In Malakand district, in Pakistan's North West Frontier Province, the local population has been affected by conflict between the Pakistani army and armed opposition groups. Médecins Sans Frontières (MSF), one of the only international organisations present in this region, has supported  a sub-district hospital in Dargai, since 2006. An MSF medical team (comprising doctors and a surgeon, anaesthetist, nurse and gynaecologist) works with Ministry of Health staff in the hospital's emergency room, operating theatre and inpatient department. Here is an interview with one of the MSF nurses.

To her patients she is a merciful sister and mother with a soft and compassionate touch. Her happiness comes from serving others.

Shahnaz Rafiq is a nurse in a country where doctors outnumber nurses two to one. Despite recently higher numbers of women enrolling to train as nurses, the total nursing workforce in Pakistan is only 65,387  strong. That means that the current ratio is about five nurses per 10,000 people – the same as for the Democratic Republic of the Congo, and lagging far behind the global average of 28 nurses per 10,000 people. This in a country where maternal mortality is among the highest in the world, means that not having nurses in hospitals is deadly.

Shahnaz has worked with Médecins Sans Frontières for four years now, and is a senior nurse in the inpatient department of the Dargai 'Tehsil Head Quarter Hospital', a sub-district hospital known as the Dargai THQ, in the Malakand District in Pakistan’s Northwest Frontier Province. MSF is an independent emergency medical humanitarian organisation offering free medical care in communities where the needs are great, while also providing support to the Pakistani Ministry of Health at certain medical facilities.

Here she is tending to a young boy, brought in by his mother. He has been suffering abdominal pain, and with a gentle touch and soft voice Shahnaz assesses him. The youngster, although in pain, stops squirming, while she works.

When Shahnaz was a young girl she had already decided to become nurse, but it was a personal tragedy that further propelled her to the profession.

"I was ten years old. I was travelling with my father when he had a heart attack. Nobody could help him and he died by the roadside. That was when I decided to I want to serve people. I could not become a doctor, so I trained as a nurse."

Shahnaz, like many other qualified Pakistani nurses, at first decided to work abroad in order to support her family, working at private hospitals in Saudi Arabia for a couple of years:

 "I realised that I wanted to serve people in other countries. I knew that people in Africa and elsewhere needed nurses and I wanted to help them," she explains. In 2005 Shahnaz returned to Pakistan for vacation from her job in Saudi Arabia to see her children and family -- tragedy again played a role in the course her life would take.

On October 8 2005, a massive earthquake measuring 7.6 on the Richter scale hit Kashmir, killing over 70 000 people and leaving 3.3 million homeless.

"I spoke to my mother. I told her that I want to volunteer, to go there and help people, they need more hands. MSF was there, and said: 'I'll go with MSF'. I saw how they worked and I felt something [stir inside me], working there in Kashmir. So I sent my resignation to the hospital in Saudi Arabia where I had a good position as a head nurse. Money is nothing. If I am happy in my heart, that is my money," Shahnaz says about her decision to work for MSF in Pakistan.

"Even though it is difficult to be a nurse, I do not want to do anything else."

MSF started working in Dargai in December 2007, after setting up an emergency room and an operating theatre for trauma and elective surgeries. MSF also set up a maternal and child health clinic to deal with complicated deliveries, and built a 40-bed inpatient department.

Between July and September this year, MSF and the Ministry of Health treated 100 cholera patients in a cholera treatment centre. In August, 2,300 patients sought treatment in the hospital; 142 of them were suffering from violence-related injuries. Some patients arrived in very bad shape; ten of them died. The constant stream of patients with violent trauma bears testimony to the ongoing violence in Malakand.

At the end of October, the Pakistani local authorities requested all international staff to leave Malakand district due to security constraints. Pakistani staff continue to work in the hospital, which is still functional thanks to their presence, and efforts are being made to restore as soon as possible the complete return of MSF international staff in Dargai.

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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