THE PAKISTAN AND INDIA EARTHQUAKE SIX MONTHS LATER - AN ONGOING CRISIS

Richard J. Brennan, M.B., B.S., M.P.H.
and Ronald J. Waldman, M.D., M.P.H.

The magnitude 7.6 earthquake that struck northern Pakistan and India on October 8, 2005, was the world's third-deadliest natural disaster of the past 25 years, surpassed only by the 2004 Asian tsunami and the 1991 cyclone in Bangladesh. An estimated 74,650 people lost their lives — a higher death toll than the average annual loss to all natural and man-made disasters combined during the 1990s, excluding armed conflicts. Yet the outpouring of concern, solidarity, and assistance was of short duration. Today only 66 percent of the "flash appeal" issued by the United Nations — an appeal for emergency aid initially estimated at $312 million and rapidly increased to $550 million — has been funded. Important needs remain unmet.

There are no more tales of dramatic rescue, televised scenes of devastation, or high-profile visits by politicians. Why should we be concerned with the ongoing relief and recovery efforts? For disaster-relief professionals, the answer is obvious: the scale of need remains enormous.

In addition to those who died, more than 76,000 people were injured, 2.8 million were left homeless, and 2.3 million have insecure access to food and other essentials. And the affected population is spread over 30,000 km 2 in impoverished, mountainous, and difficult-to-reach areas.

Pakistani authorities estimated that of 564 health facilities in the affected area, 291 (52 percent) were totally destroyed, including the district hospitals in Muzzafarabad and Mansehra, and an additional 74 (13 percent) were seriously damaged. Health-sector coordination meetings during the first two weeks, under United Nations leadership, focused on the reestablishment of hospital-based surgical care. The need for continual review of health-sector priorities prompted by the rapid evolution of public health threats was not initially recognized by some health officials. Overcrowding, poor sanitation, limited access to clean water, environmental exposure, and the widespread disruption of health care services quickly superseded surgical services as primary considerations.

Although large outbreaks of infectious diseases are relatively uncommon after natural disasters (certainly as compared with refugee crises), such outbreaks do occur in settings such as that in Pakistan, with its poor environmental conditions and overcrowded, camp-like settlements. To accommodate the survivors, 144 relief camps were established, housing nearly 140,000 residents. As early as mid-October, mobile clinics that were operated by relief agencies documented that infectious diseases accounted for at least 65 percent of all illnesses, and ongoing surveillance has shown that acute respiratory infections, including pneumonia, and diarrhea continue to be the most common causes of clinic visits

The establishment of preventive services is often neglected after disasters. In Pakistan, mass vaccination against measles was undertaken, and water and sanitation facilities were urgently reestablished. But the most critical public health intervention — the distribution of tents and other shelter materials — was not managed by the health care sector at all. Early targeting of health care facilities and their staffs for tent distribution permitted these facilities to be reactivated. Most tents, however, were not suitable for harsh winter conditions, and many collapsed under heavy snow. Winterization of shelters soon became the most important priority of the relief effort.

Despite the overwhelming needs, it is naive to rely on altruism alone as the basis for foreign assistance. When natural disasters occur in countries in which the United States believes it has a national-security interest, a strong case can be made for long-term involvement. The U.S. government, including its armed forces, has already made important contributions to the relief effort in Pakistan, as have many nongovernmental organizations based in the United States. The same was true in Indonesia after the tsunami, and polls have shown that U.S. assistance improved Indonesians' opinions about the United States.

Many lessons may be learned from the earthquake and the response to it — the first response to a large international disaster in which the United Nations implemented its new "cluster" approach. This approach entails the identification of a lead agency within each sector to improve coordination among responding agencies, as well as the quality, consistency, and predictability of the relief effort. In Pakistan, 10 main cluster working groups were established, focusing on health, emergency shelter, water and sanitation, logistics, camp management, protection, food and nutrition, information technology and communications, education, and reconstruction. The approach had an uneven start, largely because of a general lack of understanding about the objectives, procedures, and responsibilities, as well as inconsistent leadership.

Fortunately, under the leadership of the World Health Organization, the Health Cluster Working Group in Geneva has initiated a process for training future sector leaders, with an emphasis on both technical and management skills. It is in the interest of all future victims that an "A team" be consistently deployed to manage large-scale disasters.

How You Can Help

In order to address the pressing health concerns following the October, 2005 earthquake, Operation USA has partnered with two local groups, the Organization for Micro-Economic and Educational Development (OMEED) and MURSHID Hospital and Health Care Center (MURSHID).

Operation USA and OMEED are currently building a clinic 15km outside of Muzaffarabad, intended to meet primary care needs, specializing in soft-tissue injuries. This 10-room clinic is intended to serve between 200 – 400 patients daily, operating in a valley heavily impacted by the earthquake and in close proximity to several remote mountain villages. Operation USA has funded the immediate material needs for construction of this clinic, but hopes to provide continual support to OMEED for the next 5 years, providing the necessary medical supplies as well as engaging in capacity building and training of medical personnel.

MURSHID Hospital has been providing subsidized health care to residents of tribal villages in and around Karachi for the past 15 years. MURSHID and Operation USA have joined together to develop an amputee rehabilitation center in Bargh, relying on the expertise of the Peshawar Prosthetics Institute. This center will get recent amputees back on their feet and provide training for them to engage in rehabilitation among other vocational training options well-suited for amputees. MURSHID has conducted an extensive needs assessment, and has initiated this project based on the expressed needs of amputees. The construction of this center has begun, but Operation USA needs your help in providing it with long-term support which is essential in rebuilding the lives of individuals and communities in Pakistan.