Understanding Covid-19 pandemic in Gilgit Baltistan through the lens of Public Health

The outbreak of Coronavirus Disease 2019 (COVID-19), which started in Wuhan, China, in late 2019, has now spread to about 188 countries of the world and has been declared a global pandemic by the World Health Organization (WHO) on March 11, 2020.

The first case of COVID-19 was reported in Sindh province of Pakistan on February 26, 2020. On the same day, another case was also confirmed by the Federal Ministry of Health in Islamabad. Both confirmed cases were from citizens who traveled to the Islamic Republic of Iran for pilgrimage and returned to their hometowns of Karachi and Rawalpindi with initial respiratory symptoms of the virus.

The index case of COVID-19 in Gilgit Baltistan was documented on March 2, 2020 and the patient was a 45-year -older woman who had returned home from Iran after pilgrimage. With the identification of the first COVID-19 patient, the pandemic started placing heavy burdens on the already overstretched health system in Gilgit Baltistan. Like many other countries and regions globally, the local health system of Gilgit Baltistan was also unprepared for such a large-scale outbreak. Secondary care health facilities were without ventilators and isolation beds.  Health workers had no easy access to personal protective devices (PPEs).  Because of the unavailability of internet or poor internet connectivity, most health providers in remote rural areas had no access to online training materials on Infection Prevention and Control (IPC) and case management guidelines of COVID-19. Despite COVID-19 risks, doctors, nurses, and other medical staff in the region devoted themselves to saving lives. Dr.Osama Riaz from Gilgit Baltistan was the first healthcare provider in Pakistan who lost his life to COVID-19.

As of August 14, 2020, the deadly virus has hit all four provinces and three federally administered areas (Islamabad, AJK and Gilgit Baltistan) and has infected nearly 288,047 people and claimed 6,162 lives, according to data collected by Ministry of National Health Services, Regulation and Coordination (MNHSRC).

The confirmed coronavirus cases in Gilgit Baltistan has increased to 2,452. If you look at a news website, you will see many beautiful graphics and dashboards that will provide you with the latest COVID-19 statistics revealing the number of total confirmed cases, number of tests, recoveries, and deaths. Sometimes, you will feel a relief when the overall trend on the graph is on a downward slope. Many times, these will add to your fear and stress when the numbers are on an upward trajectory. The question that can be asked is: what is the best way to measure the progress of the COVID-19 outbreak? An entirely accurate and a real-time snapshot of the progress is not possible for many reasons, but there are many key metrics that can paint a picture of the outbreak’s trajectory in Gilgit Baltistan. I have outlined here a few of those metrics to understand how successful we are in preventing the coronavirus spread based on daily COVID-19 data reported by the Ministry of National Health Services.

DAILY CONFIRMED CASES: Daily case count is a crucial indicator of community spread and indicates if the infection is under control.

Data Source: Ministry of National Health Services Pakistan

The daily count can be confusing if reports from far-flung hospitals and labs are delayed and hence lumped into single days. To prevent the data from skewing too far in the other direction, data scientists usually use the moving average of daily new COVID-19 cases to calculate the rate of change. For today’s analysis, I have used a 7-day moving average. As shown in the graph above, the 7-day moving average of daily new cases in Gilgit Baltistan was declining between June 6, and July 10 then again began to trend back upward, which at the time of writing this article appears to be holding fairly steady at just under 30 cases per day. The data shows that the number of new COVID-19 cases reported each day is on a downward trend, but the outbreak is not yet contained.
To know how bad the outbreak has been in Gilgit Baltistan and how many people are infected with the coronavirus compared to other provinces and regions in Pakistan, it is important to visualize the data per 100,000 population since the start of the outbreak.

Data Source: Ministry of National Health Services Pakistan

The data in the table above shows that Gilgit Baltistan is the third most affected province/region in Pakistan, with the highest reported number of COVID-19 cases per 100,000 population (after Islamabad and Sindh). From the beginning of the pandemic up to August 14, 129 people in 100,000 were infected with the coronavirus. If we look at the previous two-week period, then the data depicts a surprising result. Gilgit Baltistan has reported more cases per 100,000 residents in the last 14 days (@17 cases per 100,000 population). The daily case count here might not reflect the real picture on the ground as there would have been many infected people in the population who had never manifested any symptoms or might have exhibited mild ones and hence did not get tested for COVID-19.

 DEATHS: Another important indicator for measuring the burden of the COVID-19 in the community is mortality.

 Data Source: Ministry of National Health Services Pakistan

The table above provides two types of mortality statistics. The figures on the left side show the number of deaths per 100 confirmed cases (called case fatality ratio). The right side shows a total fatalities per 100,000 population (that includes the general population, with both confirmed COVID-19 cases and healthy people).  The overall case fatality ratio of Gilgit Baltistan (as of August 14) is 2.4 %, which is the third-highest in the country after Khyber Pakhtunkhwa and Azad Kashmir. Similarly, since the beginning of the outbreak, the region has reported 3.16 deaths per 100,000 population, which is a little above the national average of 2.95. The observed differences in mortality are likely due to different population demographics, characteristics of the health care system and differences in the number of people tested across different provinces. There could also be many other reasons which would be known after detailed research studies.

POSITIVE TEST RATE: This metric measures the percentage of people who test positive for the coronavirus of those overall, who have been tested.

Data Source: Ministry of National Health Services Pakistan

The test positive rate will be high if the number of positive tests is too high or if the number of total tests is too low. A higher test positive rate suggests higher transmission, and there are likely more people with coronavirus in the community who have not been tested yet.

Gilgit Baltistan recorded its lowest positivity rate between April 12 -May 5, at approximately 5 %. After May 7, the positivity rate started climbing and reached 28 % on August 1. One of the reasons other than higher community transmission was the lowest testing rate. According to official figures, 4,613 tests were performed in Gilgit Baltistan in May (with an average of 154 tests per day), 4,881 tests were conducted in June (with an average of 163 tests per day) and around 2,465 tests (with an average of 82 tests per day) were processed in July. It means the number of tests in July went down by almost 50 %, and this can also be seen in the graph above. However, in August, the number of tests has started to increase at an average of 128 tests per day (as of August 14).

On May 12, 2020, the World Health Organization (WHO) advised governments that before reopening the test positivity rate should be at or below 5 % for at least 14 days.
Gilgit Baltistan's seven-day moving average positivity rate stands at 16 % (as of August 14), which is still higher than the WHO’s recommended positivity rate of 5 %.

Data Source: Ministry of National Health Services Pakistan

If we look at the test positivity rate of all provinces and regions in Pakistan, then it becomes evident that only Punjab, Sindh, Islamabad, and Azad Kashmir have successfully brought down their test positivity rates below WHO recommended level of 5%. Khyber Pakhtunkhwa and Balochistan provinces stand at 5 % and 6 % respectively while Gilgit Baltistan stands at much higher than other provinces (at 16 %)

To further lower the positive test rate, the focus must be simultaneously on reducing the amount of coronavirus transmission and increasing the number of people who get tested. To further reduce the transmission of COVID-19, people of Gilgit Baltistan need to continue complying with strict preventive measures such as wearing face masks, ensuring physical distancing, maintaining good hand and respiratory hygiene, and avoiding large gatherings.

As Gilgit Baltistan is among the coldest regions in Pakistan so the coming winter might be a little harder than the previous ones. It could complicate the COVID-19 response if the outbreak is not controlled before the start of cold weather. The task of finding out who is sick with COVID-19 and who is suffering from a simple respiratory tract illness will be more arduous and complicated than we can imagine. The pressure for COVID-19 tests might push existing clinical labs to their limit. The demand for hospital beds may outpace the supply, and this could further strain an already strained health care system in Gilgit Baltistan. It’s time to stay more cautious and act responsibly to help the government in controlling the spread of the disease.

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 8^th, 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

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.

In 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.

                                Follow Aziz Baig on Twitter: www.twitter.com/drazizbaig

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

                                    Follow Aziz Baig on Twitter: www.twitter.com/drazizbaig

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

AQIL SHAH - my role model and an inspiration in life

It was 7:00 am on a dreadful morning of August 22, 2012 when my mobile rang. I ignored it thinking that it was a blank call. Surprisingly, the phone went into hibernation for a little while and then started buzzing over and over again. The situation became extremely uncomfortable and even a bit scary when my wife’s cell phone also began to ring at the same time as mine.  The moment I picked up my mobile, it stopped ringing but a flash SMS popped up on its screen. It was sent by Rahman Posh (my brother in law) from Pakistan. The text message was as follow:

“Dear Aziz, I heard a bad news that a van carrying BARATIS of Inayat from Kamaris - got into an accident and our beloved Aqil Shah and Bakhtullah passed away on the spot. May Maula rest their souls in eternal peace- Ameen”

An unforgettable moment with Aqil Bhai during my wedding in
 Gilgit on March 14, 2009

The text message numbed my body, dulled my mind and soaked my eyes with tears. I could not believe what I just read.  I grabbed my laptop and immediately opened the "Pamir Times" an online Newspaper of Gilgit Baltistan. The horrendous road accident was the breaking news on the front page.  It was a tragic day for my entire family but alas, I was a thousand miles away from everyone. I was not in a position to pay my last homage to my late great cousin and beloved brother. I have never felt so helpless in my entire life.  At such a difficult time, the only person who consoled me in my grief was my wife. She right away dialed my sister number in Pakistan who along with my other family members was in a deep shock

Many days have passed since my lovely brother has died but the traumatic incident of August 22 is still fresh in my mind as if it happened today. I was looking for ways to cope with the situation and decided to let all my pain out through writing.  

 August 2005: Aqil Bhai with his eldest son in Islamabad

Three people have influenced and touched my life and contributed to what I am today. They were; my beloved mother, my incredible father and my adorable and caring brother Aqil. It  is said that some people come into your life for a reason and they change your life in ways you cannot imagine. Aqil Bhai was among the few people who left Gulmit for Karachi in the late seventies with a determined attitude, unbreakable will and a clear objective in mind to complete his higher education. It was a time when parents were reluctant to support such a decision. Like others, he forgot his sleep, worked nights and attended his college/university classes during the day. One can easily get to the intended destination- no matter how bumpy or steep the path becomes and Aqil Bhai proved it. He has an honor to be the first post graduate degree holder from very small villages of Kamaris and Odver. He also set an inspiring example for the younger generation. He was the first spark that ignited educational and social revolution in Gojal.  During his stay in Karachi, he supported thousands of students. His home was a ray of hope for all new comers. Even today, people love him like a father, remember him like a brother and respect him like a teacher.                                                                   

Aqil’s life took a new turn when he completed his education and returned to Gilgit Baltistan. He joined the Ministry of Tourism in Islamabad as a Tourism Officer and worked until 1994 when he took the responsibility of a Civil Supply Officer at the Department of Food and Agriculture in Gilgit Baltistan. Just a couple of years ago, he was promoted to the position of Deputy Director and remained in this position until his death. During his professional career, he never detached himself from his area. He continuously helped people, guided the young generation and actively participated in all types of social work.  He was not only a great social worker and a towering figure in Gojal but people from Ghizer, Hunza Nager and Diamer districts also remembered him as a kind hearted, generous and wonderful human being. Irrespective of his social status, he always lived a simple life. Unlike other government officials, he neither had any property nor owned a home anywhere in Pakistan. He lived in the rented property until his last day.

1985: A memorable family photo with Aqil Bhai in Gilgit 
when he came on vacation from  Karachi.

Aqil Bhai was not just a brother with a pure soul and golden heart but the relationship goes much deeper and beyond genetics or family ties. He was my greatest source of achievement, pride and inspiration. His selfless support has always been with me throughout my academic career. He always believed in my capabilities, instilled in me self confidence, taught me the meaning of life and pushed me to work harder to achieve my goals. I cannot forget those days when I was a third year student at Rawalpindi Medical College and my father was severely injured in an accident. We faced the worst financial crisis of our life. I could not pay my tuition and accommodation fees for months. At one point I became so helpless that I decided to relinquish my studies, return to Gilgit and take care of my family.  The moment Aqil Bhai heard this from a source in family; he immediately traveled to Islamabad and paid all my expenses. 

Aqil Bhai attended the last family wedding in Gojal on August 22, 2012
a  few hours before his death  [Courtesy: Asghar Khan]

He told me never to give up, be strong and work hard until I achieved my goals. The story does not end here. The list of his contributions is endless. I have no words that could truly represent my feelings.  Whatever I am today; it is all because of him. Aqil Bhai was and remains my childhood hero and I strongly believe that true heroes never die.  He has left a legacy for many generations. We will always fulfill his dreams that were left incomplete due to his tragic death and continue with his great mission. May God rest his soul in peace. Ameen

My Journey to Afghanistan

It was June 2004 when Focus Humanitarian Assistance Europe (an agency of Aga Khan Development Network) invited me for an interview at its office in Croydon, UK for a position based in Afghanistan. My thoughts were completely entangled with confusion. The western media was busy publishing and broadcasting horrendous stories about Afghanistan and at such a crucial time, going there would mean putting my own life at risk.  Nevertheless, I still decided to appear for the interview.

The most hard-hitting moment of the show was the day when I opened my email and found the job offer. I was indecisive, nervous and befuddled. I contacted Dr.Adnan – my best friend who was working as a medical officer at Ipswich mental hospital and told him about the situation.  In the meanwhile, I wrote to Dr.Sardar Ahmad – an old Afghan friend from medical school days who used to work for World Health Organization in Kabul. The two close friends suggested me to accept the job offer. I decided not to inform my family members in Pakistan about this life changing decision; I knew that they would not be very excited hearing about this.

I left London for Islamabad on July 3, 2004. After two days, I left for Gilgit to meet my parents and other immediate family members as I had not seen them for almost two years. After spending a very joyable week at home, I finally departed for Afghanistan – a country where I had never been before – never even thought to be there in life. It was not easy to be in Afghanistan soon after the 9/11 incident when its painful memories were still fresh in everyone’s mind. 

On July 12^th, I took a United Nations Humanitarian Air Service (UNHAS) flight to Kabul. Remnants of war were still obvious at Kabul International Airport.  Wreckage of Soviet fighter jets and burned out tanks were lying near the run way.  The airport security personnel guided me to an immigration desk where a middle aged, male immigration officer looked at me and greeted me with a lift of his eye brows. I also returned the gesture. Before stamping my passport, he asked me something in Dari.  I had no idea what he said and remained silent. After a few minutes, I came out through the arrival gate and went to the parking lot where the office car was waiting.  The driver took me to a guest house located on the main Wazir Akbar Khan road. He mentioned that the United Nation Assistance Mission for Afghanistan (UNAMA) had been renting the building for many years. But now, it has been rented out to AKDN but everyone still called it "UNAMA guest house”. My room was on the first floor, facing the main Wazir Akbar Khan road and hence I found it a little bit noisy. I stayed in Kabul for a week, enjoyed delicious Afghani food and attended all orientation meetings before heading to Faizabad Badakhshan where I was to be stationed.

First arrival at Faizabad airport on July 26, 2004

On July 26^th, FOCUS chartered a PACTEC plane to Faizabad (the capital of Badakhshan province). It was eight of us who were traveling to Faizabad.  We were directed to the aircraft without passing the security checkpoint. “Oh my Lord isn’t it too small” I asked one of my colleagues after first glimpse of the aircraft. I was very excited and was looking forward to an interesting journey. After a few minutes, we all boarded the plane. There was no cockpit door and it was interesting watching the two pilots as they navigated the plane towards our destination.  The co - pilot put our luggage in the trunk, closed the door and briefed us about the in-flight safety procedures without a live demo. It was my first ever flight without a stewardess or flight attendant. The PACTEC pilots were doing everything themselves.  The flight took off from Kabul airport around 11.00 AM and started flying over rugged hills and beautiful snow covered mountains of Kabul, Salang, Baghlan, Kunduz and finally Badakhshan. In the beginning, I was a bit scared because there was a lot of turbulence and on the top of that, it was my first time being on such a small aircraft. To cut a long story short, we finally arrived in Faizabad at 12.30 PM. The landing at Faizabad airport was an amazing and memorable experience of my life.  The Faizabad runway was made of metallic sheets and had been built by the Russians in 1980. As soon as the wheels touched the runway, we started hearing loud scraping sounds. Trust me, I was scared and was in a state of shock. When the propellers came to a complete standstill, one of the pilots said, “Welcome to Faizabad. We hope you have enjoyed your flight”.  He opened the door and asked us to leave the aircraft one by one. I took a deep breath of fresh air and immersed myself in the raw and beautiful landscape of Faizabad. I felt like I was in heaven when I stepped out of the plane. Focus Faizabad’s logistic and administration team members along with office vehicles were there to pick us from the airport. We were first taken to FOCUS guest house. I went straight to my designated bed room, showered and changed my clothes.  Later on, we went to AKF guest house for lunch. I really enjoyed Afghani food.  At the same time, I was introduced to Aga Khan Foundation (AKF) and Aga Khan Health Service (AKHS) team members. All of my colleagues were very friendly, warm hearted and welcomed me with open arms.  

Dr.Salim Sumar – Executive Officer of FOCUS Humanitarian Assistance –Europe and Dr.Iqbal Kermali –Country Director for FOCUS were also in Faizabad to help me acquaint myself with the area and ongoing projects. On the very first day, they took me to the office of Provincial Governor.  I still remember that moment quite well. We drove through a police guarded gate, followed the narrow trail through lush trees and shrubs until we got closer to an old building. We parked our vehicles and walked into this building. The entire building was made of mud and straw and had only three rooms. The traditional pit latrine was only a few hundred yards away from the building. The provincial or state governors in my own homeland live in beautiful buildings. The lavish decoration provides recognizable evidence of their wealth and importance. It is not possible for a common man to meet the state/provincial governor and share with him either personal or  community related issues. If you are lucky enough to get an appointment, the so called security procedures will definitely make you cry and you will regret your decision.

First official meeting with the  Provincial Governor of Badakhshan 

Let me rewind back to the original scene without going into too much detail. A guy - most likely governor’s assistant greeted us with respect and directed us to a room. When we opened the door a, middle aged, serious looking man with white beard greeted us with kindness but without a smile on his face. He was Sayeed Ikramuddin Masoomi - the provincial governor of Badakhshan. One of our local Afghan staff introduced us to his Excellency Provincial Governor and his team.  In a nutshell, he welcomed us open heartedly, appreciated Focus’s contribution and asked us to do more for the poor and deprived people of Badakhshan. As a gesture of welcome, we were offered black tea (Chai), sweets and dried mixed fruits displayed on a tray in a traditional style.

On our second and third days, we visited UN agencies and other government departments in Faizabad. The orientation period that lasted for almost a week went very well. At least, I had some idea of what life looked like in Badakhshan and what were the real challenges.  At the same time, I was also perplexed and in state of imbroglio as I had no experience of managing multi-million dollar programs in post conflict countries like Afghanistan. There were many unanswered questions in my mind.  I was constantly asking myself, “Would I be able to comply with the expectations of the people and Afghan Government? Would I be able manage and keep my staff happy? Would I be able to do what the senior management was expecting from me?”  My heart's deepest inner feelings boosted up my self- confidence and aroused my enthusiasm and forced me to say, “I can, I will”.

  

Last but not the least; I worked for Focus Humanitarian Assistance (Europe) for almost two years. During my stay in Faizabad Badakhshan, I faced some tough times. I cannot forget the Faizabad incident when AKDN offices and guest houses in Faizabad were burnt, two other colleagues and I were made hostage and beaten by an angry mob in September 2004. I also can never forget the Baharak incident when some unknown people lobbed a hand grenade at my guest house - Ehsan Assad (my colleague) and I got minor injuries but luckily survived the incident.  I will go into more detail about these incidents some other time.  At this point, I can only say that these ill-fated incidents never bewildered or frightened me at all. My courage, pride and determination were never influenced by these events. I never lost my belief and confidence in the people of Badakhshan. I always prayed to God to give me the true strength and courage to serve these people.

With Shohada community members and Mission East staff

In August 2007, I joined Mission East (Danish NGO) and it was another golden chance to work with the hospitable people of Badakhshan.  I had a very strong affiliation and deep attachment to the land and people of Badakhshan not only because I lived and worked here before but also the place in Gilgit Baltistan where I was born and bought up, the language I spoke, the type of food I ate, the kind of music I listened and the form of dance I liked – were also a few considerable reasons behind this connection. North Pakistan (now called Gilgit Baltistan), Badakhshan Afghanistan, GBAO Tajikistan and Xinjiang China have so many things in common. Same landscapes, same beautiful snow covered mountains, same food, same religion, same customs, and same language are bringing together people from four different countries.

The two and a half years stay with Mission East was an amazing period of my life. It was one of the best international organizations to work for in Afghanistan. This organization has done so much to increase access to safe drinking water supply and sanitation services in North East Afghanistan.

With AKHS - health team in Darwaz District of Badakhshan

In January 2010, Aga Khan Health Service Afghanistan (AKHS-A) provided me with an exceptional opportunity to design, implement and oversee the community health programs in the province of Badakhshan. Badakhshan drew international media and donor agencies attention in 2003 when a joint survey report of UNICEF, CDC and Ministry of Public Health Afghanistan (MOPH-A) revealed that Badakhshan had the highest recorded rate of maternal mortality [6,500/100,000 live births] in the world.

I feel not only lucky but blessed to be part of AKHS-A, MOPH, USAID, UNICEF and other development agencies in Afghanistan to come up with effective strategies to implement long term health partnership programs in Badakhshan. AKHS-A also provided me with a golden chance to work on some new innovative projects that have rarely been executed in the world. The cross border health program between Afghanistan and Tajikistan was one the most amazing and memorable project that I have ever come across in the twelve years of my career. Every day, every hour and every second that I spent with AKHS were the most creative periods of my life.

The prolonged, impressive and memorable journey of six years came to an end in January 2012 when I decided to bid farewell to Afghanistan to join my family in Texas USA.

With Badakhshan Midwifery School students and faculty staff

Afghanistan will never fade away from my memory. Every morning I get up and miss the beautiful mountain landscapes of Badakhshan when I look out the window from my house in Sugar Land, Texas. I really miss my friends, colleagues and above all, the friendly, peaceful, loving, warm and hospitable people of Badakhshan. I have no words to express my feelings to those other than to say “thank you”. You will always have a special place in my heart.  I will never forget those difficult days when you took me to your house and saved my life when the security situation worsened in Faizabad.  I will never forget your kind hospitality and warm welcome to your house on Eid, Novroz and other occasions when I was alone in my guest house.   How could I forget the rocking farewell parties you organized, those beautiful words you spoke and the wonderful gifts you gave me when I was leaving Afghanistan?

With Dr.Nadira Hayat- Afghanistan's Deputy Health Minister

My journey to Afghanistan would be incomplete without recognizing the people who supported me along the way.  My special thanks go to Dr.Salim Sumar [who is the Chief Executive Officer for FOCUS Humanitarian Assistance Europe] for providing this wonderful opportunity to come and work in Afghanistan. I was always on my toes in my career because of him.  I am very grateful to Jacques Dailoux (who was the Desk Officer for Mission East in Brussels) for giving me a fantastic opportunity to work with a well respected organization in Afghanistan. It would not be an exaggeration to say that I have yet seen a humble person and true professional like him in my career.  It will be a great injustice if I do not thank Dr.Gijs Walraven- Director of Aga Khan Health Services (in Aiglemont France), Dr.Nayamat Shah (former Country Director for AKHS program in Afghanistan) and Dr.Fatima Mohbat Ali (Regional CEO for AKHS in Afghanistan and Central Asia) who believed in my capabilities and gave me the opportunity to work for Aga Khan Health Service in Afghanistan.  

With Excelleny David D.Pearce- U.S Ambassador to
Afghanistan and Dr. Waliullah -  Governor of Badakhshan

Last but not the least, Afghanistan not only developed my career but it also brought a special aroma to my personal life. This beautiful land blessed me with an opportunity to meet and marry my beautiful wife –Shazia Nota. My journey to Afghanistan would have not been possible without her never-ending love and support. She lived without me in USA for so many years but encouraged me to work for the people of Afghanistan for such a long duration. Thank you so much my love!

Although my six years journey has now come to an end but the beautiful memories will continue to live in my heart and mind forever.