On October 10, two days after the earthquake that struck Kashmir, Dr. Jean-Francois Corty left for the devastated region to join a Doctors Without Borders/Médecins Sans Frontières (MSF) exploratory mission to assess the MSF relief effort. Dr. Corty is MSF's deputy program manager for aid projects in Malawi, Korea, Georgia, and France. Here he gives an account of his mission.
– Dr. Jean-Francois Corty
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Tuesday, October 11
Accompanied by the head of mission, Nick Lawson, and logistician David Lang, I left Paris the night before and arrived in the Pakistani capital, Islamabad. On arrival we meet up with our other MSF colleagues. We decide to split up to cover the following geographical regions: they will head to Pakistani-Kashmir, leaving us to go to the North-West Frontier Province, to Mansehra, and the Kagan Valley. David stays in Islamabad to oversee the dispatch of material, a lot of it by air. Nick and I head to the hospital in Abottabad where there are a large number of patients, many of whom have been brought there by helicopter. The 1,000 available beds are all occupied and there are doctors and medicine. The building was damaged during the quake and as a result the sick find themselves outside under fragile shelters. Hygienic conditions are deplorable; it's pouring rain and the number of latrines in insufficient.
Wednesday, October 12
Morning
We arrive in Mansehra, a region of 1 million people, 30,000 of whom are in the city itself. Here as well the hospital has suffered. The walls show heavy cracks. The maternity ward, the operating room, and an outside building are the only facilities still of any use. Four hundred to five hundred patients are in tents opposite the hospital. The hygienic conditions are the same as those in Abottabad. Eight thousand injured have been transferred here by army helicopters, and 300 new patients arrive each day. A Pakistani civil surgery team is on the ground and is operating as best it can. There are around 40 doctors. We do a tour of Mansehra: some schools, public buildings, and private clinics still stand, and are used as makeshift wards. More than 1,000 patients wait on the campus of a university, the Post Graduate College, where Pakistani doctors carry out 150 operations a day. In total, five surgical teams made up of surgeons are in the town. At each welcoming point for the wounded, however, we see the same shortfall in hygiene and post-operative follow-up.
Afternoon
Balakot is the last town accessible by road. After that, a helicopter is required to reach the Kagan Valley. Balakot is totally destroyed. The Pakistani army is on the ground stabilizing the sick before evacuating them by helicopter to hospitals operating in the large cities throughout the country. Health posts have been set up by the ministry of health. Facilities have also been set up by aid teams from foreign countries, namely China and the United Arab Emirates. Emergency rescue workers, including teams from France, are still on the ground. The streets are filled with people and it's impossible to distinguish between the thousands of victims and volunteers who have come to help.
October 13-14
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– Dr. Jean-Francois Corty
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On Thursday we return to Mansehra for a medical assessment. This will be the departure point for the helicopters. I must also look into finding a house for the teams. On Friday, two MSF doctors and an MSF nurse who arrived the night before join the Pakistani teams in the hospital at Mansehra. While there's no shortage of doctors, the organization is nevertheless chaotic. One load of material arrives by helicopter, the other by truck: we start to unload. Work starts on setting up the pharmacy.
October 15-16
On Saturday, Nick conducts and exploratory mission in Batagram (30,000 inhabitants), which is north of Mansehra and accessible by road. Ukrainian and Japanese civil security teams have set up a rural hospital here. After some internal discussion, it was decided we would start working again, much of it surgical. Teams are made up: one in Balakot and one in Mansehra (pharmacy and hospital) where a water and hygiene operation has been launched (installing latrines, showers, and water outlets for all the sick accommodated in the tents).
The following day, Nick goes to Balakot accompanied by a logistician, a nurse and a doctor. From there he reports that all sorts of associations–NGOs and otherwise–are pouring in.
Monday, October 17
Two teams (comprising a logistician, a nurse, and a doctor) each bringing one ton of material, leave Mansehra by helicopter bound for the Kagan Valley. Work will focus on two areas in the valley: Kagan and Kawai. Helicopters have spotted many villages (some of around 4,000 people) that are yet to receive material or medical aid of any sort.
In Mansehra 80-square-meter tents are being set up to provide post-operative care to the injured in need of medical follow-up and nursing care. A surgeon, an anaesthetist, an operating room nurse, a general practitioner, and a midwife have joined Batagram to take charge of the rural hospital set up by Ukrainian civil security.
Tuesday, October 18
Two MSF psychologists leave Islamabad for Mansehra and begin work immediately.
SHOCKING SCENES REMINISCENT OF A WAR ZONE
Every minute helicopters drop off more injured with terrible and infected wounds. The operations and surgical procedures are endless. All around amputees and people in plaster wade through mud. It's a total emergency, with everything happening at breakneck speed. It reminds me of images from a war zone.
The traditional Pakistani dwelling is a permanent structure made from stone. As a result there were many fractures. Seven days after the quake we're seeing complications such as wounds and infected fractures, gangrene, and cases of tetanus. When the quake struck (at 8 a.m.) many men were working outside. Consequently, I've seen mainly women and children injured following the collapse of houses and schools.
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In an emergency of this scale and the amount of injured there is no time to carry out micro-surgery: there are many amputations. MSF is thinking of implementing an orthopedic rehabilitation program on a medium-term basis, probably in Mansehra. We're also planning to set up a medical "camp" there for 500 to 1,000 patients (plus their family, a potential total of 5,000 people) requiring ambulatory follow-up, medical care, decent shelter, water, latrines, food as well as a resuscitation ward and the necessary material (including defibrillators, suction, and ventilation) to handle tetanus. To be effective, vaccination requires three months and for this reason we treat the sick directly with immunoglobulin.
In addition, there are people suffering from "crush syndrome." Crush syndrome is a condition in which muscle tissue damaged by severe internal injury can release massive quantities of toxins into the bloodstream and lead to kidney failure. Left untreated, crush syndrome can be fatal. Cases of psychological trauma will also require treatment as will people suffering from chronic illness (like diabetes and heart disease). Provisions also have to be made to treat those who fall sick during this period when the hospital system is overloaded. Winter is coming and we can expect to treat hypothermia and respiratory infections. The earthquake will not itself cause epidemics, but the grouping of the quake's victims in precarious conditions means we have to be vigilant. It may be necessary to carry out a vaccination campaign against measles in future camps due to the low vaccination coverage (61%) in the region.
A WEEK ON FROM THE QUAKE AND SOME VILLAGES REMAIN ISOLATED
It's been over a week since the earthquake and we're still finding villages that aid has not been able to reach: 200 to 300 villages perhaps and who knows how many isolated people. MSF will station itself in strategic locations from which it will fan out. Teams will also use any means–be it helicopters, donkeys, or mules–to carry out exploration missions.
It's difficult to predict what the reaction of survivors will be. Some people, though probably very few, will want to stay home during the winter. Others will want to head for the towns as the cold arrives. Traditionally, mountain populations spend the summer at altitude before going down to the towns to spend winter with their families. Without food and basic needs, the majority will probably decide to leave. Roads still have to be made passable. And there is no guarantee that their families will be able to accommodate them or that they will even be there. Where will all these people go? Camps will no doubt have to be set up but where? We'll report on this as the situation develops.
Finally, we will not be intervening in Abottabad or in Balakot where the needs have been met by other aid organizations.
A VERY DIFFERENT SITUATION TO BAM IN IRAN IN DECEMBER 2003
The situation in Pakistan is very different to the one I experienced in Bam in Iran following the quake in December 2003. I was there as the head of mission. The damage was centered around the city itself rather than on the outskirts. Access was a lot easier in this case. The Iranian authorities and the Iranian Red Crescent (auxiliary arm of a strong state, in a rich country) handled the situation perfectly: in two days, 15,000 injured were evacuated; tents and mineral water were distributed on the same day. What's more there was no shortage of medicine. The Iranians have lived through earthquakes before not to mention years of war with Iraq. In Bam, MSF took charge of latrines and showers, set up a consultation tent, and offered mental health-care services, but did no surgery or post-operative care as this was handled by local hospitals.
Although the intensity of the quake in Bam was weaker than in Pakistan, on a proportional basis the death toll was far higher owing to suffocation with the collapse of clay houses. Thirty thousand to eighty thousand inhabitants of the town perished, but few of the survivors suffered serious injury. Where as in Pakistan, last official updates put the death toll at 41,000 with 70,000 injured, a figure, which is expected to rise. Despite their reasonably high admission capacity, the hospitals are overrun. Patient follow-up, notably in providing post-operative care or psychological care, is not the current priority. In France, if we'd been struck by a disaster on this scale, the hospital system would be equally overrun!
LOCAL RELIEF A DETERMINING FACTOR
Disorganization doesn't mean lack of aid or care, on the contrary I tip my hat to the Pakistani medical organizations who reacted quickly and took control of the situation. As with the tsunami, the most efficient are the local teams who arrive first on the scene. It's not until after that international NGOs like us join the effort. The added value of an NGO like MSF is autonomy: thanks to our resources we can parachute teams and material into this mountainous part of the world.
