New lives amid chaos: pediatric nursing in war-torn Afghanistan

An Australian pediatric nurse describes learning, sharing and working with Afghan women and their babies, surrounded by violence.

As part of its broad operations in Afghanistan – a mission now in its 32nd year, having commenced in 1980 but closed for five years from 2004–09 – Médecins Sans Frontières (MSF) supports the Ministry of Public Health in Ahmad Shah Baba hospital in eastern Kabul, Dasht-e-Barchi maternity in western Kabul, Khost maternity hospital in Khost Province, and Boost Hospital in Lashkar Gah, Helmand Province. At Boost, MSF support includes surgery, internal medicine, emergency services, and maternal, pediatric, and intensive care. In 2014, the maternity ward’s capacity was expanded from 40 to 60 beds, facilitating the delivery of 9207 babies. Helmand is one of the provinces most severely affected by the conflict in the region and malnutrition is one of the main causes of child mortality.

Having recently completed a nine-month placement in Boost Hospital – in southern Afghanistan – with MSF, pediatric nurse Sam Templeman took the time to provide some insights about his experiences.

In this editorial, Templeton reflects on the challenges, rewards, joys and frustrations of his deployment.

Project objectives

My job was to supervise the general pediatric ward and inpatient therapeutic feeding centre. I worked alongside an Afghan head of department and together we managed both wards.

The job involved a mix of direct hands-on care, bedside teaching, classroom teaching, as well as more managerial tasks such as rostering, leave planning, supply/stock management, HR and so on. I enjoyed being in a position with that sort of variety.

The focus of my assignment was simply to improve the quality of care our patients were receiving. I’m proud to say we achieved this through staff training and supervision, renovation works, ensuring that we had the right resources and equipment, while also updating policies and procedures as necessary.

Boost Hospital is quite a large one and a large project by MSF standards. MSF international nurses and doctors support national staff in running the different departments – everything from surgery to intensive care and malnutrition wards. The organisation employs almost 700 national staff there.

In the general pediatric ward and inpatient therapeutic feeding centre, we had all female nurses and health assistants. I appreciated working with our Afghan staff. I was always aware that it was quite a rare privilege to be able to work alongside, and learn from, Afghan women.

I was nervous at first, worried about saying or doing the wrong thing because we have different cultures, traditions. But I was quickly struck by how reactive they were. There was a nurse in the general pediatric ward who loves her cricket. After the World Cup, I was told that because Australia won, I had to buy kebab for everyone working that day. My argument that since my country won, they should buy kebab for me, was not well received!

Medical and humanitarian challenges

Where do I start? There is little free healthcare in Helmand province. Most people visit private clinics or pharmacies, where they pay for treatment. The healthcare professionals often lack training and the quality of publicly available medicines is also dubious. Often people spend what little money they have on poor-quality services. We saw the knock-on effects of the lack of primary healthcare in the hospital; many people present with ailments that do not need hospitalisation.

The malnutrition ward brings many of the province’s issues into focus. Malnutrition is not caused simply through a lack of food. Anyone who’s been sick before can appreciate that you often lose your appetite and a bit of weight at the same time. But a child in this context – without access to good primary healthcare, good nutrition or adequate sanitation – is at an increased risk of getting sick again. As this cycle repeats itself, a child ends up losing more and more weight until he or she is severely malnourished.

Another issue was the easy availability of antibiotics, often either inappropriately prescribed or bought without a prescription, thus fuelling antibiotic resistance, and as these antibiotics become less and less effective, health outcomes will only get worse.

Patient stories

I remember a mother in the malnutrition ward whose son had kwashiorkor. This is the type of malnutrition where a child’s body becomes swollen. These children tend to have a higher risk of dying in hospital. We started him on the standard treatment and hoped to see the child improve and the swelling reduce. But there’s so much we still don’t know about malnutrition, so much research yet to be done.

We went through other possible diagnoses, checked his urine and blood and did a chest x-ray to look for signs of tuberculosis. Nothing seemed to fit and we couldn’t work out why he wouldn’t respond. But that’s not why I remember him. I remember him because of his mother. She was young, like so many were, and she cried for him. She cried and cried and didn’t stop because she was so worried about him. No one knew what to do. We were all so unused to seeing so much emotion; we didn’t know what to do for her.

Some of the other mothers tried to comfort her. Some of our staff tried to soothe her. In the first few days, I sat with her and explained what was happening and that we expected him to improve after a few days of treatment. After a few days, I had to tell her some children take longer to respond than others, then that we were running some tests to look for other causes. Finally, I didn’t know what to tell her. After about two weeks I was told she’d left and taken him to Pakistan, hoping for better treatment. I’m not sure he survived the trip.

Resilience in the hardest times

We would often hear fighting between armed groups and government forces. One day, word spread that there had been an explosion not far from the hospital.

One of the nurses got a phone call from her sister telling her their house had been destroyed. Thankfully, no one was hurt. She asked me if she could leave work early to see the damage and salvage what she could.

She’s one of the tougher nurses and usually gets on with work without complaint. Most people would be in tears after seeing their house destroyed but she managed to keep them at bay when she came back. Later that afternoon, one of her patients died, yet she didn’t fall apart. At the end of the shift, she put on her burqa, took her bag and went back to where her house used to stand. On her next shift, she showed up to work and worked as hard as she always did.

A small world

There are many anecdotes, but the one people often enjoy hearing relates to the international staff not being allowed out due to the tight security rules. We used to drive from our house through the bazaar to and from hospital and see people go about their business. We all longed to be able to get out and walk around, sit and have a tea. I remember near the end of my assignment, one of the nurses asked if I’d ever been to the bazaar. I saw one of her colleagues shaking her head and making a gesture – something like ‘only A to B’ and then they started laughing.

“Really?” the nurse asked me. “You’ve never been anywhere except the hospital or your compound – in nine months?”

“Once,” I replied. “I went to a meeting. I’m not allowed out”

The nurse just couldn’t stop laughing.

I sat there being laughed at by this 19-year-old nurse for not being allowed out. That I did not like. My international colleagues, however, seemed to enjoy the story quite a lot.

Sam Templeman is a pediatric nurse working with the international medical aid organisation Médecins Sans Frontières.