 A man trapped for 24 hours after his flat collapsed is being carried out on a stretcher by Indian army personnel. |
Editor's Note: On January 26, 2001, at 8:46 a.m., the Kutch District in Gujarat State, India, was shaken by an earthquake that measured 7.9 magnitude on the Richter scale, the biggest earthquake in India since 1737, when 300,000 people died in Kalkota. At the request of the World Health Organization's Emergency and Humanitarian Action Office, Dr. Luis Jorge Perez of the Pan American Health Organization's Emergency Preparedness and Disaster Relief Program went to India to help authorities there manage health-related effects of the massive earthquake near Bhuj. In this account, Dr. Perez weaves observations in his diary with descriptions of the assistance provided by the disaster assessment team.
|
January 31, 2001, Bhuj. In almost 20 years of work in disasters, I have never seen greater destruction than what I am seeing now in a five-kilometer tour of the city of Bhuj. The pungent, almost sweet smell of decomposing bodies in the rubble is everywhere. Men are clearing the rubble from the main road, but access to all other parts and to injured people is by foot and is difficult.
The local population seems almost stoic in the face of the disaster-I do not see or hear people crying in the streets-yet they are suffering severe injuries and their lives have been turned upside down. The "Aztec Moles," a Mexican search-and-rescue team, are overcoming difficult obstacles to reach people in need.
I was travelling with two members of the World Health Organization disaster assessment team from the Southeast Asia WHO Regional Office. We quickly evaluated the damages and the immediate health care and prevention needs, and then contacted authorities of the State Ministry of Health, the civil authorities, and military and United Nations officials.
Multifamily, multilevel buildings had collapsed along with stone and adobe houses. The 400-year-old stone walls around the old city had become rubble. About 70 percent of Bhuj had been destroyed. At Bhuj's military airport, the control tower and air terminal had collapsed, and more than 50 officials of the Hindu Air Force had been killed.
Fortunately, it hasn't rained in this area, and probably won't for awhile because it is a desert region. However, because it is a desert, the temperatures are very high, about 95 degrees Fahrenheit in the day, and quite cold at night, about 35 degrees. It is very dusty here.
In the two weeks I stayed in the Kutch District, an arid area with blue skies and yellowish brown terrain, I visited most of the other affected cities. These included Anjar and Bhachau, which were almost total rubble. Half of Gandhidham had been destroyed. All these towns had lost their health service infrastructure-community health centers, all primary care centers, and hospitals had been either destroyed or damaged so seriously that they will have to be torn down and rebuilt in the near future. Even the castle of the Maharaj of Bhuj had collapsed.
February 1. Ahmedabad, Gujarat. A preliminary meeting took place in Ahmedabad, where humanitarian assistance for the district of Kutch is being coordinated. At the meeting were Dr. Eigil Sorensen, WHO regional adviser on emergency and disasters for Southeast Asia, and several representatives from other agencies. Then we flew to Bhuj, 420 kilometers west, where there are no communications facilities. We met with officials of WHO, representatives of other agencies of the United Nations system, and several national and international nongovernment organizations.
In the various meetings, we identified multiple urgent needs: support for the health authorities by self-sufficient teams of epidemiologists who could help the health authorities re-establish the epidemiologic surveillance of the district; reinforcements in sanitary engineering to ensure quality control of the water that tank trucks were distributing, to control solid waste disposal, and to construct latrines; and distribution of materials to set up temporary shelters and medical centers. Corpses recovered from the rubble had to be dealt with, as did emerging mental health issues among the living. Systems for internal communications were needed for coordination and response to needs.
February 2. Ahmedabad. First, we need a system for communications and mobility of relief services, and to provide technical training and assistance. The commitment and solidarity of the staff from all the international organizations there to help is profound.
To enhance the health authorities' ability to respond to the needs in Kutch District, the WHO team provided mobile cellular telephones and rented 10 vehicles for three months.
Also critical to getting relief efforts to where they are needed is the ability to monitor and chronicle damages and services. In the Americas, the Pan American Health Organization (PAHO) has made extensive use of video and photography for documentation, and we recommended to WHO's Southeast Asia Regional Office that it do the same. We arranged for a film team to record and communicate what was happening with the health service infrastructure, systems of drinking water and wells, water and food distribution, and the capacities of emergency hospitals and temporary shelters.
Health authorities in the State of Gujarat needed resources that would help them provide services in the disaster area, so we photocopied and distributed PAHO's technical cooperation publications to them. These publications were important instruments of orientation and reference for sanitary management in disaster situations, drinking water services, sewerage, and mental health and humanitarian assistance, as well as vulnerability analysis of health services infrastructure.
Hospitals have been destroyed. Temporary medical centers must be set up.
In the various field hospitals set up by civil and military authorities, both Hindu and foreign (for example, Israel sent a fully equipped military field hospital to India), medical personnel cared for more than 146,000 wounded. The Bhuj District Army Hospital in temporary tents, the Israeli Medical Hospital, and the Norwegian International Federation of the Red Cross (IFRC) Medical Hospital offered medical attention to the people of Bhuj, and they served as referral centers for the surrounding area. The Kutch health department consolidated medical brigades that visited all the villages of the Kutch District daily to offer medical attention and conduct epidemiologic surveillance, the latter activity reinforced by WHO surveillance teams.
Emergency surgery teams, mobilized by military forces within the first six hours of the earthquake, operated in surgical units set up in tents, since the two hospitals in Bhuj had collapsed. Amputations-2,000 within the first four days-were performed on patients who arrived with clinical signs of gangrene or with multiple exposed fractures that were life threatening. Many of these patients were evacuated by air to distant cities such as Ahmedabad, Mumbay, and Pune.
Tens of thousands of people are homeless, and temporary shelters must be provided for them. The role of women is very important. They have organized themselves and run these shelters on their own. In one town, 300 women besieged the mayor's office, demanding tents. The shelters are big tents crammed with people sleeping in rows, with no family divisions, but there is no chaos and the children are organized and kept busy.
Food preparation is difficult and depends highly on water to cook lentils and beans. Water is delivered in tank trucks from nearby sources, but people must wait in long lines to receive their water rations.
Shelter management was not a WHO responsibility, but we made technical contributions on the water distribution, construction of latrines, food safety information, vector control, and solid waste collection in all the shelters, both those operated by the Armed Forces and by nongovernment organizations (NGOs). We had 10 portable backpack insecticide sprayers delivered to the district military health authorities. We recommended to the health authorities that they carry out a mass public information campaign on food safety, in all the shelters, in the languages of Gujrati and Hindi.
February 3. Bhuj. One of the most complex activities I have been asked to undertake is the coordination of interagency meetings with national and international health groups to avoid duplication and waste of human resources and supplies.
The initial response of the state and military health authorities could be called adequate, taking into account the magnitude of the event, but without a doubt it would have been much more efficient if the national, state, and local health sectors and other sectors would have incorporated disaster preparedness measures before the earthquake. It was unfortunate to observe the coordination problems in international assistance resulting from the decisions of state authorities in Gandhidanar and Ahmedabad and national authorities in New Delhi, which were not always responsive to the real needs that were being determined in Kutch District.
Immediately after the earthquake, our team made close contact with the United Nations Disaster Assessment and Coordi-nation (UNDAC) team, and a WHO national medical consultant was integrated as part of the field team. After the arrival of the second team of WHO personnel, WHO established its operation headquarters in the UN compound next to UNDAC. We continued offering logistic and technical support to the UNDAC team during the entire operation, which served to enhance WHO's presence and position both in the field as well as at state and national levels. During the entire mission, we maintained a strong and close relationship with all UN Development Program personnel, and the coordinating role of WHO as leading health agency was reiterated and supported by that agency.
February 4. Ahmedabad Because so many agencies are participating, the daily coordination meeting of the international cooperating community is becoming too large and unwieldy, and we cannot properly discuss the technical aspects of recovery.
To make planning and coordination meetings manageable, we decided to create four sector groups: health, relief, shelter, and water and sanitation.
The health sector meetings were chaired by WHO and held three times a week in the IFRC Emergency Hospital on the Lallam College grounds. During these meetings, priority topics were openly discussed. With the participation of Kutch District health authorities, representatives of the Indian Army Medical Corps, UNICEF, United Nations Population Fund (UNFPA), WFP, and many other agencies, consensus was reached on important issues, such as the management and referral of critical surgical patients to Ahmedabad during the next three months, until field hospitals established the facilities required to serve these critical patients.
The health care sector group created a mental health subcommittee. As is the case in most disasters, mental health became a priority within the first week. Considering that many NGOs were interested and had trained personnel in this field, we recommended that the NGO MSF/Holland coordinate this area jointly with the Kutch District health authorities.
Post-surgical follow-up of survivors became a public health issue, since more than 2,000 persons had had limbs amputated and needed follow-up to provide treatment, rehabilitation, and psychological treatment. A rehabilitation program was established for amputees from the Kachche District who were still in the area and for those who were returning from the cities where they were evacuated.
The WHO assessment team contributed to these activities by coordinating the health sector meetings with various national and international NGOs and with state health authorities. PAHO/WHO materials on mental health were distributed to health officers and to the interested NGOs. The WHO office in India followed up to determine if technical assistance was needed in this field, preferably from neighboring states that knew the culture and language (Gujrati) of the rural communities. The role of WHO, both in the field and at the state and national levels, was strengthened when national technical staff who spoke both Hindi and Gujrati were rapidly mobilized.
In water quality and environmental sanitation, the first priority identified by the authorities was the distribution of potable water, and it was the responsibility of the health sector group to supervise its quality. We recommended that a sanitary engineer be deployed by the Southeast Asian Regional Office of WHO to rapidly assess the situation and identify the urgent needs. Another engineer was detailed for at least three months to help maintain water quality, latrine control in temporary shelters, and solid waste collection. As an immediate action for distribution to the health surveillance teams and to the Gujarat Water Supply and Sewerage Board, WHO purchased 2,500 chloroscopes to measure chlorine levels in water.
February 13. Bhuj. Three weeks after the earthquake, the number of recovered corpses that are either cremated or buried, depending on the religious practice of their families, exceed 17,000, with another 5,000 or more remaining buried in the rubble.
WHO participated in the field briefing on February 13 offered by the state and district authorities to the joint mission of the World Bank, USAID, Asian Development Bank, and the government of the Netherlands, and gave them pertinent national contacts for the health portion of their assessment.
The health sector group conducted an evaluation of post-disaster health problems through field visits to a number of affected localities with the UNDAC team members and epidemiologic surveillance teams.
In Naliya, two destroyed villages had received tents, water and food, and medical supervision. The villagers were already salvaging material from their homes to reconstruct them. In Anjar, medical assistance was provided by state health authorities with the support of many national and international NGOs. The Indian Army set up temporary shelter camps in nearby villages.
Bhachau was the first town where the measles immunization campaign, plan-ned before the earthquake, began on February 9. In the town of Bidada, a referral hospital run by the Share Bidada Sarvodaya Trust was taking care of almost 300 amputee patients from the Bhuj area, offering both physical and psychological rehabilitation. They were seeking additional specialized volunteers to offer mental health counseling and physical therapy over the long term.
In Gandhidham, three different institutions were offering post-surgical services to the population of Gandhidham, Kandla, and Anjar at different levels: the Lifeline Express "Jeevan Rekha" with its three operating theaters and rehabilitation area, the 100-bed medical relief camp at Sindhi Dharmashala with an orthopedic team, and the Danish Field Hospital complementing the activities of the previous two.
Information for the public on health-related topics is critical after a disaster.
We advised the WHO offices in India to prepare daily press releases during the emergency phase and send them to international, national, state, and local media. During the post-disaster phase, not only was it crucial to disseminate important health policies relevant to continuing relief efforts, but also to eliminate many of the myths that appear after all natural disasters, such as those surrounding epidemics, management of dead bodies, and vaccination activities. Written and video interviews were offered during this mission to national and international reporters.
Staff must continue relief efforts beyond the emergency phase.
We needed to identify additional technical field staff and administrative staff-including a sanitary engineer, a communicable disease expert, and one additional epidemiologist-to continue the surveillance begun during the emergency response phase. It was also necessary to appoint an administrative person to manage all the clerical and managerial aspects for the rehabilitation and reconstruction period.
India could benefit from national and state disaster preparedness programs to ensure that it can respond in a more rapid and efficient manner.
For the long term, the health sector group "highly recommended" that the WHO office in India contract an experienced disaster manager, because of the way the office responded to this disaster and the high vulnerability of the country to periodic natural disasters. We referred the office to documentation on PAHO's experience and recommended technical support through
its Regional Documentation Center "CRID" in Costa Rica and other WHO Collaborating Centers.
We also recommended that the PAHO-developed humanitarian supply management system, SUMA, be presented as a way to manage incoming supplies to avoid the chaos often caused by vast amounts of humanitarian aid. If this instrument had been installed in the state of Gujarat, the management and follow-up of all the humanitarian aid received would have been much less burdensome to the state government.