EARTHQUAKE IN NORTHERN PAKISTAN

OCTOBER 8, 2005

0850 HRS

Health Assessment and Response

Report on the field trip to Rawalakot and Bagh 18-22 October, 05

EMERGENCY RESPONSE TEAM

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Table of Contents Summary Observations Page 3 Situation Report of Rawalkot, AJK Page 4 Situation Report of Bagh, AJK Page 6 Challenges and Future Options for WHO Page 9 Annex 1. UN Agencies NGO operational in Bagh Area. A draft list Page 12 Figures 1, 2 & 3. District Headquarter Hospital, Rawalakot Page 13 Figures 4 & 5. District Health Officer Office, Rawalakot Page 14 Fugure 6. BHU Khai Gala, Rawalakot Page 15 Figure 7. BHU Ali Sojal, Rawalakot Page 15 Figures 8 & 9. District Headquarter Hospital, Bagh, AJK Page 15 Figures 10, 11 & 12. TB Hospital, Chamankot, Dhirkot, Bagh Page 16 Figures 13, 14 & 15. Rural Health Centre. Arja, Dhirkot, Bagh Page 17 Figures 16 & 17. Basic Health Unit. Rangla, Dhirkot, Bagh Page 18 Figure 18. Basic Health Unit, Malot, Bagh Page 19

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SUMMARY OBSERVATIONS 20% of buildings in Rawalakot town and 40-50 % structures in rural areas of the

district have been damaged. The damage in Bagh is more severe, the city is 80 % destroyed (structural damage in buildings that are still standing), and the destruction in rural areas is around 60-70 %.

Estimated number of deaths in Rawalakot is 4500 - 5000, and + 30,000 injured. In Bagh, the number of deaths range from 5000 to 10,000, with +20,000 injured.

DHO Offices both at Rawalakot and Bagh are destroyed Main hospitals at Rawalakot and Bagh are destroyed. Almost all of the other

health facilities have been destroyed or damaged in Bagh. At Rawalakot, a few facilities have escaped damage.

One physician and three staff of the District Health Hospital in Rawalakot, and one health staff of TB Hospital in Chamankot, Bagh have died. The number of reportedly injured among the health staff are 3 and 4 in Rawalakot and Bagh respectively.

The main hospital in Rawalakot is now operational (emergency surgeries and out patient services). Similallry, three emergency hospitals are operational in Bagh city and one at Sudangali, Bagh.

In spite of damages, almost all RHCs and BHUs in Rawalkot are operational. In Bagh district, there are several health centres that are operational. All these are operating through makeshift arrangements.

Selected (measles and TT) vaccination has been started, in areas of Rawalakot and Bagh

Emergency evacuation of serious patients is now down to very low levels. The majority of the patients seen at the rural facilities are injuries and infected

wounds. At the main hospitals, the proportion of patients with injuries and wounds is declining. The need and (demand in rural areas by health workers) for antibiotics is high.

There is no evidence of out break of any diseases reported as yet. Two cases of tetanus were reported in Bagh on 18/19 October, 05.

MSF has pledged to build a 50 bedded fabricated material hospital at Bagh, within the next 6 weeks

UNICEF has pledged to provide Medical kits and 5 tents to each of the 19 BHUs in Bagh

WHO-MoH health teams are now operational at 10 sites, (5 each in Rawalakot and Bagh)

WHO coordination offices have been established at Bagh and Rawalakot Army has begun the debris clearing process in Rawalakot and Bagh. However,

bodies are still being recovered. Several rod links have been restored, but still some forward areas remain in accessible.

There is great need for shelter (tents) and blankets particularly in the rural areas. The Army has begun distributing tents, beddings, food and medicines in the remote areas.

In the face of approaching winter, the Army has begin storing food and medicines in some selected sites of the remote areas, access to which is closed during the 3-4 month (December thru March) winter period.

A large number of volunteer organizations are providing health care in Bagh (fewer in Rawalakot). However, many are expected to leave by Eid ul Fitr (First week of November)

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SITUATION REPORT OF RAWALAKOT DISTRICT (AJK) I. Briefing with District Health Officer (DHO), Rawalakot, Total population of the district: 455,000. The district is divided into three tehsils (sub districts); a) Rawalakot, Hajira and Abbaspur. DHOs estimates of damages1 to the district are summarized below; Population Affected:

- 20% of buildings in Rawalakot town and 40-50 % structures in rural areas of the district have been damaged.

- Between 70-80 % of all structures (buildings) in the district have suffered varying levels of structural damages.

- Most rural population are residing in make shift tents, but lack of tents and severe cold is forcing people to spend the nights inside (damaged) houses

- The worst affect sub district is Abbaspur, and some areas of this district are still inaccessible

Health Services

- The only tertiary level hospital at Rawalakot (250 beds, 100 for military and 150 for civilian population) has been destroyed

- The Office buildings of District Health Office, Rawalakot are totally destroyed.. DHO operates in makeshift tents, not adequate to house the entire staff of DHO office.

- Of the 4 Rural Health Centres (RHC), 3 have been destroyed or severely damaged o RHC Hajira (recently up graded to tehsil hospital –destroyed o RHC Abbaspur (recently up graded to tehsil hospital –destroyed o RHC Tain (damaged) o RHJC Paniol (OK)

- Of the 30 BHUs, nearly 25 have been totally destroyed or suffered damage. - 8 fatal casualties (including one doctor) among the staff and dependents of the

hospital. No fatal casualties reported among the district health staff. - All the district health staff personnel are reporting on duty. - Vaccine delivery infrastructure has been damaged. - Medical and drug stocks are depleted due to damaged stores and there is

shortage of medicine Estimated Casualties (please see also foot note 1) - Deaths 4500 - 5000 - Injuries + 30,000 Health Services Response in the aftermath of the earthquake; as of 19 Oct, 05.

- Nearly 2200 injured victims treated in improvised hospital 1 Army Figures: 11500 houses totally destroyed; deaths 1247; Injured / wounded 24340; Most (90% spend their nights outside. Distributed 1150 tents, 23900 beddings , 24,500 dry rations in affected areas; Army is now storing / dumping rations,; medicines and supplies in forward areas of Bagh, Kahuta, and Hajira before roads close due to winter snows.

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- Almost 600 with severe injuries referred to Islamabad and Rawalpindi, half transported by helicopter and half by road transport.

- The Rawalakot tertiary hospital has been made operational. Emergency trauma care services and routine medical services are functioning. Two Operation theatres are working. Teams of surgeons from Army, the Republic of Czechoslovakia and Jordan are deployed at this hospital.

- The load of earth quake related injures in the hospital is now declining and the hospital is now catering for routine illnesses. Of nearly 650 patients examined in the hospital on 18th October, 25 % were earthquake related wounds and infections. On 19th October, 870 patients were treated at the hospital, and the earthquake related injuries / wounds was under 15 %.

- The number of referral patients from the hospital has declined. 4 patents were evacuated from the hospital by helicopter on the 19th October.

- With the opening of roads, many affected / injured patients are reported to be directly self referring to hospitals in Rawalpindi and Islamabad.

- The majority of the district health staff has reported on duty, and health services ( primary health care) are being provided in majority of the health facilities despite damaged structures.

- There is no evidence or report of epidemics from Rawalakot yet. Vaccination Programme Only two vaccination centres operational 10 vaccinators arrived from outside (of AJK) to assist the vaccination programme in the district on the 19th October II. WHO / Ministry of Health Medical Teams; 5 teams each comprising of surgeon, public health physician, surveillance officer and two paramedics were sent to Rawalakot district on 18th October. The objective was two fold;

a) to assist the district health services in providing health care in worst affected areas and

b) to undertake active (as well as passive) surveillance for disease outbreaks . The medical teams have placed in the following areas; 1. Sub division (district) Abbaspur Khali Draman Team No 13 2. Sub division (district) Hajira. Serari Team No 14 3. Sub division (district) Rawalakot Tain Team No 15 4. Sub division (district) Rawalakot Janadala Team No 12 5. Sub division (district) Rawalakot Ali Sojal Team No 11

III.. Field Visit to Selected Health Facilities in Rawalakot Sub district (19-10-05) Summary Table 1 Facility Place Structure Water

Supply Electricity

Comments

1 BHU Hussain Kot Intact ok ok Facility operational 2. BHU Chotta Gala Intact ok ok Facility operational 3. BHU Ali Sojal Destroyed

100 % No No This facility has been

operational despite suffering damaged by MOH-AJK doctor. WHO-MoH Medical team is now providing additional services.

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4. BHU Khai Gala Destroyed 100 %

No No Health services are being provided by the staff in neighbouring shops

4. BHU Namnota Destroyed 80 %

? ? This facility was not visited but the information comes from a credible source

5 FAP Rehrban Damaged No Yes Structure standing but damaged 6 FAP Kokot Destroyed No No Facility operational 7 FAP Khori Channa Destryed No No Facility operational IV. WHO Coordination Office has been established. V. Contact Persons in Rawalakot 1. District Health Officer: Dr. Shabbir Ahmed 2. Assistant District Health Officer: Dr. Nasim Kazi Tel No: DHO Offices: 05-8710- 45122; 05-8710-43022 3. CO CMH Rawalakot SITUATION REPORT OF BAGH DISTRICT (AJK) I. Current Health Situation in Bagh (Total population 440,000). An overview2 of health infrastructure (as described by Assistant DHO) is given below;

Staff situation: One death (female janitor at Dhirkot hospital), 4 injured 3 at Dhirkot (including Medical Superintendent, cook and a dispenser) and one dispenser at Kahuta.

Two hospitals at Bagh, one at Kahuta completely destroyed. One TB hospital at Dhirkot partially destroyed. (See table 2 below)

5 out of 6 Rural health Centres in the Ditrict are totally destroyed Almost all BHUs (19) vaccination centres (35), FAPs, MCH Centres are

destroyed. Total health facilities in Bagh is 79 including all categories The District Health Office has been destroyed.

The main district head quarter hospital building in Bagh (newly constructed

facility, and had started to function some three years ago) is completely damaged and unusable (the structure still stands though). One Temporary Hospital for emergency care (60 Beds) established at DHQ hospital site. It is managed by MoH, and staffed by medical team from Sind (including UNFPA

2 The Armed Forces are playing a major role in the evacuation of seriously injured patients, provision of health care services, opening roads, establishing communication channels such as roads and telephone links, reconstruction and rehabilitation, repair of water and electricity and restoring law and order. It has accessed many of the hitherto un-accessed areas and provided necessary relief. It is thus far supplied over 2000 tents, large quantities of beddings and delivered food and medicines to the needy. It has established a number of helipads in the area for bringing in relief goods and supplies. It is still recovering bodies from the destroyed houses, and has begun the pain staking debris removal process. It has helped open two schools for children in tents in Bagh district. It has helped restore 70 % of Bagh city’s water supply.

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staff), MSF and Mercy Malaysia. The X-ray and Dental machines of the DHQ hospital have been retrieved and are now in use.

The old hospital (a military facility) also catering for civilian population was

completely destroyed. It is now being reconstructed as a tent hospital. An emergency hospital and evacuation centre established by the military at the Degree College ground in Bagh. This facility is operational with support from civilian volunteers and military health workers. As soon as the military hospital is rebuilt in tents, this emergency hospital and evacuation centre will be moved to its previous location.

A third hospital is functioning at Bagh since the second day of the earthquake.

This is run by an NGO (Islamic relief) at Pearl school site. There is also one hospital at operational at Sudangali, run by an NGO “Land Mark”. This has been operational since 11th October. The hospital is run by a team of 14 doctors, has established an Operation Theatre for minor surgeries and an indoor facility for admitting patients.

Summary Table 2. Iinformation provided by ADHO Bagh (verbal communication). (Comments in bold are based upon physical observations made by WHO teams) Sub Division

Location Facility Comments

Bagh District Head Quarter Hospital

A 60 bedded facility, completely destroyed

Bagh Army Hospital 40-50 bedded facility catering for both civil and military patients. Completely destroyed

Chitratopi Rural Health Centre Partially destroyed Chatter 2 Rural Health Centre Partially destroyed. (WHO-MoH

Medical team reports; 100 % damage to this facility. No water or electricity available)

8 BHUs All destroyed 15 vaccination Centres All destroyed Rerra BHU WHO-MoH Medical team reports; 100

% damage to this facility. No water or electricity available. One NGO “DAWN” has set up a relief camp, Army doctors also providing medical relief work

Kharal Bural BHU WHO-MoH Medical team reports; 100 % damage to this facility. No water or electricity available

Kharal Abbassian BHU WHO-MoH Medical team reports; 100 % damage to this facility. No water or electricity available

Kharal Multalian BHU WHO-MoH Medical team reports; 100 % damage to this facility. No water or electricity available

Bagh

Dhulli FAP WHO-MoH Medical team reports; 100 % damage to this facility. No water or electricity available

Kahuta Sub Division Hospital 50 bed hospital. Completely destroyed.

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Staffed by 70 personnel (including 3 physicians MS 2 MOs ), all of whom escaped injuries

Khurshidabad Rural Health Centre Destroyed 6 BHUs All destroyed 12 vaccinator centres All destroyed Chaman kot TB Hospital 50 bedded TB hospital. 50 % destroyed.

WHO team verified damage. Dhirkot Rural Health Centre Partially (25 %) destroyed. WHO team

verified damage. Sessar Rural Health Centre Completely destroyed. Had a laboratory Arja Rural Health Centre Partially destroyed. Had a laboratory.

WHO team verified damage. 5 BHUs All destroyed

Dhirkot

9 vaccinating Centres 8 destroyed II. Field Visit to Selected Health Facilities in Bagh district (21&22-10-05) Summary Table 3. Facility Place Structure Water

Supply Electricity

Comments

1. TB Hospital

Chamankot, DhirKot

60 % Destroyed

ok ok 50 bedded facility. The indoor ward, OPD, EPI facilities, Lab & X-ray facilities, two vehicles, hospital kitchen and dispensary destroyed. Administration building suffered structural damages. The new 50 bedded ward and Nurses hostel intact. 39 patients were admitted at the time of the earthquake. All have left. One staff (female janitor) died, and 3 including the medical superintendent, cook and driver were injured. All medicine stock has been lost. The facility is now closed for indoor patients. The hospital is providing anti-TB treatment to registered patients. Running low on medicines.

2. RHC Arja, Dhirkot 70 % buildings totally collapsed

ok ok Facility is partly functional

3. RHC Dhirkot 25 % destroyed

ok ok The old buildings comprising; dental centre, MCH centre and residential quarters destroyed. The new building escaped damaged. Facility operational

4. BHU Jaglari, Bagh Destroyed 100 %

No No The health worker in charge has opened the treatment facility in a neighbouring shop

5. BHU Malot Destroyed 100 %

No No WHO-MoH Medical team operating at this facility since 19th October. Periodic assistance was provided by mobile teams from NGOs, Army and MOH-AJK before.

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6. BHU Sir Sydian Destroyed 100 %

No No This facility was not visited but the information comes from a credible source.

7. RHC Rangla, Dhirkot

Destroyed 80 %

No No The facility was closed. An NGO operated medical camp was operational in the nearby area. WHO-MoH Medical team is operational from BHU site since 19th October. The BHU staff has been asked to report for duty.

III. WHO-MoH Medical Teams

5 teams each comprising of surgeon, public health physician, surveillance officer and two paramedics were sent to Rawalakot district on 18th October. The objective was two fold;

a) to assist the district health services in providing health care in worst affected areas and

b) to undertake active (as well as passive) surveillance for disease outbreaks . The medical teams have placed in the following areas; 1. Sub division (district) Dhirkot Rangla Team No 10 2. Sub division (district) Bagh Sudan Gali Team No 7 3. Sub division (district) Bagh Rerra Team No 8 4. Sub division (district) Bagh Chitratopi Team No 9 5. Sub division (district) Bagh Mallot Team No 6

IV. WHO Coordination Office at Bagh Established at the UN camp site in Bagh (Current location; near the District Head quarter Hospital) V. Contact Persons in Bagh Army Medical Personnel 1. Col Saeed 2. Lt Col Habib District Health Personnel 1. Dr. Atiq; Medical Superintendent DHQ, Bagh Tel: 05-8710-44894 (o) 2. Dr. Latif; ADHO Bagh 4. Dr. Qamar, Cardiologist Medical Officer Incharge of medical Camp at DHQ Hospital Premises Dr. Zareef, MoH, Islamabad CHALLENGES AND FUTURE OPTIONS FOR WHO 1. Coordinating International (and national) Health Response in the Earth Quake Affected Areas: Currently there is a huge influx of agencies, NHOs and volunteer individuals, groups and organizations that are providing emergency health care response in the earthquake affected areas. There is an urgent need to coordination to mount a more organised

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response that can serve the affected population better. Most volunteers groups and organizations providing health care in the area are likely to leave before snowfall. There is therefore the need to identify and establish links with the major partners / organizations to develop a planned delivery of emergency health care to the affected population that can be sustained, especially in the coming moths of winter. WHO coordination offices in the affected districts should;

i) lead the coordination effort at district level, ii) identify and liaise with major partners in the affected zones (including army, major NGOs, MoH-AJK and other partners) to ensure the continued provision of health care to the affected population during the coming winter. iii) participate in the daily Army briefings iv) support (on priority basis) the re-establishment (even on temporary basis) and strengthening of the district health offices both at Rawalakot and Bagh, so that these entities are able to communicate effectively both within the districts as well as with outside partners.

WHO should participate in coordination and developing medium and long term planning of health care infrastructure development and implementation of rehabilitation plans. WHO should lend support to the MOH-AJK in negotiations with international donors and partners that are keen to provide long term support and assistance to health systems development in AJK. 2. Rebuilding of Health Care Infrastructure The health care infrastructure both curative and public health in the three major districts of AJK has been decimated. The health staff has suffered casualties, and loss of loved ones. There is need for;

a) NEEDS ASSESSMENT: urgent appraisal of the existing situation of the health service capacities

b) IMMEDIATE HEALTH CARE NEEDS: identifying the most immediate and urgent needs and establishing (even in temporary structures) the most urgently needed health facilities, before winter sets in. It is strongly suggested that the special WHO-MoH Medical teams continue to operate in the affected areas throughout the winter and coming summer (at least for one year). These teams should;

a) assist the district health services in providing health care in worst affected areas and

b) undertake active surveillance for disease outbreaks . c) EMERGENCY MEDICAL SUPPLIES: collaborating with the military to place

adequate stocks of medicines in places that may become inaccessible during the coming winter.

d) DEVELOPING HEALTH SYSTEMS: developing medium and long term plans for health infrastructure development, with a view to not only restore the pre earthquake status of services, but with a view to establish health care services that are more efficient and focussed on the needs of the poor.

e) HEALTH SYSTEMS TO ADDRESS SPECIAL NEEDS: identifying new and additional health needs of the population emerging from the aftermath of the earthquake e.g. long term care of the physical disabilities, long term psychological and social implications and their impact on health. It is crucial

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that the new health systems address these issues, as failure to do so can have disastrous consequences.

f) SURVEILLANCE: developing public health infrastructure for disease surveillance (including common and known epidemic diseases), prevention, therapy and health promotion

g) HUMAN RESOURCE DEVELOPMENT: building human resources in clinical and public health.

3. Health Care in Populations living in the Camps or settlements (to be established) The government of Pakistan is planning to establish camps and temporary settlements in areas of Punjab and NWFP for the population of AJK who;

a) have lost their houses b) have to be moved out from the cold areas of AJK

Health care for such populations needs to be provided through a coordinated effort of the Governments of AJK and the NWFP and Punjab provinces (and UNHCR). WHOs role in this will be critical. 4. Food, Nutrition and Environmental Health Problems The loss of lives, damage to property and massive injuries among those who have survived has further weakened significantly not only the poor economic status of the population, but has rendered them incapable of responding to cater adequately to their needs for food and shelter. Massive debris (still with dead bodies buried underneath) animal carcasses, breakdown of water and sanitation facilities pose extra risks to the human settlements. WHO role would e crucial in;

a) identifying the weak and vulnerable for priority assistance in food and shelter b) coordinate with partners in effective delivery of food and shelter to those in

most need c) assist the communities and AJK government to develop implement plans /

projects to improve environment and reduce ensuing risks 5. Possible Risk of Increased Infantile Visceral Leishmaniasis (Infantile Kala Azar) in AJK AJK is endemic to infantile visceral leishmaniais. This is a sporadic disease with dogs as reservoir and the Phlebotomine sand fly as vector. The increasing number of infected stray dogs (reservoir), the debris created by the earthquake ideal for sand fly breeding, and the likely compromised immune status of the affected population pose a potential threat for spread of this disease. It is therefore pre-empt the spread of this disease through initiation of interventions such as surveillance (both of human cases, and vector) culling of stray and pet infected dogs) and if and when needed vector control measures.

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Appendix 1. UN Agencies NGO operational in Bagh Area. A draft list (PS: This needs updating)

Organisation cluster POC Function address and coordinates tel:

UNDAC

Jehmila Mahmood, Rolf Bakken, Iris Schneider

Team leader, team member, team member

Bagh, near general hospital

0088221650602097, 00764038526, 00870771172229

MSF Belgium health

Paul Annys, Olivier Fenichiu ?

in direction of the helipad 008821651100214

Mercy Malaysia health Chak ? Bagh field hospital

Oxfam ? ?

Tearfund shelter, food

Shona Macpherson, Nigel Bull ?

located at Goals place for time being 0333-7805624,

ACTED shelter Dominik Zwicky ? 0333-5606864

Goal shelter, food

Donna Smith, Nicola Leadbetter, Katherine Jobber ? located near the

00882-1621154331, 00882-1621154336, 008821621154337

Save the Children shelter, education

Umair Hasan, Sam Rush, Tony Taylor ?

0321-5250735, 008821621154447, 008821621157846

ARC shelter

Angie Fleischer, Alex Erolin, Mr. Najdi ?

0308303973, 008821689854381, 008821689855055

Mercy Malaysia health

Dr. Alamin Daud, Chak Siu Keat ?

Pearl International Village School 00882162115022721

WFP x Aslam Khan ? 008821621117514

WFP- AJK logistics, food

Sultan Mehmood ? located with Goal 008821654200210

JEN shelter

Kiyotaka Tamavi, Hiderako Golo ? ?

0088216898852012, 008821689852011

Red Crescent (IFRC) health

Farood Burney ? ?

IFRC health Agnes Madaras ? ? 008821654201469

Alisei Roberto Marazzini ? ? 008821651190790

Islamic Relief shelter, food

WHO health

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Figures 1, 2 & 3. District Headquarter Hospital, Rawalakot

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Figures 4 & 5. District Health Officer Office, Rawalakot

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Figure 6: BHU Khai Gala, Rawalakot

Figure 7. BHU Ali Sojal, Rawalakot

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Figures 8 & 9. District Headquarter Hospital, Bagh, AJK

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Figures 10, 11 & 12. TB Hospital, Chamankot, Dhirkot, Bagh

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Figures 13, 14 & 15. Rural Health Centre. Arja, Dhirkot, Bagh

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Figures 16 & 17. Basic Health Unit. Rangla, Dhirkot, Bagh

Figure 18. Basic Health Unit, Malot, Bagh

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