In May 2009, one million people fled fighting in Swat valley and Buner district to Mardan, a district in Pakistan's North West Frontier Province. More than 80 percent of the displaced stayed with host families. Médecins Sans Frontières / Doctors Without Borders (MSF) helped local health clinics and hospitals to cope with the massive influx of people and provided medical care, tents and relief items such as soap and blankets to thousands of displaced families staying in one of the camps. In the Mardan Medical Complex, MSF ran a 40-bed inpatient department, and managed activities in the emergency room. MSF also set up a cholera treatment ward. By the end of October, MSF medical staff had carried out more than 3,000 consultations in the Mardan Medical Complex emergency room. 817 patients were  hospitalised and 1672 patients were treated for cholera.

It's painful to watch 14 month-old Maaz AMANKHEL writhing in pain from severe stomach cramps. For the last three days, she has suffered constant diarrhoea and vomiting. Her exhausted and worried mother tries to comfort her. "We all have this disease in the village, mostly the children. In my family, we are 20; there are five children with this disease," she explains.

The intravenous drip feeding into Maaz's tiny arm contains an all important rehydrating solution, which means that she will be able to recover soon.

It is just after 9am, but the heat is stifling and there is barely a breeze stirring through Nowshera, a town in Mardan District in Pakistan's Northwest Frontier Province. Inside a small building adjacent to the district hospital, the cries of anguished children are thick in air of the Cholera Treatment Unit (CTU), where Maaz is wriggling on a stretcher in the female ward.

MSF is a private and independent emergency medical humanitarian organisation, that started operating a few months ago in the Mardan District, in response to the massive influx of hundreds of thousands of people fleeing heavy fighting between Pakistani military forces and fighters from armed opposition groups in the Swat District since May 2009. Following the sudden influx, health services in the area were stretched to their limits due to the basic medical needs of such a large number of people. Between June and early November, MSF provided medical support to help alleviate the patient load of local health structures. Most of those who fled to Mardan were able to find shelter with host families, or school buildings and mosques. A camp housing up to 5,000 people was also set up by MSF to accommodate some of these displaced people.

In September 2009, due to the high incidence of cholera in the area, MSF established the Nowshera cholera treatment unit. MSF staff had determined that up to 40 percent of patients seeking treatment at the Mardan Cholera Treatment Centre, a 20-minute drive north, were from Nowshera and surrounding villages. Within days, word spread and treatment wards were full of patients each day – impoverished patients who otherwise would have risked dying, suffering at home, or would have had no choice but to shell out money to travel to Mardan city for treatment.

The noon sun is unforgiving as it beats down outside the Mardan Medical Complex. Most townspeople in Mardan have confined themselves indoors.  But at the 60-bed cholera treatment centre on the hospital grounds, nurses and doctors rush  about busily from bed to bed despite the heat, tending to patients. In just under a week, this treatment centre saw 100 patients admitted – a sign that the flow of patients is subsiding after the peak of over 1,000 patients one week in August.

In the tented cholera treatment wards, the humming of large electric fans is interrupted by the sound of an ambulance coming to a halt on the gravel. Nurses and attendants are carrying Mudasher, a 13 year-old boy, in on a stretcher. He is immediately given oral rehydration solution, containing glucose and electrolytes, but minutes later he is caught in a vomiting fit once again.

In another tent, Hussan Asra, aged 45, is also one of the new arrivals. She is a mother of five and is very weak and dehydrated. She can barely lift up her head to speak.

"Most patients, up to 70 percent, are severely dehydrated when they reach us. About 30 percent have to put on intravenous rehydration immediately. The patients often don't seek treatment until their case has become severe. While we treat them, we also have to do a fair amount of counselling about health issues, because as soon as they are taken off the IV lines, they demand to go home," says MSF doctor Sylke NEUMANN, who heads the facility.

She says that the majority of patients seen here are women, and they often arrive in a much worse condition than men. This is often because women cannot leave home unaccompanied, and have to wait for husbands or male relatives to bring them to healthcare facilities, while their condition deteriorates. Inadequate hygiene and sanitation infrastructure also explains the rise in the number of acute diarrhoea and cholera cases in Mardan. Sylke also explains that rudimentary latrines built without septic tanks, contributes significantly to health risks.

As time passed in recent months the number of internally displaced people in Mardan slowly decreased as families started moving back home to Swat. Dr Asad ALI, one of the doctors working in the emergency room, says that at the peak of activities about 50 people were treated at the emergency room each day. More recently about half as many people sought assistance, the majority of whom were from Mardan – another indicator that the internally displaced people were returning home.

Between June and the end of October MSF teams treated 1,672 cholera patients in three cholera treatment centres set up in the Mardan area. 58 percent of patients were suffering from severe cholera. There were no cholera-related deaths among children under five. MSF medical staff continued to support the emergency room at the Ministry of Health Mardan Medical Complex until the end of October. 3,224 patients were treated between June and October.

Since writing this article, the vast majority of displaced families have headed back home to Swat and Buner. MSF wound up its activities in Mardan at the end of October, and closed its project in November. MSF provided training to Ministry of Health staff and prepared the hand over of the cholera treatment facilities to state officials.

MSF does not accept funding from any government for its work in Pakistan and chooses to rely solely on private donations. MSF has been working in Pakistan since 1998.

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