Nursing With a Humanitarian Assistance Organization

Peggy Dryden, RN, MSN, MBA

Disclosures

October 21, 2002

Introduction

In this interview, we return to Afghanistan with Donna Armstrong, RN, OCN. As members of a humanitarian assistance medical team, Donna and her husband (Figure 1) traveled to Mazar-e-Sharif during January and February 2002 to provide medical care for displaced Afghans.

Donna Armstrong and her husband, Tom, at a bazaar in Tashkent, Uzbekistan.



Question: Please describe your and your team's role in Afghanistan. Could you explain how you and your husband became involved with the Christian humanitarian assistance organization Northwest Medical Team (NWMT) International?

Response: In February, I was fortunate to serve with NWMT's third team to enter Afghanistan in 2002. Our 4-person team consisted of a pediatrician with a specialty in nutrition, an internal medicine physician, my husband (an EMT), and myself, a nurse with 10 years of medical oncology experience. We all met in a team briefing at NWMT's offices the day before our departure. We were all from the northwest and shared many interests and values. We formed a good team relationship that facilitated our travels.

I first served with NWMT in 1992 as a recently graduated RN. I went to Africa to work with a medical team assisting the Somalian refugees in Wajir, Kenya for 6 weeks. Several years later, after my husband retired from the fire department, we served together for 6 weeks on an NWMT mission (6-person team) in Northern Albania, caring for the Kosovo refugees who were housed in an abandoned tobacco factory.

NWMT is located in Portland, Oregon, close to my home. My employer, Southwest Washington Medical Center, supports this type of volunteer service, and my manager and director were very understanding in setting a timeline for my return to work.

Question: What were you told prior to going on the trip? What were you told about the other NWMT teams that visited before you, what was their experience? What were your expectations?

Response: In the departure briefing, we were shown a map of Afghanistan and told about the experience of first 2 teams in getting into and out of the northern part of the country. We were told we would be entering from Termez, Uzbekistan, as that was considered safer than any other area at the time.

The 2 previous teams did the initial survey of the areas in and around Mazar-e-Sharif. They reported that there were several large camps with hundreds of displaced people and little or nonexistent help. The teams initiated contact with Afghan leadership in the area, the United Nations (UN), and nongovernmental organization (NGO) groups working in the area. The housing, the interpreters, a cook, the guards, the drivers, and all logistics had to be secured. The previous team's work was a great help to our team. They located where our clinics would be located, based on need and the information from the UN. When we arrived, we surveyed new options for an additional clinic out of town inside a small rural hospital. This provided us with 3 areas of service.

My expectation of the housing was worse than the reality. Our housing turned out to be a 3-story concrete building with windows, inside stairs, electricity (on and off), a flush "toilet," shower, and even carpet! Our team occupied the third floor, which was divided into bedrooms with sleeping mats, living area, kitchen, and bathrooms. We all brought very warm sleeping bags that eliminated the need for kerosene heaters, which are very dangerous because they are hooked up to a gas line.

At night, tucked inside my warm bag, I would hear the icy wind howling, and I wept for the people still out in the cold suffering in their flimsy tents. There had not been any assistance given to the people of this particular camp from any previous group. The day after we arrived, we helped with a blanket distribution. We had only 150 blankets, and there were several hundred more people needing supplies. It was emotionally upsetting to hear the cries and pleas just over the wall of our clinic.

The people in our 2 camps were miserable (Figure 2). It was cold, wet, and muddy, and there were no resources to meet their needs. Families lived in makeshift "tents," with no fuel for heat, no clean water, and no sanitation. Ten people died of exposure the week prior to our arrival.

Camp Korasan in the city of Mazar-e-Sharif after a February rainstorm.



There is a big difference between a "refugee" and what the UN calls "displaced people." Refugees receive a lot of humanitarian help, starting with tents, food, blankets, cooking supplies, latrines, and water. The displaced groups appeared to receive no assistance, as the aid is focused on refugees who have had the means to flee across the border. Those left inside their country who have fled their villages for their safety are "displaced," and aid is not provided. It seems to be the belief that if help is too readily given, these people will not return to their villages. Their houses have been destroyed, their animals slaughtered, and some or all of their family murdered. They are in shock and have nothing on which to survive.

Question: Could you describe the 5 days of traveling prior to walking into Afghanistan?

Response: We traveled into Afghanistan through Tashkent, Uzbekistan, then boarded a 2-hour flight to Termez, Afghanistan. We had to stay in Tashkent at a prearranged apartment rented for us by NWMT while we waited for our visas. The organization arranged interpreters to be with us and help us with our travel to the border.

Tashkent is a huge metropolitan blend of post-Soviet "modern" Russia. It had espresso bars, cyber cafes, restaurants, shops, bazaars, large tree-lined boulevards, parks, tall buildings, and lots of traffic. The faces of the people were revealing. Many people smiled at us, knowing we were Americans. There was evidence of alcohol and drug abuse among some of the youth. Life in Tashkent for many was very good compared with what we would witness inside Afghanistan, a short 2-hour flight away. I kept wondering about what the next part of out trip would bring.

Once we landed in Termez, we packed ourselves and all of our supplies into 2 taxis. We were told we would be at the border in 30 minutes, where we were to meet our contact who would help us cross. The people who helped us in Termez were in a well-known influential business family who seemed to have all the contacts. Their influence was apparent by the way the airport clerks and taxi drivers readily responded to the nod of our guide's head. Summoned drivers would materialize to get us safely to the border. Money was slipped into certain hands at certain times by our contacts. Throughout the entire journey, these men did a great job delivering us from Tashkent to inside the border of Afghanistan. I was glad someone knew the "ins and outs" of crossing the famed Friendship Bridge. Being able to cross the bridge definitely depended on who you knew.

Question: The December 2001 prison revolt of pro-Taliban fighters occurred in the Mazar-e-Sharif fort shortly before your visit there. (The American John Walker Lindh was captured there.) Can you describe what you saw at the fort?

Response: On February 2, 2 months after the Taliban prison battle, we visited the fort to view a piece of living history. The prison, on the outskirts of Mazar, had held the Taliban fighters the Northern Alliance had captured. The outer walls were made of the red clay used throughout the region and resembled the ramparts of a castle. Inside were concrete rooms and outbuildings.

The center of the fort held a very battered looking, concrete, one-story building. This was where about 60 of the Taliban had been fighting from inside the basement. As we walked around, we noticed a hole-like opening to the basement of this one-story building. Our interpreter told us this opening was where some of the intense fighting occurred, and the battle signs were evident. It was during that battle that the first American soldier, CIA Officer Spann, died. Later in the battle, some of the Taliban fighters who surrendered came up out of the hole, including the American John Walker Lindh.

Question: How were you received by the Afghan people in Mazar-e-Sharif?

Response : While in Mazar-e-Sharif, we were invited to meet with the fort's commanding officer and offered tea. We were led to his "office," where we all removed our boots before entering. I was glad I was wearing my heavy socks. (During my time in Mazar, I would start giving away such items to women coming into our clinics, all of whom had no socks and some barely with "shoes" on their feet, many wearing only little plastic sandals.)

As we entered the commanding officer's room, each of us bowed slightly to the Afghan commander and his men, and then placed our right hand briefly over our heart in greeting. (Handshakes among the men are very important also.) We sat in a circle on a rug around an old kerosene stove. I sensed a lot of tension in the room among the Afghans and our group.

The hot tea was passed around. We talked through our interpreter; our conversation was markedly polite. We explained why we had come and our concern for the health of the people in the area. The commander then told us we were welcome to be there. They were amazed and happy that Americans cared enough to come over to them with help. Most of the men in the room stated they had lost all or several family members. We all felt great loss from all the recent tragedy in the United States as well as in Afghanistan as we sat together in the ancient ritual of a circle, sipping tea.

Our team asked about the medical needs of the soldiers and the plight of their surviving families, who were all in desperate need of food and medicine. The grim fact was that these soldiers and the entire nation had not had received a salary in 5 years. We explained to the soldiers what we were doing in the "displaced persons" camps with our clinics. We explained that we transport and that we cover hospital care for the most fragile children, as well as mentoring the 3 Afghan doctors who work closely with us, one a female Afghan internist who re-entered practice after 5 years of hiding from the Taliban.

Our meeting was indeed a 2-way cultural exchange; a small step toward a more balanced understanding of each other's lives. Some of the men were fathers and spoke of their families with great sorrow, some with tears.

Question: Could you describe how the medical/nursing care was provided at the camps?

Response: We worked in 2 different camps. We used a vacant clay building as clinic space at the edge of the camp area. One building could be locked up inside a walled, gated courtyard. The other building had no security. In both places, we carried all our medications and gear there and back every day. We had small portable kerosene heaters to take off the chill in the examiningroom. One of the clinics had a bed with a wire frame (no mattress) for the most fragile adults.

We had a privacy curtain used for examinations on the women. Usually the female Afghan doctor or myself cared for the women. We collaborated often as a team with each other and with the 3 Afghan doctors working with us.

Our supplies were primarily various kinds of medications, blood pressure cuffs, babyscales, and otoscopes. We had large metal boxes that I had organized into compartments to help us find a needed medication. Intravenous medications and hydration were done in the hospital setting. However, we covered the cost of the medications each time we transported a patient to the hospital. There are many pharmacies inMazar that were well stocked, but very few people had money to buy what they needed. All necessary medications and equipment for surgery had to be purchased by the families (or sponsoring NGOs). We knew the Afghan doctors did charity cases occasionally, especially if the problem was something the younger physicians had not seen yet. We treated as many as 40-50 patients in a half-day clinic when we had 4 clinicians, including myself. Some days, we had only 2 team members available, which meant that many people were turned away.

Some days, I was designated to represent our organization at the daily UN-sponsored logistical, nutritional, and safety meetings. It was interesting meeting personnel from the otherNGOs, but it was also very frustrating because very little seemed to be accomplished as a result of the meetings. My team worked very hard to organize the many classifications of medications that had been brought in by our teams, and to spend time in direct patient contact.

Frequently seen conditions included respiratory infections; ear, nose, and throat infections; skin problems' and intestinal diseases. Dysentery, worms, and pneumonia were the most common problems. We did not see much malaria because of the time of year, but the effects of previous malarial infection certainly played a part in the general debilitation of many of our patients. We saw fungating tumors, abscesses, boils, scabies, fungal disease, and postpolio problems.

Sometimes we saw patients with more challenging symptoms such as signs of a possible collapsed lung, enlarged liver, enlarged heart, or abdominal tumors. These patients were taken to the hospital for x-ray. At the time, the Jordanian army had a peacekeeping segment outside Mazar with a well-equipped field hospital. They had agreed to take cases from the NGO medical groups on a case-by-case referral. They provided the needed diagnostic tests in some of these more difficult patients.

My nursing skills for this kind of relief work were enhanced by a relief position in my hospital's outpatient pediatric clinic years before, as well as the clinical experience I had as a medical surgical nurse in our busy medical/oncology unit for several years. When I served the Somalian refugees on the Kenyan border andlater the Kosovo refugees, I was fortunate to work alongside several highly experienced pediatric, emergency room, and gastrointestinal physicians and nurses who all collaborated together, if needed. In addition, the NWMT outgoing teams are given laminated protocol cards with signs and symptoms and recommended medications and dosages. It doesn't take long for assessment and diagnostic skills to sharpen quickly with such large numbers of patients having similar problems. Public health nursing is different from oncology nursing, but in serving patients in such impoverished countries, my basic nurse assessment skills combined with pharmacology knowledge went a long way.

Question: What health problems did you see in the Afghan children coming to your clinics?

Response : We saw infants with advanced malnutrition, and many with lung and skin infections. Pneumonia was the biggest and cruelest killer of the children (Figure 3). Our team had 6 babies come in with pneumonia over several days, each laboring with apneic, fragile breaths, and much lung consolidation. One of the team members would start rescue breathing and rush the child to the hospital in our vehicle. Once there, an intravenous line was immediately started. Medications and fluids would slowly help the infants breathe easier, though, unfortunately, oxygen was not consistently available in the hospital.

Donna Armstrong feeding a baby with pneumonia.



It is a grim fact that 1 in 4 toddlers die in Afghanistan before they reach the age of 5 years. Most of the country's people live in remote villages, some in the very inaccessible mountains. When starvation is present, which is how it has been the last year, the male infants have a slight edge in receiving all of the mother's milk, and the older child, especially if a girl, languishes from hunger.

When a sick child arrived at our clinic, a parent or sibling stayed by the bedside. These family members each needed food brought to them, as they had nothing, and their family was a long distance back in the camp. Our team paid for the IVs and other medications, and gave the mother daily meals. The daily cost for care was low to us, but impossible for those Afghan people who have lost everything in the warring times they live in. It was a joy to be able to provide this care for these families. How we wished we could provide care for all the children suffering in so many places throughout this country (Figure 4).

Child with end-stage liver disease.



Question: Having completed this 5-week mission, do you have plans for another? Can you offer any suggestions to other nurses who may be interested in going on a mission like this?

Response: I am open to new opportunities to serve people in medical need anywhere. Nursing certainly does open many kinds of doors. To do this kind of nursing requires a sense of adventure and compassion combined with a flexible attitude. There are several medical NGO groups in the United States; of course, I would say NWMT is one of the best. I encourage any nurse who can arrange the time away, and has a willingness to give care in sometimes very uncomfortable and potentially risky situations, to talk to the volunteer coordinators of one the various groups.

Thank you, Donna, for telling your story. Readers interested in contacting Donna Armstrong, RN, OCN may email her at donnalarm@hotmail.com.

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