Stephen Hayes was working in Pakistan as an adviser on health management issues when he found his stay cut short by the events of 11 September.He describes his experiences to Jennifer Trueland

Published: 10/01/2001, Volume 112, No. 5787 Page 14 15

On 11 September 2001, at around 6pm local time, Stephen Hayes turned on the BBC news. From his guest house in Peshawar in the North West Frontier province of Pakistan, he learned, with the rest of the world, that a plane had crashed into the World Trade Center

Mr Hayes, a former chief executive with the then Lomond Healthcare trust in Scotland, was three weeks into an eight-month healthcare management consultancy contract. He had arrived on 20 August. By 15 September, he was back on British soil.

'When I saw the news, I didn't make a link with Pakistan, or, indeed, with Afghanistan. At the time, it just seemed a terrible event a long way away, ' he tells HSJ.

'But the next morning when we were driving to the health department, we passed the American consulate and saw that it was even more heavily guarded than usual.

The local papers were also hinting that the finger of suspicion was pointing at Afghanistan. By lunchtime, that was becoming even clearer and US citizens were being told to go underground, heavily guarded. That was worrying because they do not normally do that.'

Mr Hayes, 52, had already spent three years in Pakistan, working at first as chief executive of the Aga Khan Health Service, a large nongovernmental organisation.

His wife Shivonne and two children, Sean, who is almost three, and Clare, 18 months, moved back to the UK earlier last year but he wanted to continue working on healthcare in the developing world.

So he had leapt at the chance to work with Oxford Policy Management, developing a healthcare strategy for the impoverished country.

Even before 11 September, however, there were indications that Peshawar had its dangers. 'A few mornings before, I heard a very loud bang and was told it was a bomb going off. The Taliban have quite a strong presence in Peshawar and there is rivalry between different factions of refugees. After the events in America, I was worried, especially when I saw how rapidly people who were coming from Afghanistan - such as foreign aid workers - were being moved away.

There were all sorts of rumours, that Islamabad airport was closed down, that American troops were landing. We certainly expected instant retribution - we didn't think the Americans would hang around. And Pakistan's role was equivocal because it had been a backer of the Taliban.'

Mr Hayes had a flight home booked for the Monday, but, urged on equally by his wife and the fact he had a serious chest infection, managed to get an Emirates flight out on the Saturday. 'I arrived in Gatwick and could barely move for people - I couldn't even get to the airline desk to see about my onward flight.

'So I took the train. I got back to Glasgow on the Sunday evening.

My wife was pleased to see me, I think, and I was glad to be back.'

Despite his family's misgivings, Mr Hayes returned to Karachi in November to see out his contract with Aga Khan. The financial year in Pakistan runs with the calendar, so there were end-of-year issues to deal with, as well as planning for 2002. But it wasn't really the Karachi he had known previously. 'I kept a very low profile and just moved between the hotel and the office.

'There were very few foreigners there. The hotel where I was staying, the Marriott, is normally buzzing, but it was very quiet. The restaurants were closed and everything was very low-key.

There had obviously been a total clear-out of foreigners, and, though some were beginning to come back it was very slow.'

Mr Hayes had one frightening moment. 'I saw a demonstration going past and that was a bit worrying. But I stayed in Karachi - I didn't go to Peshawar.'

He returned home again at the end of November. Whether he will return to Pakistan hangs in the balance. He has written up reports from the early work in Peshawar, but his involvement in the project's future is uncertain.

'I've told OPM that I am prepared to go back to Islamabad. Lots of ex-pats have returned and it doesn't look as though foreigners are being targeted.

'My wife's not too keen, but There is also the issue that if There is no work, There is no pay.'

Mr Hayes is clearly enthusiastic about the strategy which he and the Pakistani consultants were trying to draw up. The problems of North West Frontier Province, and, indeed, Pakistan, leave in the shade any which the people of even the west coast of Scotland might have to face.

'There is no comparison. Take any measure of health - maternal mortality, life-expectancy - and Pakistan fares worse than other countries in Asia like India, Sri Lanka and even Nepal. There is obviously a link between the health service and the status of women, poor economic situation and sanitation, and so on.'

The government health system is very centralised and hospitalbased. It is free at the point of use, but people have to pay for drugs and often for consultations as well.With medical staff so poorly paid, there is also plenty of scope for corruption. While the rich 2 per cent of the population can afford good care, the rest do not fare so well and having to pay for third-rate services is the norm.

The strategy being worked on by Mr Hayes and others is to devolve responsibility locally - making hospitals work almost like UK trusts - and to develop primary care. The Asian Development Bank, which is funding the strategy, is also keen to put up more money in the form of loans for implementation.

It is a far cry indeed from Lomond, which was at the time a trust that covered the Vale of Leven Hospital as well as primary care and mental health services in Dumbarton and the surrounding area.

Mr Hayes decided to make the move after 27 years in the NHS, starting as a management trainee.

As a senior manager, he had overseen overseas management students on attachment, and had spells teaching in Kenya and India. When he became chief executive of the Aga Khan service he had the challenge of an organisation which spread across Pakistan as far as the Chinese and Afghan borders.

'My job was partly to streamline the management, ' he says. 'I feel that we - that is, Britain - have a lot to offer and should engage with the developing world. But I also find it exciting and challenging personally.' l