November 02, 2013

I Walked To Alleviate Global Poverty

Partnership Walk is a purpose driven public event held each year by Aga Khan Foundation (AKF) and its network of volunteers across the United States to raise funds and awareness in the fight against poverty especially in African and Asian countries.

Partnership Walk 2013 - Houston Texas 
Houston, Texas was honored to host this great event at Sam Houston Park on Saturday - November 2, 2013.  I was eagerly waiting for this day. For me, the partnership walk is more than walking a few miles to raise money. It has a special connection with my life - a connection that is based on a common goal, commitment and a purpose in life.

The Partnership Walk provides me with a chance to remember those beautiful days of my life when I used to work in far flung and mountainous regions of Pakistan, Afghanistan and Tajikistan. It provides me with a special place and time to pay homage to those hundreds of thousands of courageous people who lost their kith and kin and became homeless during war in Afghanistan and Tajikistan but never lost infinite hope in any situation. It provides me a chance to thank those poor but hospitable people who always stood behind Aga Khan Development Network (AKDN) and supported its work. There can’t be a  better platform than the Partnership Walk to recognize the contributions of all those AKDN staff and volunteers who work under extremely difficult circumstances to alleviate poverty and suffering amongst some of the world’s poorest communities.

        An old man from Wakhan Afghanistan is receiving food aid from FOCUS [2004]
As the sun rose on the day of the walk, a ray of hope flamed up in my heart.  As soon as my wife and I started driving to Sam Houston Park, vivid scenes from my past started flashing before my eyes. I recalled the emergency situation in Afghanistan when AKDN initiated its humanitarian aid program through Focus Humanitarian Assistance in 1994. It was the most grueling situation that Afghanistan has ever faced. Hundreds of thousands of people were dying from malnutrition and hunger. Women and children were living under open sky during extreme winter with no access to shelter, heating, clothing and medicine.  

There is not a day that goes by when I do not think about a remote village in Badakhshan, Afghanistan where a ten year old girl was sold by her father to an influential commander for just 50 Kilogram of wheat as the family had nothing left at home to eat. 

The story of a 20 year old young mother from Wakhan, Badakhshan is also still fresh in my mind. She was not only herself an opium addict but was also puffing smoke in the nose and mouth of her six month old child so that she could fall asleep. In response to my question, “Why are you consuming opium?” she replied 

“We are very poor people. Because of the extreme cold weather, we cannot grow anything. Our farm production is just enough for 4-6 months. We use opium every day as it suppresses our appetite and enables us to consume less food. In this way, we prolong the food stock until the next farming season”

Students from a remote school in Badakhshan Afghanistan 
                   [Courtesy: FOCUS -2002]

My write up will be incomplete if I do not mention about those hundreds of thousands of Afghan pregnant women who lost their lives on their way to a health facility. In the rural province of Badakhshan Afghanistan, 6, 5000 out of every 100,000 women died during child birth. It was the highest recorded maternal mortality rate in the world. The story of 40-year old Watan Sultan of Shughnan district of Badakhshan which has also appeared in one of my articles published in the Huffington Post on March 21, 2013 is still ringing in my ears. She shared with me the most heart-rending story of a family member who died during pregnancy because of unavailability of a midwife. She said,

Inside view of a class room in Maimi, Darwaz Afghanistan [2010]

“Fifteen years ago, an immediate relative of mine got pregnant. We were very excited to find out the good news. Everyone was waiting anxiously for the new addition to our family. Anxiety began to pile up when the due date passed but she could not give birth despite of arduous labor pain. We waited a few more days but her condition started deteriorating because of the massive bleeding she had. Finally, we decided to take her to Faizabad Hospital. As there was no road so my husband placed her on a donkey and we departed for Faizabad at night. It was almost a ten days walk. The patient was crying and bleeding continuously but except praying, we could not do anything as we were all helpless. After two days when we were somewhere close to Ghoron village, the patient breathed her last. We started moving back to our village with tears in eyes, pain in heart and prayers on lips. We arrived home with the dead body after two days. It was the most terrible day of my life. I saw a family member dying in front of me and there was nothing we could do to save her. Though, it happened over 15 years ago but the incident is still fresh in my mind”

Darwaz is an inaccessible district in Badakhshan Afghanistan. People use this 
     dangerous route while transferring sick patients to the nearest health facility [2011]
A collection of such heart touching stories from Afghanistan will never end.  However, it would be injustice on my part if I do not write a few lines about the world’s deadliest earthquake in Pakistan on October 8th, 2005 that killed more than 80,000 people, injured hundreds of thousands and displaced millions. During my deployment in Azad Kashmir, I met a 20 year old girl from Chakama valley who shared with me her breathtaking story. Even today, I can’t control my tears whenever I think of her.  She said,

On Saturday, I got up in the morning, wore my school uniform, did breakfast with mom and dad and left for school with a hope to return home in the afternoon and meet my parents again. I was less than a mile away from my school when a powerful earthquake shook the ground. Within just a few seconds, all houses, schools and clinics collapsed to the ground and the entire village plunged into sorrow. I was very worried about my parents and hence rushed home quickly. What I saw was unbelievable. My house was reduced to rubble and my parents were buried underneath the collapsed structure. No one was available to help me at that crucial time. It was such a chaotic situation that everyone was busy with their own battle. I started removing the debris with a hope that my parents would be alive and I would take them to the nearest hospital. After many hours of searching frantically, I saw their lifeless bodies. I was standing hopelessly in front of them like a bird that has lost its feet and is unable to alight upon the ground. With the help of a relative, we dug a hole in my garden, buried them there and offered prayers at their graves. I don’t understand why life is so unfair to some people. In just few seconds, I lost everything:  my parents, my house, my joy, my dream in life”.

A sick patient from an inaccessible village (Shiva) in Badakhshan Afghanistan
is being transferred to the nearest clinic in Winter [Courtesy: Mahbob Rahgozar]
Thanks to AKDN for supporting these underprivileged communities in the mountainous regions of Afghanistan and Pakistan. Today, when I look back, I know without a doubt, change has started to blossom in Afghanistan.  Badakhshan is no more the most dangerous place in the world for a woman to give birth. Majority of the people have access to basic necessities like safe drinking water, electricity, road, schools and clinics. Pen is replacing gun, life is replacing death and hope is replacing despair. No doubt, there are still many places in Afghanistan, Pakistan and Tajikistan, where people have no access to some of the basic necessities of life.  But it is also our moral responsibility to continue to support AKDN in the fight against global poverty, hunger and inequality. I strongly believe that today is better than yesterday and tomorrow will be better than today if we reaffirm our commitment to these poor people in Asia.

      AKF’s newly constructed school in Fitoor village of Wakhan Afghanistan [2004]
Today, God has blessed us with everything that we need. We live in a country of opportunity. We have ample financial resources, we live in good houses, we wear good clothes, eat good food, have access to good medical facilities and moreover, our children go to the best institutions of the world. But my question is: Are we really thankful to God for what we have? I certainly don’t think so. Despite of living in a knowledge society, we have not yet grasped the meaning of poverty. We assume that people living in apartments are poor but do not know that there also many places in Asia and Africa where people live in slums. We believe that people using public transport are the disadvantaged ones but do not realize that there are many places in Afghanistan where people walk for 15 days in order to get to the nearest hospital. We deem that people on Medicaid are the less fortunate ones but still do not understand that there many poor countries in Asia and Africa where people can’t afford to buy a single tablet of Tylenol. We think people who shop at thrift stores and resale shops are poor but do not recognize that there are millions of people in developing countries who have no shoes and clothes to wear. We label people rich and lucky if they are able to send their kids to private schools but fail to realize that there are millions of children in Asia and Africa who are deprived of their right to education.

         AKHS’s Comprehensive Health Center (CHC) in Shughnan district 
of  Badakhshan Afghanistan [2011]
While returning home in the evening from the Partnership Walk, I was asking myself, what did I learn from the day? How will I make a difference in the lives of others? Whilst finding answers to these questions, a beautiful quote came to my mind and touched my heart. “Never underestimate the difference you can make in the lives of others. Step forward, reach out and help. We can make a big difference by just reaching out to someone who might need a lift.” (Unknown) 

                                   Published in "The Huffington Post" USA on November 14, 2013

August 28, 2013

Role of Midwives in Improving Maternal and Child Health in Afghanistan

Midwives are an integral and inseparable component of the health care delivery system. They play a vital role in improving maternal and neonatal health worldwide. Midwife is the first point of contact for most of the women during pregnancy and also the first one to lay a hand on a child as soon as it is delivered.
In developing countries like Afghanistan, midwives bring great hope to the tens of thousands of women who have no access to doctors or clinics. Just ten years ago, Afghanistan was the most dangerous place in the world for a woman to give birth. The life time risk of maternal deaths was 1 in 6 which translated to one woman dying every 27 minutes.
According to a report released by World Health Organization (WHO) in 2012, the maternal mortality worldwide has dropped by 47 percent since 1990. The most encouraging news is that the number of maternal deaths in Afghanistan has declined by 65 percent. It's without a doubt one of the most admirable achievements of the Ministry of Public Health and international humanitarian organizations operating in Afghanistan. You may wonder, how did this happen? Is this the real situation on ground? The intent of this article is not to defend the above stated findings of the WHO report, rather to shed light on those avant-garde interventions and indefatigable community based approaches that led to a significant reduction in maternal mortality in Afghanistan.
Adequate and qualified human resources for health (HRH) are widely recognized as a key element of sustainable and effective health care system. World Health Organization (WHO) recommends one skilled birth attendant for every 175 pregnant women. In contrast, Afghanistan had only 467 trained midwives in 2002. Badakhshan, the most remote and inaccessible province in Northeast Afghanistan, painted an even gloomier picture where 6,500 out of 100,000 women died as a result of pregnancy, child birth or post-delivery complications. The most unfortunate situation was that the entire province had less than ten trained midwives to provide emergency obstetric and new born care to women and newborns in Badakhshan.
2013-08-27-100_2276b.jpgIn order to support and complement Basic Package of Health Services (BPHS) and Essential Package of Hospital Services (EPHS) projects in Afghanistan, the Ministry of Public Health in collaboration with the U.S. Agency for International Development (USAID) and other donor agencies established community midwifery schools in almost all provinces of Afghanistan. Badakhshan -a province with no road access, harsh and long winters, low level of literacy and above all high rates of maternal deaths, was the most challenging place in Afghanistan to implement this ingenious project. Aga Khan Development Network (AKDN) in partnership with Ministry of Public Health Afghanistan, Jhpiego and local community took up the challenge with gusto and kicked off the community midwifery education (CME) project in Faizabad in early 2005. It was a time when girls had no access to education, employment and health care in Afghanistan. At that time, finding eighth grade matriculated girls from remote districts in Badakhshan for Community Midwifery School was a hard nut to crack. A joint team from Department of Health and Aga Khan Development Network went door to door to convince parents that the battle against maternal and child mortality in Badakhshan cannot be won without their support and commitment. They need to allow their daughters to go to the midwifery school to become community midwives. The religious leaders also voiced support for the community midwifery education program which without a doubt, paved way for high value maternity care system in Badakhshan. Sairam Saadat was amongst the first batch of eighteen students who enrolled in the community midwifery school in 2005. In 2011, she shared with me the challenges that she overcame to become a midwife.
"In 2005 I was an eighth grade student at Najeebullah Shaheed High School in Faizabad. I still recall the day when some people from AKDN came to my house to persuade my mother to allow me to study at Faizabad Midwifery School. In the beginning, my mother was very reluctant and of course she should be. After all, I was her eldest daughter and after the death of my father, all responsibilities had devolved on her shoulder.
It had always been my dream to be a health professional and save the tens of thousands of women in Afghanistan who were dying during pregnancy or child birth. After struggling for many days, I finally convinced my mom and made my way to the community midwifery school. My relatives and other people in the area were distraught over my decision. Some of them stopped talking to me. When I left for midwifery school in the morning, everyone stared at me with an odd enigmatic smile. Some people thought I would become a traditional birth attendant whose job would be to clean up the filth after birth. Some were fearful that I might interact with male doctors and nurses in the hospital and bring shame to my family. Despite all these challenges, I never lost my motivation to work toward achieving my dream in life. I always stood by my commitment"
Today, Sairam's dream has turned into a reality and she has now become a source of inspiration to thousands of women across Badakhshan. Because of her commitment and hard work, she climbed to the position of Program Coordinator and started leading the community midwifery school in Badakhshan. Sairam and hundreds of other graduated midwives left no stone unturned in providing quality maternal care to pregnant women in far-off areas of Badakhshan. During my stay in Afghanistan, I was always inspired by their work. Despite of resonant tribal culture and strong religious beliefs in Afghanistan, they walked on foot for many days to provide outreach health care services to hundreds of thousands of women in extreme remote valleys of Badakhshan.
So far, 109 students from 28 districts have graduated from Faizabad Community Midwifery School and are now working in remote villages of Badakhshan. Due to their untiring efforts, devotion, insatiable interest and everlasting commitment to their nation, all maternal and child health indicators have now improved in Afghanistan.I can state with certainty that the community midwives played a pivotal role in the improvement of maternal health care in Afghanistan. No doubt, there are still many areas in Afghanistan particularly in the province of Badakhshan where women do not have access to midwives. The international community should continue to lend a helping hand to the people of Afghanistan and keep striving for a healthier tomorrow.

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                                   Published in "The Huffington Post" USA on August 28, 2013

March 21, 2013

Maternal and Child Health in Badakhshan Afghanistan: Progress and Challenges

Badakhshan -a beautiful province of Afghanistan nestled in the lap of Hindu-Kush Mountains is surrounded by gorgeous snow-caped mountains, splendid green valleys, turbulent rivers and fascinating lakes.

Badakhshan came in the limelight of both national and international media in 2002, when the Ministry of Public Health Afghanistan discovered that Badakhshan had the highest rate of maternal mortality in the world: 6,500 out of every 100,000 women die during child birth. And a woman in Badakhshan faces almost 600 times the risk of dying during child birth than her counterparts living in North America. The survey report not only stunned the whole world but it also sparked my interest in going to Afghanistan to be part of the global effort of reducing maternal deaths in Badakhshan. In July 2004, I got an amazing opportunity to work for Aga Khan Development Network (AKDN) in Badakhshan. At the onset, I was not sure if going to Afghanistan was such a good idea. The western media was filled with horrendous stories about Afghanistan and at such a time, going there would mean putting my own life at risk. However, the rays of insecurity, fear and doubt disappeared behind the beautiful mountains of Badakhshan when I stepped on the beautiful and lush green land of Faizabad - the capital of Badakhshan Province.
My first encounter at the Provincial Health Department struck me as a bolt from the blue. The tumbledown, two-story building validated the poor health status of Badakhshan. It never dawned on me that a Provincial Health Department in Afghanistan could be without basic furniture, stationaries, national guidelines and provincial action plan. The health situation was far worse than what had been reported in the international media. Eleven health facilities in total were providing basic health care services to one million people in twenty eight districts of Badakhshan. In other words, one health facility was for a catchment population of approximately 91,000. Almost all health facilities were without female health professionals, equipment and lifesaving drugs. Laboratory facilities were nonexistent. Except Faizabad Provincial Hospital, all other health centers were entirely at the disposal of non-certified male nurses. Health professionals had never undergone any formal training since they had graduated from medical universities. Immunization coverage and hospital delivery rate were almost zero. The most heart touching story that brought tears to my eyes were of those hundreds of thousands of pregnant women who developed complications during pregnancy and left their home for Faizabad with a hope that they would return alive and rejoin their family but died on the way. The story of 40-year-old Watan Sultan - mother of seven children whom I met in Shughnan district of Badakhshan in September 2011 when she was under treatment at a local hospital touched me to the very core of my soul. She shared with me the most heart-rending story of a family member who died during pregnancy because of unavailability of a midwife. She said,
Fifteen years ago, an immediate relative of mine got pregnant. We were very excited to find out the good news. Everyone was waiting anxiously for the new addition to our family. Anxiety began to pile up when the due date passed but she could not give birth despite of arduous labor pain. We waited a few more days but her condition started deteriorating because of the massive bleeding she had. Finally, we decided to take her to Faizabad Hospital. As there was no road so my husband placed her on a donkey and departed for Faizabad at night. It was almost a 10 days walk. The patient was crying and bleeding continuously but except praying, we could not do anything as we were all helpless. After two days when we were somewhere close to Ghoron village, the patient breathed her last. We started moving back to our village with tears in eyes, pain in heart and prayers on lips. We arrived home with the dead body after two days. It was the most terrible day of my life. I saw a family member dying in front of me and there was nothing we could do to save her. Though, it happened over 15 years ago but the incident is still fresh in my mind
The UN sponsored Bonn Conference in 2001 emerged as a ray of hope for Badakhshan when the people of America pledged to support Afghanistan through United States Agency for International Development (USAID). The Ministry of Public Health Afghanistan in collaboration with renowned international agencies achieved a major milestone by developing "Basic Package of Health Services" (BPHS), "Essential Package of Hospital Services" (EPHS) and reproductive health policies for Afghanistan. Ministry of Public Health and USAID in partnership with international non-governmental organizations (NGOs) like Aga Khan Development network (AKDN), Merlin and Medair established health facilities in twenty eight districts of Badakhshan as per the BPHS guidelines which had placed great emphasis on maternal and child health, family planning, immunization, safe motherhood, availability of basic equipment and essential medicines. The shortage of human resources in health was a major obstacle to the delivery of primary health care. According to available health statistics, Badakhshan had 6-8 female physicians and 5-6 registered community midwives in 2003. Without a sufficient female workforce, the proposed goal of reducing maternal morbidity and mortality in Badakhshan was easier said than done. Due to cultural sensitivity, women prefer to be treated by a female doctor, especially where gynecological issues are concerned. Sadly, Afghan female health professionals from other provinces were also disinclined to work in Badakhshan. To address the shortage of female health professionals, AKDN set forth an idea of bringing female doctors, nurses and midwives from Tajikistan until Afghanistan attained self-sufficiency in health care workforce. The Tajik midwives played a critical role in providing quality health care to people in remote villages of Badakhshan. Almost every health facility in Badakhshan had one community midwife from Tajikistan.
The other exciting and ground breaking steps taken to reduce maternal deaths in Badakhshan was an establishment of "Community Midwifery School" by the Ministry of Public Health Afghanistan in partnership with the Johns Hopkins Program for International Education in Gynecology and Obstetrics (Jhpiego) and Aga Khan Development Network (AKDN). The community midwifery education program started at a time when Badakhshan had an acute shortage of midwives and was known for the highest maternal deaths in the world. In 2005, eighteen young girls selected by village health committees from fifteen remote districts of Badakhshan started their eighteen months training at Faizabad Community Midwifery School. By the end 2012, 109 students successfully graduated from the school and returned to their respective health facilities against which they had been selected. The community midwifery school was the very effective program that not only resolved the acute shortage of midwives but also improved the maternal and child health situation in Badakhshan to an unbelievable extent.
Afghanistan mortality survey 2010 indicates significant gains in maternal and child health. For instance, the maternal mortality ratio (MMR) and under 5 mortality ratio have reduced to 327 deaths per 100,000 live births (from 1600 deaths /100,000 live births in 2002-03) and 97 deaths per 1,000 live births (172 deaths /100,000 live births in 2002-03) respectively. Similarly, the contraceptive prevalence rate, skilled birth attendance, immunization and antenatal coverage have also improved. Today, Badakhshan province has 110 fixed health facilities and mobile health clinics. The Ministry of Public Health Afghanistan and other international agencies need to be sincerely appreciated for all the work and effort that they put in to make this happen despite volatile and insecure conditions in Afghanistan. In contrary to this, some segments of the international media and local Afghan politicians have expressed partial satisfaction over the progress made so far. They argue that the achievements are not compatible with the amount of money pumped into ailing the health sector in Afghanistan since 2001. As a public health professional, I do not deny the fact that a lot more needs to be done to improve maternal and child health in extreme remote districts of Badakhshan. However, there are several key challenges that have not yet sufficiently caught public's eye. Provision of maternal and child health care should not only be the sole responsibility of Ministry of Public Health, rather all other ministries and non-governmental organizations must also play a critical role in addressing these problems to improve the health status of the people of Badakhshan.
Inaccessibility: Badakhshan is a mountainous region and 20 percent of the total population of Badakhshan (living in Darwaz ,Khawhan, Ragh, Shughnan and Wakhan districts) have no road access. In summer, people walk for 18-20 days to get to Faizabad - the Provincial capital where the provincial hospital is located. In winter, the temperature drops below minus twenty two (-22) degrees Fahrenheit and heavy snow cripples life in the valley. These districts are cut off from the rest of province for at least seven months. The Ministry of Public Health has established primary health clinics like sub health center (SHC), basic health center (BHC) and comprehensive health center (CHC) in extreme remote villages where at least one midwife and one male nurse have been deployed. In extreme winter, the pregnant women can neither access these health facilities nor the midwife can go out to perform the outreach activities. Similarly, in case of emergencies, serious patients cannot even be transferred to the Provincial Hospital in Faizabad. Many people lose their lives to avalanches while making efforts to reach health facilities. Unfortunately in the event of emergency, not even a helicopter can land in the deep narrow valleys because of the massive snow and low clouds.
Lack of Human Resources: Badakhshan is facing a dire shortage of female doctors which afflicts the health care delivery process. Even today, a large number of health facilities in the province are without a female doctor. Though, some of the international organizations have brought female physicians from neighboring countries like Tajikistan but it is still a temporary solution to a permanent problem.
Ultra-poverty: A large majority of people in Badakhshan live below the poverty line. The exorbitant travel costs do not permit patients from remote districts to come to the provincial capital and seek the advice and care of specialist doctors.
Early Marriage: The custom of early marriage is prevalent in Badakhshan. Most of the girls get married before the age of 18 and in some districts as early as 12. This leads to several health problems like low birth weight, high fertility rate, malnutrition, increase mental distress. In addition to this, early marriage is also a potential cause of obstructed labor. Studies have shown that the younger women are married, the more likely it is that they will not have fully developed pelvis and therefore will be at risk of obstructed labor (Institute of Development Studies, Brighton UK-1996)
In spite of all these challenges, I strongly believe that today is better than yesterday and tomorrow will be better than today. The international community should continue to support the poor people of Badakhshan until all women have access to care during pregnancy and child birth. No woman should die giving birth and no child should be left an orphan because of unavailability of physicians, equipment and medicines.

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                                     Published in "The Huffington Post" USA on March 21, 2013