FPHC Begins Reconstruction Activities in Flood Areas

Sorry for the delay in communicating with you. We have been really overburdened and it continues. even now. The staff is working longer hours than routine, even the office staff.

Because our geographical area is prone to emergencies and we have needed to respond quickly in the past to earthquakes, floods and massive IDP migration, this past January we opened a special bank account to create emergency response fund. This also has helped us to track the emergency funds we received better. We had a small amount in this account when the floods hit that allow ed us to jump right into relief services at the end of July, 2010.

The need for medicine and supplies, even at the beginning, however was very big as whole families and communities had run from their flooded homes with only the clothes on their back. So we were very glad that you were able to raise and send funds to us so quickly.

Our early and effective emergency response was acknowledged by the government authorities, who put us on their official list. This helped as we then received some local donations from philontherapists and organizations. International groups such as UNICEF, WHO and UNHCR also came forward to assist us with supplies. In addition, we had realized some unspent funding in ongoing projects in the tribal areas and got approval from UNICEF for utilization of those savings in flood affected areas.

Along with the donations sent by Society of Rural Physicians of Canada, Hillman Medical Education Fund and Rose Charities we have been able to continue our work since the floods began.

Recently we have been chosen by UNHCR for an emergency grant to set up two static health care centres in government health facilities in Nowshera and Charsadda districts for the flood-affected people. Each of the static centers supports by six mobile teams. The static centre consists of LHV, 1 MCH Assistant and 1 Male Social Mobiliser. . Each of the six mobile teams supporting the static centre consists of 2 Medical Doctors, 1 Medical Technician, 1 Laboratory Technician, 2 LHVs, 2 MCH Assistants, 2 EPI Technicians and support staff. So this totals more than 50 additional staff members as well as the necessary medical and non-medical equipment, rented vehicles and medicine. As part of this UNHCR project we are also rehabilitating 12 health facilities, including several FPHC centers, that have been affected by the heavy rains and floods.

We expect to hear shortly from UNICEF regarding a possible six month Nutrition Project for flood affected people that is planned to start middle of October. Under this project FPHC will be providing Nutrition Services (specifically provision of ready to use micronutrients and nutritional information) to women and children in at least 10 Union Councils . A Union Council is an administrative unit like a big village.

In recognition of our activities, FPHC is now an established part of the the Nutrition Cluster at Country level and coordinate regularly with UN Office for the Coordination of Humanitarian Affairs (UNOCHA) and National Disaster Management Authorities. Thank you to all our generous donors for helping not only flood-affected people in Pakistan but also for assitsting all the staff of Frontier Primary Health care to build capacity in responding to these humanitarian emergencies.

from Dr. Emel Khan and FPHC

Photos: Flood relief 2010

FPHC Continues in Flood Relief in KPK

Since late July, 2010 more than 10 million children have been affected by the Pakistan floods, including 2.8 million under five-year-olds. 1.2 million people still living in 6300 camps all across the country.

Although progress is being made, many flood-affected families still have limited access to health facilities. In some areas service delivery has been totally disrupted as up to 80% of the homes and facilities were affected. With more than 200 health units destroyed or only partially functional attention has not turned to repairing them.

The majority of private sector health providers have also been disrupted by the floods. Luckily most of Frontier Primary Health Care health units are functional so they have been able to assist in areas where facilities have been destroyed..

Surveillance in the affected flood areas of Pakistan is available on the WHO site. http://www.who.int/hac/crises/pak/en/index.html In the four districts of KPK, Punjab, Sindh and Baluchistan a total of 80 health facilities were affrected, almost half (38) of them in KPK (Northwest Frontier Province). WHO has 20 health partners assisting in the flood relief in KPK including Frontier Primary Health Care, which is active in both nutrition and health in flood affected areas in Mardan district and a refugee camp.

So far it has proved difficult to track activities of FPHC on the WHO website, which better captures activities of large international organizations likely due to better access to the internet. I could not for example, identify any of their health centers on the WHO maps of KPK health facilitiy status following the flood nor was were they mentioned among partners although the number of medical contacts they have daily exceeds that of many of the other organizations and they were in the field earlier.

However, in early Sept, 14 staff from Frontier Primary Health Care (FPHC) mobile health teams were trained on the WHO Disease Early Warning System so hopefully their activities will be better tracked.

The efforts of FPHC continue in assisting provision of emergency health assistance including high impact, critical life-saving services for men, women and children in communities of flood-affected areas of Mardan, Khyber Pakhtunkhwa through strengthening, providing and maintaining essential health services.

Photos: FPHC Flood relief 2010

Responding to the 2010 Floods In Pakistan

Frontier Primary Health Care is a small, effective Pakistani NGO operating for more than 20 years in the Khyber Pukhtoonkhwa (KPK) region, formerly called Northwest Frontier Province. They provide primary health care to more than 250,000 Afghan refugees and local Pakistanis in 4 rural districts and one of the federally administered tribal areas near the Afghanistan border. They provide the complete range of PHC at a cost of less than $2 USD per person annually. While minimal in terms of cost, this PHC has increased the health status of the populations they serve enormously, with many of the parameters in their communities much higher than elsewhere in the region. They have accomplished this remarkable achievement by using an army of both male and female local volunteers and a committed group of staff paid local wages.

Over the past five years they have also responded to four humanitarian crises in their region. The earthquakes on the Kashmiri border; the deluge of Internally Displaced People (IDPs) as a result of violence in Northern Pakistan and floods in Mardan in 2009 and now a Pakistan-wide flood of 2010. Their expertise and efforts have been recognized by UNICEF and they have in the past been contracted to provide medical care and nutrition feeding centers.

In the current crisis more than 20 million people, almost 1/5 of the population of Pakistan, have been displaced and in the area where Frontier Primary Health Care operates, flood waters more than 20 feet deep flow over the roads, destroy homes and inundate the fields.

Nowsherra and Chadsadda districts have been among those worst hit. FPHC is providing assistance to the flood-affected at their health units in those districts. Additionally Frontier has been deploying two mobile medical teams consisting of medical doctors, medical technicians, Lady Health Visitors, social mobilisers, EPI technicians and support staff equipped with ambulance, medicine and equipment daily. The mobile teams focus mainly on emergency services and MCH services. The major diseases reported are water related such as skin infections, diarrhoea and also respiratory infections.

The mobile teams are also distributing food and clothing donated locally; micronutrients and vaccines supplied by UNICEF and occasionally cooked food and utensils. Each morning the mobile teams report to the District Health Officer to be sent to the hardest hit areas. As the need is so great and the resources few, the teams rarely return to the same area. The threat of cholera and dysentery, because of the difficulty in obtaining drinkable water, increases daily with nutrition of the many displaced children and pregnant women an ongoing need.

FPHC has been in contact with UNICEF and UNHCR but so far international organizations have been experiencing difficulty in moving supplies and people in place in the rural areas. I notice that several of the humanitarian sites such as Hesperian and Grassroots International are suggesting donations be sent to appropriate, reliable local Pakistani NGOs to circumnavigate the difficulties the larger international NGOs are experiencing, in the same way SRPC is doing.

The Society of Rural Physicians of Canada has partnered with Frontier Primary Health Care for more than four years. During that time we have worked with FPHC to improve the management of sexually transmitted diseases, trained traditional birth attendants and are currently developing participatory research, conflict resolution and training projects. Money sent to FPHC will be appropriately and well spent. Along with the Hillman Medical Education Fund and Rose Charities Canada, Society of Rural Physicians proudly supports their work and have found secure reliable ways to send funds. Your generous donations have allowed us to send $6000 to date. Rose Charities is a volunteer-based organization with low overhead.

You can donate online at the rose Charities Canada website.

https://www.canadahelps.org/DonationDetails.aspx?cookieCheck=true

Click on Donate Now button.

On the Fund Destination list scroll down to Pakistan Flood Relief.

Tax Deductible receipts are provided for donations over $20. Every bit helps. We can make a difference.

Photos: FPHC in 2010 flood

On-The-Job MCH Training

For many professions, the most important training one gets is the one-to-one mentoring that happens with older colleagues while you are actually doing the work. They can be formally supervising you or they can just assist you in keeping out of trouble. For years in medicine, such apprenticeship training produced excellent physicians. While it may not be sufficient it is certainly necessary. The one aspect of current medical training that seems less than appropriate, is the demise of such hands on coaching from experienced members in the field.

In rural remote areas with few opportunities for formal education and training, skilled health workers can be trained effectively in a form of on-the-job training that not only incorporates such coaching but also allows and in the case of women, actually encourages them, to undertake training. Reasons for its success include that on-the-job training can take place to the homes of potential recruits, thus allowing them to remain at home while they are trained, reducing the cost and the barriers imposed by leaving the community. Also it prepares health workers for work within that specific environment. While portability of training is overall a good thing, it negatively impinges on rural areas with a net loss of those trained. For people who plan to stay in that region, training in and for that region make perfect sense. Providing training in the home environment helps to increase educational levels in that area. A career ladder that allows the best to move ahead ensures gifted and hardworking health workers are rewarded. But perhaps the best recommendation for on-the-job training occurs when outside organizations recruit your trainees as part of their workforce.

This has happened at FPHC, where several of the recently trained volunteers have been offered jobs within the government health system, including one at the hospital. It is akin to getting a giant feather in your cap, to have someone you have trained to be recognized as useful in a formal role in the health system.

It means you are doing something right and providing opportunities for trainees including volunteers to provide for themselves and their families and to move into the regular job market. It is rewarding to hear that the women volunteers trained by FPHC continue to provide their services free to their own communities. The services they provide will also be augmented by what they learn in their new jobs.

Congratulations to them!

Photo: Sterilizer at EmOC

Maternal & Newborn Training in Refugee Camps

Mero’s sister-in-law was due to deliver shortly after she completed her training with Frontier Primary Health Care as a Female Health Worker. Most of the deliveries in the refugee camp where she lived, were done in rooms set aside for animals or for bathing. This made the cleaning up afterwards easier. Mero had seen how careful the nurses were about hygiene in the labour rooms. Mero had been impressed by the importance her trainers placed on having a delivery done in clean surrounding.

So Mero shared this new information with her sister-in-law and together they began to prepare a room for the delivery and arranged clean clothes, pads, soap and basins. While Mero and her sister-in-law were preparing the room, other women in the camp were watching them and learning. They admired Mero’s efforts. They were glad Mero would be able to assist them to have healthy deliveries.

The baby was born safe and healthy in hygienic conditions with Mero using her new Clean Delivery Kit. Things were already starting to change in the camp .

45 new TBAs were trained in Akora and Akairabad Refugee Camps in Nowsherra district of Northwestern Frontier Province in Oct and Dec, 2009. Training of these female health workers will ensure women in this remote area of Pakistan have ready access to accessible skilled maternal and newborn care. 32 in Akora and 13 in Khairabad.

A comprehensive community selection process ensures that the female health workers are trusted and respected individuals in their own community who will be allowed to visit women and care for them in their homes. The TBAs are provided with three weeks of interactive training in primary health care with an emphasis on maternal and newborn care. They are coached in to recognize and refer pregnancy complications early and to provide health promotion over the three weeks of their training. More than 15 days is spent in health center labour rooms and first level EmOC facilities of Frontier Primary Health Care.Improvements have already been noticed in Ankora within the first three months since the training was done. New registrations of mothers has increased 25% from 88 in Oct to 101 in Dec. while babies weighed within the 72 hours has increase from 92 to 131 in the same periods. The number of women delivered by skilled workers also increased 30%, from 98 to 127.

Successful TBA Training in the Midst of War

Almost 60-70% of women and their families in the isolated communities of Wardaga and Ismailia prefer and use traditional birth attendants. Over the past ten years, due to illness, old age, insecurity and relocation, the number of Traditional Birth Attendants in Wardaga and Ismailia village in Northwestern Frontier Province has decreased drastically. As the area is conservative and rigorous purdah practiced, women rarely venture outside their own homes. In these areas linking pregnant women up to women within their own community who are knowledgeable about pregnancy and child birth is crucial to reducing deaths from child birth.

4000 was obtained from the Hillman Medical Education Fund and Society of Rural Physician donors to train 30 TBAs. A lengthy consultation with the two communities ensured they were supportive of the plan to improve maternal health services, were willing to have their wives and mothers trained as TBAs and/or visited by the TBAs in their homes and had agreed upon a minimal fee for provision of birth kits and TTBA care. Discussion of the qualities needed for being a TBA lead to development of a set of criteria and identification of suitable candidates for each community. At the end of the process the communities had identified a total of 38 women were needed.

Wardaga’s population is 12,000 while Ismailia’s is 30,000. It was recognized that these female health workers as the only ones in their community would also be important conduits of health information on diarrheal diseases, immunization and nutrition as well as pregnancy and newborn care. Wardaga has a day labour room staffed by two nurses and 3 dais while Ismailia has a basic emergency obstetrical center (EmOC) providing 24 hour coverage with 3 nurses, 1 assistant nurse and 4 dais. So skilled TBAs were an important adjunct to getting services to women and women into the health centers for delivery when needed.

The need for skilled female health workers in the community resulted in the extending the training from four weeks to six weeks. This 50% increase in enrolment and training period were accomplished with cost efficiencies within the original budget with $4000 training 38 TBAs, or approximately $105 per TBA trained. This cost included provision of a supply of individual birth kits containing rubber gloves, soap, razor and tie. The individual kits form a rotating supply that will be sold to pregnant women at cost plus a small amount for the TBA which is agreed in advance by the community, approximately $0.50. In addition each newly trained TBA received a TBA kit with rubber sheet, nail brush, towels, gloves, soap, plastic apron, containers and a supply of oral rehydration packets.

The project did not include an evaluation component and information is available for only 4-6 months following the training but data from the health units show a real impact. Ismailia Health Center, where 38 TBAs were trained, reported a more than thirty percent increase in the number of ANC visits, from 240 to 320 women in the first four months following training of the TBAs and a >200% increase, from 30 to 68 in the number of women delivering at the Health Center. Prior to training. almost half of the women admitted to the obstetric unit did not proceed to delivery prior to training while six months following training less than 10% of the pregnant women who initially admitted were discharged without delivering.

Health Center, where nine new TBAs were trained, ANC visits doubled from 51-106 within six months and the number of delivered women receiving at least two doses of tetanus toxoid rose from 36-51 in three months.

While the follow-up period is short and the data preliminary, these figures suggest that not only do trained TBAs refer more pregnant women to ANC and for delivery but appear to be more appropriate and effective in their referrals. Trained Traditional Birth Attendants in this area are proving to be valuable resources in reaching women in their homes and linking them to appropriate delivery and antenatal care. Their pride and dedication to improving the care to pregnant women.

Photos: TBAs in class; TBAs using models; TBA with certificates

Floods Create Havoc in Mardan & Swabi

Frontier Primary Health Care has been called again to respond quickly to a humanitarian crisis, this time even closer to home as the recent devastating floods in Mardan and Swabi districts have played havoc in their own communities of Ismailia as well as Kagan and Baghica Afghan refugee camps. This most recent disaster comes just weeks after the Internally Displaced Refugees in camps around Mardan had been repatriated to Swat and the camps officially closes. For several weeks following the closure of The Sheikh Yaseem town camp, where FPHC had beenproviding 24-7 coverage, FPHC staff continued to provide nutritional services to other camps as well as some medical clinics in the camps until all were closed.

On August 16th a heavy deluge of rain resulted in massive damage throughout Swabi and Mardan districts. Approximately 50% of the mud homes in the Kagan refugee camp were fully destroyed and the rest remain in dangerous condition. Ismailia Health Center was also badly hit with flood waters filling the clinics with mud and debris. The home of several staff were also affected including FPHC's hardworking, stalwart administrator, Said Zaman. Luckily he and his family all escaped unscathed.

The homes in the refugee camps were especially badly affected, as they are made of mud and wattle. Many of the injuries and deaths that occurred were a result of collapse of the homes which happened suddenly and catastrophically.
As many as 27 people died in the flash floods with many more injured and thousands now without homes. The EMOC Center in Ismailia as well as the Health Centre there, both busy and active clinical sites suffered serious damage to both medical and non-medical supplies.

FPHC vehicles and staff assisted in Kagan with the evacuation of people from the worst of the flooded area as well as arranging for cooked food for those affected. The health center at Ismailia and the emergency medical team provided emergency medical care to those injured.

There are ongoing concerns about the spread of cholera and typoid in the area. Staff and community are busy rebuilding their homes, cleaning up and shifting the debris and mud that has been left behind.Everyone is busy now cleaning up the damage and putting things right.

Photos: Kagan & Baghica Refugee camps and Ismailia.

Frontier Continues Work in IDP Camps

The health group I work with in Pakistan, Frontier Primary Health Care, is based out of Mardan, North West Frontier Territory. Right now they are in the epicenter of one of the most massive movements of internally displaced persons on the globe as the number of people fleeing from Swat, Bajaur, Lower Dir and Buner, just north of them moves past three million.

The executive director of FPHC, Dr. Emel Khan, came to Canada last year to present the keynote address to the Society of Rural Physicians of Canada in Halifax. He also visited the west coast to initiate links with UBC and Simon Frazer universities. We secured a small grant later in 2008 for his wife, Dr. Wagma, the deputy director of FPHC, to take courses in conflict resolution at the Justice Institute of BC.

As the disaster unfolded in May, FPHC was among the first to respond, providing emergency and maternal care at their 14 health units. This has continued. FPHC now has a formal agreement with UNICEF for provision of health and nutrition services in the camps. The provincial health department has provided an ambulance and driver for use. Local and international organizations wanting to assist are asked by the government to coordinate their services thru FPHC, including specialist physicians from the large government hospitals from outside the area such as Punjab.

They are providing round the clock coverage to the largest camp in Mardan, that near Sheikh Yasin town with a population of 12,000.

To continue this level of support FPHC have hired 90 temporary staff members including physicians, dispensers, lady health visitors (LHVs), assistant LHVs, EPI technicians and nutrition assistants. Until a formal agreement was in place, FPHC was providing care with their own staff who number only 120. In addition to emergencies staff provide general OPDcare, MCH care, immunization, TB control and diarrhoeal disease control.

FPHC have also established nutrition services in six IDP camps that are screening children and pregnant women, providing nutritional supplements and sharing information about preparing healthy balanced diets. Prior to establishing nutritional services, three staff members, including Dr. Wagma received seven days of training on UNICEF’s emergency approach to nutritional support.

The agreement with UNICEF does not include medical supplies so FPHC struggles to provide what they can. More about FPHC can be found here.

Photo: FPHC provide emergency care during Mardan floods.

Responding to IDPs in Northwest Frontier Province

While war wages around them, Frontier Primary Health Care (FPHC) struggles to assist in mitigating the impact of the disaster on women and children.

Frontier Primary Health Care is a small Pakistani NGO, working with 200,000 people at 14 separate sites in four districts in Northwest Frontier Province of Pakistan. They have a number of Canadian partners including the Hillman Medical Education Fund, Rose Charities and Society of Rural Physicians of Canada.

FPHC works in ten Afghan refugee camps and the surrounding Pakistani communities providing the full range of primary health care at the cost of $2 per person per year. FPHC have also had some experience in responding to disasters with the recent quakes and floods in the region.

Northwest Frontier Province has been swamped with more than 2 million internally displaced people (IDP), according to the UN. It is one of the most extensive migrations of IDPs on the planet as people take flight from intensive US and Pakistani bombing, drone attacks and fires in Swat, Bajaur, Lower Dir and Buner districts. Fleeing their homes, they are quite literally running for their lives. 80% of the refugees have arrived in Mardan and Charsadda, the target area of Frontier Primary Health Care.

As the disaster has unfolded, FPHC has been providing free medical and maternity services at all 14 of their health centers including the Ahmed Shah Abdali Hospital in Mardan. On May 7th, 2009 Frontier Primary Health Care arranged for emergency health care services for IDPs in one camp and was planning how they could assist with emergency health care and nutrition rehabilitation services in four other camps. In discussions with UNICEF, FPHC indicated that although they have limited resources, their staff is eager to assist. By May 10th, staff had been deputed and health posts established in two IDP camps . Community labour rooms in Mardan and Nowsherra were also taking on deliveries of the IDPs.

Some IDPs are able to go to the homes of relatives but most look for shelter, food and health care where they can find it. The people, especially the pregnant mothers and children, have been arriving in miserable condition as the unrest and violence in their homes has been ongoing for many months. Many women and children have nutritional deficiencies. Civil society groups,government and common people are doing their best to provide relief.

Four main camps have now been established in Mardan district, Jalala, Sheikh Shehzad town, Mazdoorabad and Sheikh Yasin town. Emergency and comprehensive health care at the IDP camp at Sheikh Yasin town was officially delegated to FPHC. FPHC staff have continued to provide round the clock services with their own resources assisted by donations from friends and staff. Working in their regular health centers during the day, many staff take on additional evening and night duties at the IDP camps,extending their working days to 18 hours. FPHC have been using their own meagre drug supplies as supplies have been slow to arrive and 700- 800 patients daily present at the clinics with diarrhea, dysentery, respiratory infections and skin conditions in addition to the pregnant women who present for delivery.

FPHC urgently need funds to continue to provide medical supplies and nutritional support to mothers and children. Check here to find out more about the Hillman Medical Education Fund and Rose Charities. Rose Charities Canada is able to accept and send donations directly to Frontier Primary Health Care and provide tax receipts for Canadians. For a USA tax receipt donate through Rose Charities US

Photos: Lady doctors hold MCH clinic during emergency; field immunization clinics; FPHC responds to Earthquake; FPHC hold emergency clinics during floods.

Trip up the Mountain

One evening as it is cooling down, a group of us from the STI workshop for physicians take a trip up the mountain, heading for a dry river bed where locals picnic.

The road clings to the side of the mountain. We stop in the sun to top up our water supply with clean, clear, cold artesian water pouring out of plastic pipes along the road. Young boys sell fresh bright yellow plums, roasted corn and small black mountain figs. The figs look like plums as they are fresh. Everyone knows what they are called in Pashtoo, Urdu and Farsi but not in English.

When I inquire if they are figs, I am met with bewilderment.

Finally, I ask, “Are they are used to break the fast in Arab countries?”

“That’s it," the kids reply gleefully.

“Ah, then they are figs!”

Our second workshop in STIs has gone much smoother than the first even though there are more non-English speakers, because we have made a concerted effort to translate everything into Pushtoo. We noticed in the first workshop that although everyone understood some English, many did not have a great deal of facility in English and some points were not being sorted out until they were in small groups speaking Pushtoo.

Many of the Afghan physicians attending the workshops are not fluent in English so they sit at the back with a colleague beside them translating. Amazingly to me, they follow closely and are active in the discussions which are mainly in Pushtoo. The wonderful thing about participatory training is that so much of the learning takes part in small groups and discussion.

Since everyone speaks Pushtoo fluently, I assumed all the translating was being done in Pushtoo. But then when I asked for some of the written feedback at the end of each day which was not in English to be translated, I was told it was Urdu. I t seems that a number of the educated Pushtoo-speakers, such as doctors, do not write Pushtoo,. They write and speak Urdu. So unbeknownst to me, the workshop has been moving along in three languages, Pushtoo, Urdu and English. Make that four, it seems the Afghan physicians are using Farsi some of the time especially for the more complex concepts.

With all these languages being used, the draft flow charts needed to be available so everyone had a copy of them. I was concentrating on having everyone memorize the flow charts and not planning to print them until after the workshops. But with all these language challenges, the core material needed to be more accessible so I sat down with my marker pens and drew up the flowcharts

.

At the base of the mountain, the area of the dry river bed is huge and given the number and height of the mountains that surround it, one can imagine how quickly it would fill up in a downpour. But right now there are small trickles only and trucks, buses and taxis have wound there way down. Kids are dangling their feet in the small streams. Colourful carts move about selling gum, sweets, roast corn and chips. The woman are dressed in colourful, holiday attire, which seems out of keeping with the flat gray stone and gravel-covered dry stream bed. But there is generally a festive atmosphere. Our large van crunches slowly down the slope, and it is a slope and not a road, so we too can be part of it. But even with care it is clear this is not the best vehicle for such a spot and we carefully maneuver with some difficulty up the slope.

Down in the dry river bed there are a whole slew of beehives and some beekeepers, in their net and gloves moving supers around. I can’t quite make out what they are doing from up on the road but it seems a strange place for so many hives as it is a long way from any flowers. Later, higher up the mountain in Nathiangali I find young fellows selling their mountain honey. They have collected in buckets a number of actual bee hives wrapped around branches in a teardrop formation. They pour the honey into a plastic kilogram jar for me for 200 R (about $3.50). It is exquisitely flavoured with a light, clear consistency. There seem to be a lot of flowers similar to our jewelweed, with its long pouch full of nectrar growing on the mountain sides. I think I might have acquired some jewelweed honey.

Shortly after we have made our way out of the dry gravel river bed, it starts to rain. Not just rain, but it pours. It comes down in sheets so thick you can’t see across the road. It is monsoon season, which I had no idea reached this far inland, having only experienced it in South East Asia. There is a rapid exodus of the formerly dry river bed as bikes, carts, buses and trucks lurch up the slope. I catch this fellow in his cart with his feet drawn up as he cowers under the small shade of his cart waiting out the rain.

The most surprising aspect for me at the STI workshops has been the response of participants to the gender training. There was initially resistance as in why are we talking about gender. In the clinical sessions we had delineated the biological issues which make women more vulnerable to STIs - the increased area of genital mucosa, cervical ectropy in young women, the lowered immunity to infection in pregnancy, the high rate of assymptomatic STI disease in women and the exposure before during and after pregnancy as well as during breast feeding of the infant.

Gender issues everywhere are of concern. Women experience higher levels of poverty, illiteracy and violence but more especially in this area of rigorous purdah there are added burdens of poor access to health care, lack of mobility and shame. It would seem that without a framework for analyzing issues such as gender, the current situation becomes the norm even for a group of reasonably enlightened physicians.

At the end of the workshop, one of the doctors, who had recited a number of moving Pushtoo poems for us as energizers during the workshop, confided to me that he had three sons and one daughter who at 15 was the eldest. His daughter was brilliant at school but recently had complained to her parents that she felt they favoured the boys and neglected her. He said that since learning about gender at our workshop, he understood her concerns and had to agreed he had favoured his sons. He was going to start to listen more carefully to and support his daughter more actively.

When I shared this story with my fellow trainer Emel, he replied that he had always thought he treated men and women equally but after his first basic gender training he realized he was running the health programs of his organization differently, taking extra care to reach women.

That is the ultimate test of any training workshop, that we transform the way we see the world and are motivated to make personal changes. I feel as if I had my hands briefly on the golden ring.

Photos: boy on edge of mountain road; mountain figs, dry river bed picnics; beehives in river bed; Mountain honey; monsoon rain on cart

Trip to Nathiagali

During the week at the appointed times, the men unfold prayer mats. Occasionally a large blue rug is spread on the lawn so a group of them can pray. As ablutions are done before prayer it puts a lot of pressure on the one public bathroom but the hotel staff are accommodating and open unoccupied rooms for our participants when asked. Emel has opened his room for the 6 female participants so they can wash and pray. When I learn several days into the workshop about the lack of washrooms, I offer my room, even tidied it up somewhat but no one takes me up on my offer.

In many Muslim countries, Friday is a half day. We have planned additional time for prayer on Friday so the men can go to the mosque but when participants ask for extra time so they can visit Nathiagali, we shift around the timetable. Along with Murree, Nathiagali is a very popular tourist place not only because it is accessible to Islamabad..

Nathiagali is at the top of the mountain close to Abbottabad. Our participants have been so keen, hardworking and dedicated, we feel they deserve a chance to get out and see the sights. But not personally being one for tourist places in general, I don’t appreciate why they want to see a tourist town. So when I do visit it on the weekend, I am charmed of Nathiagali.

First, in its favour, I seem to be the only non-Pakistani tourist. The mountain is stunning. Curving roads, stupendous scenery and clear vistas. This is also the site of a massive earthquake several years ago. My friends point out the incredible difficulty of reaching people in this area, many of whom were stranded for weeks on these steep inaccessible peaks. There are still people living in the tents supplied at the time. Much of the aid, we are told, has yet to reach most of them.

Nathiagali means street and that is what it is at the top, a narrow crowded street. There are young boys selling circlets of daisies and floss candy, shops with precious stones and gems from China, pashmina shawls so soft they practically lift off your hands when you hold them and sandlewood boxes from Kashmir. Kids clamour on gaily decorated donkeys and mango milkshakes are prepared while you wait.

We meander down the street along with all the other gaily dressed families. There is not much tourist trade in Pakistan right now and I am the only foreigner around. One young fellow stands close to me and asks his friend to take my picture on his cellphone camera. I ask him if he is going to tell people I am his girlfriend or his aunt. He smiles and laughs but doesn’t understand English. My friends tell me I might be on YouTube now.

We stop in at a wonderful eating place, that just hangs over the edge of a ravine, where I get the photos of these chickens on spits that are being turned by hand. About half the time we are in Nathiagali, the town is shrouded in mist or perhaps it should be more rightly called low hanging clouds. The men go off on the mountain trails to have a look at the monkeys while we women move in and out of all the jewelry stalls.

Photos: view on Kashmir Hwy; Nathiagali; Boy selling circlets; Chicken Roasts on Spit

The Fascinating Art of Truck Back Panels

It is true. I love the truck art here in Pakistan.

Look at these two winged cenotaurs with female heads. Where else would you see this? All of it is hand painted. It doesn't look to me like it is even silkscreened but I could be wrong. Occassionally I notice that many of the trucks at a single truck stop appear to have similar styles or choice of symbols but that could be a result of hanging out together or going to the same places.

I wonder if anyone has studied this folk art? Maybe, I think it could be a way to connect with the truck drivers, who are very pleased when you want to take pictures of their vehicles.

















How about this glorious eagle?

















And this free white horse?
















I was having such fun taking these pictures that they gave me a toy truck all decorated, a very large toy truck.