Relief Work in Pakistan

In December 2005, six University of Leeds medical students spent two weeks providing assistance at a hospital in Kashmir, Pakistan which was severely affected by the earthquake of the 8th October that year. Danni Kirwan writes about her experiences there.

On December 28th 2005, a team of six fourth-year medical students from Leeds University went to Bagh in the Kashmir region of Pakistan to provide medical assistance to earthquake survivors. Although we only had two weeks due to educational commitments, and were inexperienced and underqualified, we did have some medical knowledge and monetary resources and were willing to work hard.

Initially, we were unsure as to how much help we would actually be to the population of Bagh district, and received much skepticism from people back in the UK regarding how much we could contribute. As it turned out, we found that what we had heard was indeed true – the main shortage in the earthquake region was neither money nor medicines, but man-power, and we were able to accomplish a great deal more than we expected.

Bagh is 205km from Islamabad and has a population of 400,000(1), living in villages and clusters of houses spread around the mountainous terrain. We spent two weeks volunteering at Bagh DHQ, the main hospital in Bagh district. During the earthquake of the 8th October, which killed approximately 73,000 people(2), half of the hospital collapsed. Fortunately, it did so twenty minutes after the first tremor, so the staff were able to evacuate the building, and amazingly no-one was killed. The rest of the hospital remains standing, but was badly damaged and is no longer safe for use. Sadly, the hospital was just three years old.

The initial response to the earthquake
A relief plan was set up following the earthquake by the Pakistani military in conjunction with national and international agencies(3). The strategy was composed of three tiers. Firstly, a healthcare network was set up by the army with input from international agencies such as Mercy Malaysia, MSF and military hospital units from the developed world. Secondly, dry rations were delivered to survivors to see them through the winter. Thirdly, over $100m was put towards shelter, with cash distributed to in excess of 240,000 families to help themselves improve their housing. Reports in the British media(3) claim that this has been accomplished; while we were there, the people knew of these promises but were not expecting the money for another month. Many of the tents which have been distributed so far have also proved to be inadequate(2); I spoke to someone from IOM who said that he had distributed 60 tents over the past week, and not one had survived the snow.

In the immediate aftermath, MSF provided tents which were set up in the shadow of the hospital ruins, and from which hospital services were run. These tents remain there today, and have proven to be effective; they remained standing during the recent snows, and the set-up essentially functions like a normal hospital. NATO were also quick to respond, setting up a wellequipped field hospital just up the hill from Bagh DHQ. Perhaps most striking is the immediate response of Pakistani people to the disaster; many volunteers such as nurses, doctors and students went immediately to the affected areas to do what they could.

Staff back in the Pakistan Institute of Medical Sciences (PIMA), the largest hospital in Islamabad, also felt the tremor. One nurse described seeing the equipment in ICU rattling at 8:55 am, and a ceiling air vent falling in. This caused panic in the hospital, but people settled down and continued with their work. Soon after, however, casualties began to be brought in from the Margalla Tower, fortunately the only building in Islamabad to collapse. Before long, staff were completely inundated with casualties arriving every ten minutes by helicopter from affected areas.

 

The current situation
Three months on from the earthquake, Bagh Hospital is stable and running out of the tents provided by MSF, with much equipment salvaged from the wreckage of the hospital. It provides basic services including outpatients, obstetrics and gynaecology, emergency care, pathology and radiology. It has four main wards, male and female medical and surgical, with children accepted onto the female wards, and a three-bed ICU tent. Minor injuries are treated in the ER tent, and there is an OT with facilities for more complex surgery. The hospital is functioning, but cleanliness and infection control remain a challenge.

There is a lack of human resources; the hospital has placed a request to the Ministry of Health for an extra 20 nurses, 6 medical officers and 4 specialist doctors, and at the time that we left, were hopeful that some at least would be arriving shortly. This shortage is compounded by the absence of many doctors in the afternoons, when they leave to practice privately elsewhere.

There are some facilities which the hospital cannot provide, the most notable being surgery; although there is a surgeon available, there is no anaesthetist. The diagnostic services provided by the hospital are also very limited, with only one portable x-ray machine (the quality of the xrays is shocking) and haematology limited to just full blood counts, and only when the technician happens to be in the hospital.

These deficits had until our visit been covered by the NATO field hospital, to which all critical and surgical cases have been referred, and which has more sophisticated diagnostic facilities such as endoscopy. However, this hospital was set up to provide medical relief, and not to provide longterm support. It closed on January 10th, just two days after we left Bagh. Although there are other small hospitals in the area, they too have just basic facilities. This leaves Bagh Hospital with no support, and with the full responsibility of the health needs of the population. Any cases which it cannot handle will have to be transferred to PIMA hospital in Islamabad by helicopter, weather permitting.

The tents allow the hospital to function in the short-term, but clearly this is not ideal. Patients have to wait outside the tents to be seen, and moving between areas of the hospitals involves walking outside, which are impractical in a region which experiences extreme weather conditions. Gravel paths are inhospitable to wheelchairs, the latrines are unhygienic and inaccessible to those with mobility problems, and the wards are prone to flooding.

MSF have pledged to provide 79 containers, which when we left were expected to arrive at the end of January, at a cost of €1.5million. These will provide a more suitable hospital environment in the medium term, until the hospital itself is rebuilt. Through provision of containers, MSF intend to give the Pakistani government time to plan and build the hospital properly. Following the total collapse of the military hospital in Bagh, the Pakistani armed forces also plan to reestablish a hospital of their own at some stage.

Although the initial crisis has passed, the effects of the earthquake are still noticeable in the day-to-day functioning of the hospital, with patients returning for suture removals or review of healing bones. And, of course, the immense psychological trauma sustained by so many people is highly evident. Hygiene has also deteriorated in the region since the earthquake, causing an increase in the burden caused by waterborne diseases.

What we were doing
Our first main task was to move the ER and Minor Injuries departments from their two small tents into one large tent. We salvaged furniture and supplies from the derelict hospital, and sorted through the contents of the existing tents; much of it was out of date, missing, or inappropriate, so we reduced it to the essentials and supplemented it with what we could find in the pharmacy. Although this did not necessarily engage our medical skills, at least we felt that we were being of use.

While we were moving the ER tent the weather was hot, the boys were in t-shirts and us girls found it difficult to refrain from rolling up our sleeves, but on about our third day, the weather turned. One evening we were surprised to find snowflakes the size of 50p pieces floating thickly past our window, and the next morning we waded to the hospital in our snow suits. The weather had an immense impact on the hospital. We were lucky with our accommodation: our two damp and cracked concrete rooms may have been very cold but at least they kept the weather out. Others were not so lucky. Tents lay flattened under heaps of snow. Compounded by the closure of the surrounding roads, this meant that the next morning there were few patients at the hospital, and even fewer staff. The doctors had families and responsibilities outside their work which took precedence, and their absence left us largely in charge.

We divided ourselves into three pairs. As there was no pharmacist, Andy and Naomi, two members of our team, took charge of first sorting the piles of opened boxes and
loose pills into a usable system, and then handing out prescriptions. This was by far the most demanding job, as the patients would crowd outside the tent shoving prescriptions through the windows, all demanding to be seen at once. The prescriptions were scrawled on scraps of paper, and an alternative had to be found if the drug required was unavailable, doses had to be calculated, pills counted out, and all this somehow communicated to the patients.

Another two volunteers, Faisal and Daisy, ran clinics. Fortunately, Faisal spoke Urdu, and there was a translator available for Daisy. They would each see around 30 patients per clinic, and counselled the patients, prescribed treatment and made referrals if needed and possible. The MSF nurses were very helpful as they had a good knowledge of which medications were usually given for common illnesses as well as knowing what was available on site. As there was little in the way of investigations, we had to rely heavily on our clinical skills and oxford handbooks. Often, staff were in the habit of prescribing more than one antibiotic at a time, as there was no pathology lab to identify the causative organism; the staff knew that this was likely to be causing problems with resistance, but felt they had no choice.

The third pair, myself and Helen, worked in the ER and Minor Injuries tent with one of the MSF nurses. We were less busy than the others, but had a steady stream of patients all day, often referred to us by Daisy or Faisal. Fortunately, we had plenty of support from MSF, and never had any presentations that were beyond or capabilities. Our activities involved dressing wounds and abscesses, suturing injuries, and managing dog bites, asthma attacks, children in respiratory failure, road traffic accidents, fractures and burns.

We all had a very varied experience, and learnt a lot of medicine in a short period of time. Pakistan probably taught some of us as much pharmacology as three and a half years of medical school. Moreover, we felt that we had been useful, and this was reflected in the attitudes of the staff towards us. During the last few days we had more invitations for meals than we could fit in. We were very sad to have to refuse the requests of the hospital for us to extend our stay, despite their offers to telephone and write to Leeds University and formally obtain permission for our continued absence.

Challenges
There were some aspects of our work in Bagh that we found very challenging. We had some patients who had potentially curable conditions, who had to be treated palliatively due to unavailability of resources. We had one young woman who was in excruciating pain with what we thought was kidney stones; we could do nothing but admit her, administer analgesia, and discharge her back to her village.

We also perceived, within a very short time, that there was a lack of interest from the local doctors working in the hospital. We found this surprising, as we had all expected the staff to be working very hard. The Medical Superintendent agreed that morale was very low among the staff, admitting that they themselves are still suffering from depression and other psychological problems following the earthquake, which of course affected all, staff and patients alike. A lot of resources have been put into treating the mental health problems of the survivors, not least the WHO’s Mental Health Relief Unit set up alongside the hospital. However, I felt, and it has been reported elsewhere(3), that high expectations of international and national relief efforts have led to a failure for people to recover from the shock of the earthquake and for their lives to begin to return to normal. The international community has made big promises which have given hope and a focus for the survivors, and which have subsequently been broken; this has led people and families to spend their time waiting for handouts rather than rebuilding their lives.

Tragically, all of the patient records stored within the hospital were lost during the earthquake. This loss has affected the morale of staff such that they do not see the point in making any effort with keeping present notes. The hospital also suffers a shortage of stationery, with prescriptions written on scraps of paper and patient notes scribbled down margins and over the top of printed text. As a result, patient notes are currently appalling. The hospital management has recognised this problem, and the hospital superintendent told us of plans to re-establish a reporting system within the hospital. The hospital, in conjunction with MSF Belgium, are presently researching the systems employed by different countries to decide which kind of reporting system it would be appropriate to set up in the hospital. This is a positive step and will greatly help to improve the hospital. However, it will take a long time to implement, and in the mean time the current patients would benefit from a more concerted effort to document their treatment. Furthermore, the lack of records renders the accuracy of the WHO’s weekly mortality and morbidity reports questionnable(4).
The geography of the region makes it difficult for many people to access healthcare, and this has been exacerbated by first the earthquake and then the bad weather. MSF has some health clinics in more inaccessible areas, and we spent a couple of days running clinics in rural villages; however, many people still remain stranded in mountainous villages with no access to healthcare, and this remains a major challenge(5,6).

Final comments
Towards the end of our time at Bagh, the staffing levels returned to normal as the roads were cleared. We were fortunate in our timing; somehow, we managed to be in the hospital at a crucial time when there was a deficit in staffing levels. We were then able to leave knowing that there were sufficient doctors at the hospital, and our absence would not mean that patients would remain unseen.

All six of us felt certain on leaving Bagh that our trip had been worthwhile. As well as having thoroughly enjoyed ourselves, we felt confident that we made a positive contribution. Many of the patients we saw and treated would not otherwise have been seen by anyone. We also made a small sustainable difference through our work setting up the ER tent and organising the pharmacy.

Equally importantly, we gained a wealth of knowledge and experience. We all intend to spend some time working in the developing world at some point in our careers, and everything that we learnt, that changed our attitudes, and broadened our minds during our time in Pakistan has prepared and equipped us to be more useful in any future work that we may undertake.

References
1. Bagh. http://www.apnabagh.com/bagh.htm
2. Winter warning over quake tents. BBC News 02/12/2005. http://news.bbc.co.uk/1/hi/world/south_
asia/4491378.stm
3. Has Kashmir aid gone too far? BBC News 12/02/2006. http://news.bbc.co.uk/1/hi/world/south_
asia/4599540.stm
4. Weekly morbidity and mortality report. World Health Organisation & Ministry of Health Pakistan.
http://www.who.int/hac/crises/international/pakistan_earthquake/sitrep/WMMR_Pakistan_vol_12.pdf
5. Snow disrupts Kashmir aid efforts. BBC News 02/02/2006. http://news.bbc.co.uk/1/hi/world/south_
asia/4575862.stm
6. Report of the Visit to Muzaffarabad and Bagh, Azad Jammu and Kashmir (AJK) – October 11-14 2005
World Health Organisation 2005 http://www.whopak.org/pdf/Report%20of%20the%20Visit%20to%20
Muzaffarabad%20and%20Bagh.pdf