The Lure of Pakistan : A Humanitarian Relief Experience in Muzaffarabad
A strong earthquake of magnitude 7.6 on the Richter scale struck Pakistan on 8 Oct 2005 at 0850 hours (local time). Its epicentre was at Muzaffarabad, some 120 km north-east of the capital Islamabad (Fig1). The ‘shake' lasted 6 minutes and caused massive destruction to houses, public buildings and communication networks. This high-intensity earthquake was also felt in many parts of Afghanistan and Northern India . In Muzaffarabad, more than 90% of buildings were totally collapsed. Residents spent their first night under the chilly sky in parks and fields, outside their damaged homes, or in the remnants of their damaged vehicles. Due to the mountainous terrain of the area, many were trapped in their isolated villages, inaccessible by roads and trains. As that fateful Saturday morning was a normal school day, hundreds of children were buried under collapsed schools, with many more trapped in destroyed mud houses.
Muzaffarabad city was almost completely destroyed with large sections uninhabitable. Buildings on high grounds were now simply buried as slopes had been sheared away. The city's hospitals, university and colleges were just piles of rubble now, with thousands of bodies still buried beneath. Further upriver from the Neelum Valley , it was hard not to notice perhaps a great geological damage. A range of mountains looked as if a large knife had cut through a section of it. A brand new cliff face was all that remained of forested hillsides. Scores of people had died at once when the hillside collapsed in a huge cloud of dust that blotted out the sun on that fateful morning of the earthquake. Clusters of tented villages were seen in many areas, a sign that the living carried on with their lives. The supreme court of Azad Jammu Kashmir , previously with its beautiful marble edifice, was now cracked, crumbling and unusable. On its lawns, multiple tents now serve the needs of the community, distributing relief supplies.
The short tour of the city made the scale of the devastation evident. In sombre silence, it was hard to imagine the state of mind of the residents themselves, having been visited by this major catastrophe.
Team Singapore : Efforts and Challenges
The first team of 6 from Singapore left for Pakistan and arrived at
Muzaffarabad on day 4 after the earthquake. The objectives for the first
team were:
1. To assess and evaluate firsthand the situation and needs of the victims
in the acute phase post earthquake, determine the nature and composition of
the subsequent teams to be dispatched and
2. To carry out acute phase treatment and management of disaster casualties.
Before leaving, ‘research' was performed using various resources to gather
as much information as possible on the current situation. Resources utilised
included the world wide web, news reports and articles, inputs from the
Pakistan High Commission and feedback from the Pakistani Medical
Association, our local host and contact in Pakistan . The challenges
anticipated included that of ;
• Weather conditions: especially the low temperatures at night and the
expected heavy rains. The team was prepared with warm clothing, suitable
tents and sleeping bags.
• The terrain would be mountainous in the area we expected to work. The
ground would be uneven and irregular, thus, the need for good sturdy
footwear and a certain level of fitness.
• The language: even though a few of us did understand some Urdu and
Arabic, interpreters would still be required.
• Religious and cultural sensitivities: as the majority in Pakistan were of
the Islamic faith, our dress code and behaviour would have to be in keeping
with this. Women were expected to be appropriately covered with long sleeved
garments and trousers. We would have to be cautious with our attitude and
opinion, especially in public as what seems like a misdeamenour in our
society may be completely unacceptable in Pakistan . Culture and religion
are known to influence the ways people define health, express pain, select
treatment options and also deal with grief. These characteristics of the
population involved in the disaster represent yet another challenge to the
international community sending aid.
Healthcare and The Field Hospital
Upon arrival in Muzaffarabad,
following a 5 hour drive along mountain roads, the team started working
almost immediately at Bella Noor Shah in the Neelum Valley . This was the
site of a proposed field hospital and used to be the location of the
Pakistani Army Engineering Division. The team helped with the organisation
and set-up of this field hospital. The following were quickly established:
• a simple registration and triage system that records name, address/
village, age, sex and presenting complaint
• an ambulatory consultation area
• an area for simple treatment, wound management and dressing
• an operation theatre as well as
• an inpatient ward area with beds in different tents for male and female patients
The team of six worked on the principle of doing the greatest good for the
greatest number of patients. In 10 working days, the team managed 5 123
patients (3 586, 70% male and 1 537, 30% female). Of these 25% (1 282) were
paediatric patients under the age of 12 years. Respiratory tract infection
made up 29.4% (1 508 cases), gastrointestinal infection, 5.3% (269 cases),
musculoskeletal problems/ contusion, 5.4% (278 cases), obstetrics and
gynaecology cases, 1.5% (76 pateints) and another 4.1% (209 patients) had
other problems which included headache, abdominal pain, ear infection,
allergy, rashes, neuropathy, neuropraxia and crush injury) Orthopaedic cases
made up 29.3% (1 501) of which, 1 322 were wounds and related problems and,
179 were fractures. The details of these are shown in Tables 1 and 2. Wounds
seen were very commonly infected. The nature of obstetrics and gynaecology
problems seen were, pregnancy related concerns such as decreased fetal
movements and early contractions, dysfunctional uterine bleeding, vaginal
discharge, and utero-vaginal prolapse.
The number of inpatient beds increased rapidly from 30 initially to about 150 by the time the team handed over to the next one, after two weeks. The field hospital also became established as the referral hospital for WHO and the Pakistani Army to bring in patients who had been evacuated from any of the surrounding mountain villages as well as those in the Neelum Valley . The surgical procedures done comprised of manipulation and reduction, incision and drainage, toilet and suture, wound debridement, Ray's and below knee amputations. The operation theatre had two autoclave devices. For most of the procedures, sedation was used. Regional and nerve blocks were also commonly done as general anaesthesia was not possible here. For any more serious cases, they were air evacuated to the Pakistan Institute of Medical Sciences (PIMS) in Islamabad.
Not too far from the field hospital, as the weeks passed, other services became available: The Abbas Hospital (a Ministry of Health Hospital) started functioning in its original building which was only partially damaged and still stable, There was a blood bank, laboratory service and a haemodialysis centre here. The latter had two haemodialysis machines brought in from Karachi and this was useful for the patients with crush injuries with renal failure. The French too set up field hospital in Muzafarrabad to meet the increasing demands. The International Red Cross (IRC) set up their field hospital in a cricket stadium and this started to function some two weeks after the disaster struck.
As many victims affected by the disaster
were still stranded in their remote, inaccessible mountain villages, mobile
teams were also sent out daily from the field hospital. The teams would
travel in a van with a local guide, carrying sufficient supplies to carry
out treatment. Often the teams would have to hike up steep slopes to gain
access to villages. Some of these villages may walk for days from their
damaged homes to get to the field hospital. By the time they arrived, many
of their wounds were already infected and other complications may have set
in. Some utilised simple home remedies in the interim period. There were
many wounds which were covered with tumeric powder, a spice believed to have
antiseptic properties. Some also used locks of their own cut hair to pad
their fractured limbs, before bandaging with scarfs or towels. Many suffered
from dehydration whilst making their way to the hospital.
Besides the Singapore
team, there were several volunteer doctors and paramedics from other parts
of Pakistan working at the field hospital. There were also some homeopathic
doctors.
The Singapore team also worked with the United Nations Children's Emergency
Fund (UNICEF) in launching a vaccination programme at the field hospital. A
Danish team helped with the provision and filtration of water for the
hospital. Oxfam assisted with and facilitated waste disposal at the field
hospital.
Psychological Needs
1. A young mum of 30 sits on a
bed, staring blankly. Next to her were three boys aged 1-4 years. Her two
older boys and husband were crushed to death. She has nobody and no where to
turn. The field hospital bed has become her ‘home' now.
2. A 70 year old man with bilateral open fracture of his tibia-fibular lies
on a bed, refusing to talk. Tears run down his cheeks, wetting the sheets
every now and then.
3. A 12 year old girl sits drawing pictures of mountains crumbling down and
crushing people who were trying to run in all directions.
These were just some of the examples reflecting the psychological trauma
faced by the victims of this catastrophe. All (100%) of the patients treated
by the team at the field hospital has at least some degree of post traumatic
stress disorder (PTSD). Several Pakistani psychiatrists and counselors were
kept busy talking to and helping these patients ventilate. Some were able to
give a very poignant account of their experiences, others kept it all
bottled up, but it was evident in their faces: the anguish, blankness and
spontaneous tears.
Psychological trauma is seen frequently after complex humanitarian emergencies. Both victims and responders can be affected by post-traumatic stress disorder (PTSD), but not all will develop a mental health disorder. There may be a variety of psychological, physical, cognitive and/ or emotional response to the events. Some factors which increases the likelihood of developing PTSD include: 10
• Physical proximity to
the event/ destruction
• Exposure to gruesome/ grotesque circumstances
• Diminished health status
• The magnitude of loss
• History of previous psychological trauma
• Degree of disruption encountered as well as the
• Lack of self and family stability
Despite having been victims themselves , many local people volunteered at the field hospital. They were always so driven in their designated jobs as assistants to the healthcare staff, interpreters, guarding the security of the hospital or cooking. Their commitment goes beyond volunteerism. Perhaps it was a way for them to make sense of their destroyed lives and psychologically survive their sudden losses. It may also be their own expression of PTSD. Helping the patients as well as the foreign medical teams gave them purpose and direction for the moment. It may be a way of seeking solace and comfort to help them forget the fears for a while.
Conclusion
From the two-week experience the
team learnt the following lessons pertaining to complex humanitarian
emergencies:
1. It is important to have proper planning and coordination in the midst of
‘chaos'.
2. Able and knowledgeable leaders in the field must take charge of operations and be accountable for decisions
3. Involvement at the governmental and
community levels are important but the players on the ground must each
understand their responsibilities
4. It is important to have a medium to long term ‘vulnerability reduction
plan'
5. Training in disaster preparedness cannot be overemphasized, especially in disaster prone areas
6. There must be a good networking and
communications between both local and international groups/ non-governmental
organisations.
Preparation for such disaster missions is important and there must be
flexibility to manage any unexpected turn of events. Each mission is a
learning process to help enhance the effectiveness of the next one.
Upon return, all members of the team had to go through both an operational
as well as a psychological debrief. It had indeed been a challenging but
fulfilling mission. As responsible global citizens, it was indeed
appropriate and timely for Singaporeans to contribute towards relief efforts
in this Pakistan earthquake.
Acknowledgement
The author would like to acknowledge the members of Team Singapore (1): Dr
Chin Pak Lin, Senior Staff Nuurse Jaafar Yusof, Senior Midwife Zaiton
Mohamed Tahir and Frederick Foo and Izuan Rais from Mercy Relief.
By F Lateef M.B.B.S, F.R.C.S(Edin)(A&E), F.A.M.S(Em Med)