Joe Jacob: Working for MSF in Kashmir

Joe JacobMy name is Joseph Jacob and I am a trainee radiologist at Kings College Hospital, London. In early 2009, I was given the opportunity through a sabbatical, to return to work with Médecins Sans Frontières (MSF, or Doctors without Borders) – whom I had previously worked for in Darfur in 2006-7. Though I chose a project based in Kashmir, India, fate and the intervening 11 months took me far further, to three projects stretched right across this vast subcontinent.

Médecins Sans Frontières has as its operational mandate a desire to respond to the needs of populations affected by conflict, epidemics or natural disasters. To this end, in India, we run three long-standing projects in Kashmir, Manipur and Chhattisgarh, all conflict affected states. The field teams are backed by a coordination team based in Delhi, which, in addition to managing the programmes, is ready to respond rapidly to any natural disasters or outbreaks of disease that might occur anywhere in this country (and unfortunately, there is at least one such emergency in India every year).

My base in Kashmir was Kuwpara town, carpeted with golden terraces of paddy but ringed by mountains that loom over the tense border with Pakistan. The district is home to high rugged passes, where villagers cut off in the long cold winter may walk up to 15km in the snow to reach our clinics. We are often the only doctors present in these borderlands and cases of malnutrition, severe chest infections, and families covered in scabies turn up with alarming regularity. Addressing the severe limitations in access to maternal health is one of our main focuses, the need for which was reinforced to me during a postnatal visit by the mother who finding herself alone at night, delivered her own baby and had to tie the cord and remove the placenta herself. To this end we offer regular ante/postnatal services in these very isolated settings in six basic healthcare posts.

The Kashmir valley has been affected by its widely reported conflict since the late 1980s, and though tensions still occasionally burst through its fragile surface, the majority of the trauma within the communities we serve has its roots in the recent past. For this reason, MSF runs a large mental health program that offers counselling in four districts of the state, performing over 6000 consultations a year. We try to ally mental healthcare with basic healthcare to emphasize how important both are to a person’s overall wellbeing, and a schools competition for poetry and painting that was the centrepiece of our mental health awareness raising fair demonstrated all too clearly how the valley’s scars continue to permeate the young students lives.

As Kashmir simmered in July, on the other side of India, cyclone Aila came and went, sweeping away whole villages that balanced precariously on shallow mudbanks in the Bay of Bengal. Though this disaster received little coverage at the time, it affected over 5 million people across West Bengal and Bangladesh. Whole communities had again lost all their possessions, in what must for them seem a truly bitter cycle of reclamation by mother Earth. Embankments and roads were washed away, villages and fields flooded with salt water, and whole communities forced to rebuild but without the requisite raw materials.

MSF responded initially by giving out non-food items such as blankets, plastic sheeting, jerry cans, chlorine tablets and soap to 2500 families in the worst affected district to address their immediate needs. Working as project coordinator for the surveillance system we had set up, we monitored the affected areas in the subsequent weeks to sooner respond to potential disease outbreaks such as measles, cholera and malnutrition. During one survey, my admiration at the stoicism of the elderly women who clambered to their neighbours houses, crossing gulfs in the path where the tidal flow reached their chests, swiftly turned into embarrassment when they returned to hold my hand and guide my ungainly form, notebook in hand, up the remains of the mud flecked road.

Finally in November, as my contract in Kashmir neared its end, I was asked to come and work in our project in Chhattisgarh, one of the most densely forested states in India. Here there is an active conflict between the government and Maoist rebels and MSF tries to preserve a humanitarian space for all actors and gain communities caught up in this conflict access to healthcare. To this end we run mobile clinics, walking up to 10km with backpacks, wading across rivers before setting up our consulting rooms under trees in a forest glade.

Chloroquine resistant falciparum malaria is endemic in Chhattisgarh (as stated in India’s National Anti-Malaria Drug Policy) and MSF advocates for the use of Artemisinin combination therapy (ACT) for its treatment. Within our clinics there is a significant caseload of complicated malaria, with cases of cerebral malaria or related malnutrition referred to our secondary healthcare centre. And in addition to the burden malaria imposes on pregnancy, a lack of established ante and postnatal care in the remote locations in the region has led to a worrying level of maternal mortality (according to Government of India figures Dantewara and Bijapur districts rank as among the worst in the country for access to basic healthcare (Dantewara data sheet)). In response, MSF has recently opened an inpatient mother and child health centre in Bijapur town to encourage safe deliveries and act as a referral hub to those women at highest risk of complicated delivery.
But that is just the tip of a very large iceberg. Skin conditions here are present in myriad varieties from simple scabies to leprosy (India finds its highest concentration of leprosy cases in this state). TB is also widespread and while access to these interior areas is almost impossible for the ministry of health (MoH), MSF runs a DOTS TB and leprosy program in partnership with the government. For TB, in addition to repeated health education, we identify suspected cases and obtain sputum samples, transport them to the MoH lab and if positive, take medication back. Here we identify a DOTS provider and educate and follow up both the patient and provider.

The successes of this particular program and the number of patients that have finished 6 months of therapy with cure have really surprised me. And while malaria is the most crippling burden the population face, if proof were needed regarding the importance of MSF’s work here, for me it would be seen in the face of the last man to complete his TB treatment, as he smiled and held his weight chart upon which the red felt line just rose and rose.

And now, as my time in India draws to an end, inevitably I look back on the incredible sights and characters that I have seen and met. Leaving MSF is always hard, both regarding the people and the life you leave behind, and the adjustments required for the life you reenter, but more than any other job I have done in my short life, it continues to change me in so many fundamental ways. The world continues to seem a smaller place, and humankind far more alike than most would like to admit. But mostly it’s the happiness in knowing that work like this exists, and that medicine, if you allow it, really is the best job in the world.