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Providing Health Care at -45° C: Tajikistan’s Heroes of the World’s Highest Plateau

Remoteness, harsh weather conditions, poor road conditions and virtual isolation from the rest of the world. This is the reality for the inhabitants of the Murghab plateau, the second-highest plateau in the world, located in eastern Tajikistan. During the winter, temperatures drop to -45° C in Murghab town, and even to -60° C in some other parts of the region. For health workers, it is not easy to provide care under these conditions, with many medical students deciding to not return to their native region after their studies. However, those who do return to Murghab prove to be some of the most dedicated health workers imaginable.

Amid a nationwide supplementary immunization campaign, with the measles and rubella (MR) vaccine focused on closing immunization gaps and stopping an ongoing measles outbreak in the country, WHO’s team visiting Murghab had the opportunity to meet with two of the health workers implementing the campaign. Nurse Yunus and doctor Abdimanap serve their communities every single day, at an altitude of nearly 4000 metres above sea level. This is their story.

Nurse Yunus, Karakul village, Murghab district

Nurse Yunus serves each of his guests a bowl of kurut, a dried yogurt product made from yak milk. Hospitality is extremely important in the local culture and, while seemingly calm,  his eyes reveal a certain degree of nervousness. After all, the small settlement which he has called home all his life is one of the most remote places in the entire country of Tajikistan, and he didn’t expect to have afternoon tea and lunch together with a team of WHO experts… 

Planning visits is not easy: to reach the village of Karakul from Tajikistan’s capital city, Dushanbe, WHO’s team has travelled 3 full days, driving on challenging roads. Having poured his guests some tea, Yunus settles back down on the tapchan, a traditional piece of elevated furniture covered with lightweight quilts, on which the afternoon meal is served. The conversation begins to flow, and Yunus slowly starts to feel more relaxed. 

At an altitude of 3900 meters, it can get cold in Karakul. Very cold. Strong gusts of wind make a warm jacket a necessity, even during the summer months. 762 people live in the village, but during summer, the village is mostly empty. The population of Karakul village is nomadic and moves around the vast valley to allow their livestock to graze, preparing for the harsh winter to come.

After lunch, Yunus walks the WHO visitors to the small health facility in the centre of the small town, which he manages with one other family nurse. Before giving his WHO guests a tour, Yunus puts on his nursing outfit, carefully buttoning up the blue coat and placing the freshly pressed blue nurses’ hat straight on his head.

The health facility’s two rooms contain most of the essential equipment Yunus needs. Tables for examining patients, a scale, a mobile handwashing station, an eye chart and a refrigerator in which Yunus stores the MR vaccine vials, recently delivered for the campaign. 

Yunus and the WHO team discuss the nationwide immunization campaign, which has reached Murghab. With pride, Yunus explains that all the younger children in the village have already been vaccinated with the MR vaccine, in line with the national vaccination schedule. Now those living even more remotely need to be reached. The task isn’t as simple as it sounds: Yunus regularly crosses the rough terrain by bike or car to provide care to those who are living in yurts and small houses in other remote parts of the district, tracking down children who have not yet been protected by the vaccine.

“It is difficult here during the winter months,” Yunus explains. “It is cold, and the wind makes it hard to go outside. But we have to. It’s not only about vaccines – people get sick more often during the winter, and sometimes call us during the night. We are the only ones they can call, and we have to help them around the clock. It is a tough job to do, but it has been my childhood dream to have a medical education. I always knew I would come back to work in the village where I grew up. It is my duty to serve the people from Karakul.”

Dr Abdimanap, head of the primary health care facility in Murghab town

A decorated teapot is kept warm on the little wood stove in Dr Abdimanap’s office. It is summer now, so the wood stove is used mainly for tea. During the winter, however, the stove is indispensable to keep the office warm. Outside of the office, a baby is crying. The hallway is filled with parents, grandparents and their small children. They have all come to the primary health care facility in Murghab to get their children vaccinated against measles and rubella. Patiently, he gives instructions to the health staff to manage the large flow of patients, one family at a time.

Dr Abdimanap studied in Dushanbe to become a surgeon but had to return after a few years to his native Murghab in order to support his family. He now lives in Murghab town, which, with its 6000 habitants, constitutes the largest settlement in the eastern part of the Gorno-Badakhshan region in Tajikistan. Conditions are harsh. During the winter, the main road is often blocked for days at a time, isolating Murghab from the rest of the country. It can be -45° C in Murghab town, or even colder in some of the nearby villages where Dr Abdimanap works.

After a general health check-up, the children in the facility are invited in with their parents for the vaccine. From personal experience, Dr Abdimanap acutely understands its importance. “This immunization campaign is crucial. I myself got sick with measles as a child. I hadn’t been vaccinated, and I fell very ill. This is why I want to protect all children in Murghab from illnesses that can so easily be prevented.” 

According to Dr Abdimanap, some people in Murghab have concerns about vaccines, ranging from fear of side-effects to superstition or religious beliefs, and these concerns sometimes stop families from coming for the routine vaccination. The health staff do their best to explain the benefits of the vaccine and to gain the trust of the population, and they work together with local religious leaders to counter any misinformation. Leading by example is another important strategy, Dr Abdimanap explains. “I myself have four children. I vaccinated each of them. This showed the community that we can be trusted and we’re here to protect them.”

Conditions have improved significantly in Murghab since Dr Abdimanap returned, some 15 years ago, initially working without electricity. The primary health care facility is in good shape, allowing the doctor and his staff to provide essential health services to the entire population of Murghab. This includes immunization, despite the geographical challenges. “People here are nomadic and can stay very far away from our town. However, we know exactly where they are staying – in which gorge – and we remain in close contact with them. We overcome the geographic barriers with mobile brigades. Sometimes, they travel as far as 70 kilometres to immunize just a handful of children.”

Working on Murghab plateau is not just any job; it’s a mission.

Source: World Health Organization