am able to join the CRF team easily – its small size and ready acceptance of volunteers allow me participate in a way that I could not with more established organizations. I have never heard of CRF before this week so I consult a friend who is involved with hiring for NGOs. He affirms that CRF is a decent organization, yet he disapproves of the liability waiver I am asked to sign. Given that every other position I have looked at requires previous field experience, I decide that I will complete the waiver and take my chances.
After a frantic night and morning of packing, shopping, and paperwork, I am at Pearson airport meeting the eleven people I will be spending the next two weeks with. Both of my parents are with me indicating their level of concern; usually my father just drops me off at the terminal and drives away.
My team consists of physicians, nurses, and paramedics from all over Canada. We introduce ourselves and don our bright red CRF t-shirts. Amidst the towers of suitcases and boxes of medical supplies we are an eye-catching sight. The physicians on the teams consist of a GP, plastic surgeon, orthopedic surgeon, ophthalmologist, and an ophthalmic plastic surgeon. One of the nurses is our team leader. We discuss our planned deployment – eight of us are to go to Bagh, a devastated small town north of Islamabad and south of the epicenter of the earthquake, and the surgeons will work in a hospital in Islamabad.
The kindness we receive in these first hours is already overwhelming – numerous Pakistanis who are on our flight approach us to thank us, and the Pakistan International Airlines employees are unending in their generosity. We are moved into business class, our team is recognized over the intercom, and am I allowed full access to the cockpit to meet the pilots (an impossibility I’m sure on any other post-September 11th airline). As a somewhat insecure first-year Family Medicine resident I feel completely unworthy of their appreciation.
We arrive in Islamabad, a city that was relatively unscathed from the earthquake with one poorly constructed apartment building collapsing – I have heard the horror stories of cities such as Balakot in the north where virtually every structure was leveled. I am reminded of the slow speed at which time moves in South Asian countries as we wait for our luggage to leisurely arrive and be loaded onto our vehicles. Despite our eagerness to depart, the following day is spent meeting various officials, attending a UN security briefing, purchasing two weeks worth of food, and waiting for twelve people to agree on each decision.
We visit the Pakistan Institute of Medical Science (PIMS), the hospital with which CRF is affiliated. There are boards outside the hospital with rows of pictures of patients waiting to be identified and claimed by family members. Signs outside the hospital state that children are not available for adoption. The hallways are filled with patients, yet we are told that the crowd is significantly less than in previous weeks. The operating rooms are still running twenty-four hours a day, staffed by Pakistani and international teams, struggling to treat the wounds and fractures continuing to pour in.
Finally, it is time to go. I have already found my workout partner on the team and we complete our run, push-ups and sit-ups and then settle in for a six-hour busride. The two ophthalmologists make a last-minute decision to join the field team and they pile into the van with us. We embark on what is a fairly petrifying drive – roads that were at the best of times narrow, guardrail-less, and filled with sharp curves and precipitous drops, now have the added complication of rubble littered along them. However, we are told that the drive took seventeen hours immediately after the earthquake, so our drive is comparatively calm.
The views along the route are breathtaking. I have never been in Kashmir, even in India, and driving into the mountains reaffirms all I have heard about the beauty of the area. The brilliance is especially evident as our van wheels seemingly drop off the edge of the cliff and we gaze down into the valley. There are homes of concrete and wood peppering the landscape, located along what seem to be impossible mountain angles. As we move closer to Bagh the houses begin to change – what seem to be intact structures from a distance become slabs of corrugated metal perched over rubble. There are typically tents located nearby where we can see displaced families living.
The signs of the earthquake are evident as we drive into Bagh. There are still many buildings standing; however, the unreliability of the structures and the many deaths in the city mean that there are few occupants. We come upon a makeshift tent hospital with facilities being run by various NGOs. We are shown the out-patient centre where there is a mass of people waiting to be seen. The “operating room” is in another tent where supplies are loaded against the walls and sterility is a struggle to maintain. The “ward” is where approximately thirty people are lying in recovery, some with a family member beside them holding up an IV bag. We meet up with the previous CRF team who has taken up residence in the home of the District Inspector General. He has kindly opened his home to relief groups, and there are dozens of people camping on his lawn and staying in his extra bedrooms. The site offers us some security and numerous offers of tea and food.
That night we are informed of a military security briefing and it is recommended that members of our team attend. We listen (while drinking tea) to reports from officers outlining their surveys of various areas: dead, wounded, treated, tents and food distributed. The numbers are read out in a straightforward fashion, belying the magnitude of the lives represented. In a country that is run by a military government, soldiers have been instrumental in the disaster response efforts. This despite the thousands of soldiers that were lost in the earthquake. Many were stationed near the epicentre at the contentious Line of Control between Pakistan and India.
As I listen to the reports, I learn of my importance as a “lady doctor” – in a Muslim country, it is typically unacceptable for male physicians to examine carefully covered female patients. The military is seeking female healthcare workers, and we offer our resources of myself and a female nurse, as well as the remainder of our male team and our medical supplies. The quickly accept, and we arrange to return to the military headquarters the following morning. My ethnic background motivates curiosity – having an Indian working with the Pakistani military is not a routine occurrence.
The next morning we arrange the supplies for our clinic. We are all neophytes in emergency situations, and we rely heavily on the advice of the previous team. Dressing and debridement equipment, antibiotics, pain control, and splinting paraphernalia are the mainstays of our packing. I realize I should have reviewed my antibiotic dosages, and receive a quick lesson from one of the other doctors. I am glad that another physician will be with me – I feel more comfortable knowing I have someone with far more experience to consult.
We meet our military escort and set out farther into the mountains. The immediate area of Bagh has been inundated by NGOs – MSF, Mercy Malaysia, the Islamic Circle of North America, are but a few. Although there are still local needs, we decide to focus on the remote villages that have yet to be accessed due to poor road conditions.
We arrive at the military camp in the village of Piniale. Or what used to be Piniale. We can see the previous homes on the plateau below us, and the villagers are settled in make-shift tents. There is a long line of men along the road – they are waiting for the military personnel distributing tents, food, and blankets to try to stave off the quickly approaching winter. The stare at us intently – our group of Caucasian men and one brown-skinned, non-Pakistani, short-haired, jeans-wearing woman.
Major Rasheed is a young, well-spoken, enthusiastic host, and he welcomes us and inevitably serves us tea. His initial comment to me is “You seem Indian. But that’s okay. You’re still welcome here.” No one else partakes in the drinking as it is Ramadan and all of the soldiers are fasting. We feel uncomfortable, yet the Major will not hear of our protests. It is a common theme that people we meet, who in addition having lost everything are also fasting, will still insist on having us eat.
We then set out on another precarious ride, and yet again we are awestruck by the mountains. There are innumerable levels of plateaus, with lush green vegetation, small waterfalls, houses, and tents. We can also see the evidence of landslides – brown, rocky triangles trailing down the mountain as well as large rocks on the road itself. Sitting in the back of the military jeep, careening along corners at deathly speed, we feel both close to and afraid of the mountains. With my Bengali background I can catch some of the Urdu words being spoken by the soldiers, and I recognize the nickname they have teasingly given me – “Chotu” – little one.
Our convoy stops at a location beyond which the vehicle can no longer travel due to the rocks and the destroyed mosque blocking the path. The inundation of patients is immediate and a crowd gathers around us. The three of us who have come with this military team are handed two children before we have even begun to unpack our supplies.
I feel a moment of panic. What do I do with this listless baby in my arms? The basics, start with the basics, I think to myself. Laying the baby down I do my assessment and decide on a course of treatment. The day has started. And I have faced my first patient.
From that moment there is no rest. I find myself running a women’s clinic as the mass of patients accumulates around me. The soldiers set up a tent that I can use for examining and I take the women in after having the Major question them about their complaints. The cases we see that day range from routine primary care complaints – coughs, fevers, rashes, aches and pains – to viciously infected wounds, poorly healed fractures, and other earthquake-related injuries. We see a two-year old girl with a post-fracture massively swollen left leg and have her urgently sent down to Bagh with the fear of a compartment syndrome that we are reticent to decompress on in this setting.
As I lead women and girls into my tent I am repeatedly struck by the beauty of their smiles once they move their hijabs. Despite their immense tribulations, they readily smile at my attempts to speak Urdu and communicate through body language. We are all amazed by the children – the ones who laugh and run away from our waiting tetanus vaccine needles, who stalwartly (or loudly) withstand our debridements, or who are brought by an aunt or a grandfather because their parents have perished. There are also the elderly that are carried to us still on their beds from even more remote locations – the news of medical care in the mountains has spread quickly.
We unintentionally fast as the day flies by and the patient load continues unabated. We work as a team, with myself and the other physician consulting each other on various cases, and our paramedic colleague organizing treatments. The soldiers, eager to help, become our pill dispensers and translators. The assessments are extremely rapid due to language barriers and time constraints. What would have been a fifteen-minute appointment at home is finished in a minute or two. I feel nervous about my diagnostic abilities working in these parameters, but the deluge of patients necessitate speed. Unlike my clinic at home, I cannot have patients return the next week to follow up. I am confident of most of my decisions, but not all, and I do not want these villagers to receive substandard care simply because I am their only option.
Eventually we have seen all of the patients and the day is coming to a close. Our team looks at each other – we are exhausted, energized, saddened, inspired. Until that moment the earthquake in Pakistan had been a media event…now it is real. We have met and treated villagers who had been a five-second newsflash. And we have seen an immensity of resilience, trauma, and strength.
That night we report back to the rest of the team. It seems disrespectful to say that we had fun…but we did. The warmth of the villagers we had met, the majestic surroundings, and the generosity of the military had contributed to one of the most satisfying days of my life. The other CRF members are intrigued by our descriptions and it is decided that we would all join the military the following day. It was almost possible to imagine that we had been running a primary healthcare clinic under perfectly normal circumstances – but the stories and the rubble quickly reminded us of the harsh reality.
We establish a firm link with the military and the subsequent days are filled with driving and hiking with them out to various villages in the mountains. They provide transportation in the form of vehicles or mules (when the roads are impassible), security, translation, and food. Any pacifist reservations I may have had about being associated with the military are quickly dispelled by the realization that the soldiers are simply young men who have suffered losses like all Pakistanis and are untiringly working to serve and rebuild their country. We have heard criticisms about the slow response of the military, yet I cannot say enough about their support of our work. The Major defends the lack of construction by citing the impossibility of building adequate before the impending snowfall. The decision has been made to try to provide tents and convince villagers to move to lower locations through the winter and begin construction in the spring.
We camp with the military on most nights, either at their base or in the village we have hiked to. Our evenings are spent in conversation with the Major or other soldiers beside a fire eating rice and dahl and drinking tea. A particularly momentous occasion is when some soldiers ask us to sing an English song and a CRF member teaches them his favourite camp ditty – the Shark Song. I take a priceless picture of the Pakistani military making shark actions with their hands as they loudly sing “Papa shark.”
There had been torrential rains and sleet in previous weeks, but we are blessed with perfect weather. Clear, sunny, hot days, and starry, cool nights. We sleep outside and I stare in wonder at the thousands of lights in the mountains (electricity was quickly restored post-earthquake) and the constellations in the sky. Just a few week prior it would never have occurred to me that I would soon be in Kashmir.
The days pass quickly, and the majority of the team is scheduled to return to Canada on November 1st. Four of us are able to stay longer, and we spend another day conducting our clinic on a plateau that has a 360 degree view of the surrounding mountains. At this point I am the only physician left on the team and I gain a better understanding of why an organization might be hesitant to accept residents as the others look to me for guidance on diagnoses and treatments. There are two cases I am particularly uncertain of – a baby with an unfamiliar rash and another with a slightly depressed skull after being hit in the earthquake. I do not advise either of their parents to make the long journey to Bagh, and later I am haunted by the thought that I missed a case of measles in one and a future of rising intracranial pressure in the other.
The time comes for us to leave the mountains and return to Islamabad. We have reached only a small fraction of villages – there are abundant stories of villages around Bagh and farther north where no medical care has been provided. Helicopters have been dropping in supplies but the state of health is largely unknown. We could spend weeks, even months hiking and working and still have villages to reach. The four of us look at each other and feel that by leaving Bagh we are leaving scores of untreated patients behind. Yet with a finite amount of time, we have no choice.
The next afternoon we head to the helipad at the military base to try to catch a helicopter back to Islamabad. Flying would convert a six-hour journey on terrifying roads to a half-hour journey. The District Inspector General assures us that he has reserved our spot, but our hopes ebb as we patiently wait on the edge of the helipad watching the traffic. One helicopter to Islamabad gets diverted to carry a seven-month neonate that is being bagged as it is rushed in by ambulance by a Spanish team from the mountains. Another is quickly filled with military personnel and other patients. We are the last priority, and we finally admit defeat and start the journey by road. Beginning something half an hour before breaking fast is never a good idea, and our driver lurches at breakneck speed to reach the closest hotel for sunset. After food and several cigarettes he is calm, and we continue to Islamabad.
Back in Islamabad we have several days before our flight back to Canada. By then the next CRF team has arrived and we help them to prepare for their mission. They have decided to head to Muzafferabad, a larger town northwest of Bagh. As my time winds down, I find myself wishing I could head out with the new team. The two physicians on the team, a GP-anaesthetist and a trauma surgeon, are staying in Islamabad, and we decide to join them at PIMS.
Apart from our initial tour, I have not had any contact with the hospital. There are still patients in the hallways, although less than what I had seen before. Operations are still being conducted at a rapid rate, but are no longer occurring on a twenty-four hour basis. There have been over 130 cases of tetanus reported, and six are on ventilators at PIMS. I am interested in surgery and I follow our GP-anaesthetist to the children’s hospital where he is working. At the entrance is where patients wait to be called in – family members literally carry children to the door and then pass them on when their name is called.
Chaos reigns as I enter the OR suite. Petrified children of all ages are screaming and crying as they await their anaesthetic and as they wake up post-surgery. A make-shift post-anaesthetic care unit has been set up by my colleague; prior to his arrival children were wheeled directly from the OR back to the ward to recover. There are two operating rooms, with two surgeries being conducted concurrently in each room. The concept of sterile technique is largely ignored. There is a theoretical sterile field around each table, yet personnel circulate between patients, and the scarcity of equipment has forced innovations such as wrapping sheets around surgeons to replace gowns.
My eyes take in the scene as I move into the closest OR suite. It is then that I am confronted with injuries more gruesome than anything I have seen in my life. There had been relatively little acute care required in the field – people with threatening injuries had already been sent to hospital. Or had died. I am now seeing those children who had survived the initial trauma. A six-year old girl with an infected brain herniation being debrided by a neurosurgeon. A three-year old boy whose entire left leg has been “de-gloved” as he was aggressively pulled from the rubble – his underlying muscle pathetically exposed as the surgeon assesses the possibility of a skin graft. A nine-year old boy with quiet, dark eyes, and a left below-the-knee amputation. Children with elaborate external fixations and gaping open wounds to be cleaned.
I feel ill as I watch child after child be wheeled into the OR. I read their charts – “2-year-old girl. EQU victim. No family. Tibia fracture” and other similar, blunt descriptions. I aid with whatever task is needed – assisting the surgeons, running for supplies, holding a child’s hand. These children are different than the ones I had seen in the mountains – despite cajoling, toys, candies, it is difficult to coax a smile. One Pakistani anaesthetist comments that their sadness is so pervasive that she cannot reassure them. I see them and I try to imagine my brother, every child I know in the same position, yet their suffering is more than anything I can imagine. Thousands of children have passed through this hospital and others with similar tears and wounds. Tens of thousands of children are dead.
I spend two days working in the hospital, forcing myself to confront a mere slice of these children’s pain. We wheel the last patient of the day, a ten-year-old girl, out of the operating room to be returned to her family. There is no one awaiting her when her name is called by the surgeon. He calls her name again, and a tiny girl, not more than seven years old, emerges from around the corner.
Her only surviving family member.
We are all fighting back our tears as we accompany the two children back to the ward. Her story along with every other story I have heard over the past month tumble over each other in my mind. Certain faces are etched in my consciousness and they flash back to me as I sit on the plane leaving Islamabad. We have been so busy over the past weeks that there was little time to contemplate, but over the sixteen hour plane ride I find the sadness overwhelming.
Working in Pakistan both reaffirmed my desire to work in emergency situations, yet also underlined how individual actions are miniscule in the face of enormous destruction. The tasks in Pakistan are only beginning with the emergency phase diminishing, although care is still required for thousands in the mountains as winter with its snow and freezing temperature looms. Next will be rehabilitation and reconstruction – the prostheses, homes, mental healthcare. Local, national, and international efforts are needed. My participation in the effort has hopefully brought some relief for some people, yet I know that I have learned more than anything I could have contributed.
