|
Jammu
& Kashmir Earthquake of 8th October 2005
Mission Report of Rapid Health Assessment
03 November 2005
Background of the Jammu and Kashmir earthquake
An earthquake of severe intensity (magnitude 7.4 on
the Richter scale) occurred on 8th October 2005 at 8.50.38 AM (local time)
with epicentre at 34.432°N, 73.537°E in the Muzaffarabad Region of PoK. The tremor, which lasted for 6 minutes
caused widespread death and destruction to property and communication network
mostly in the Pakistan
administered Kashmir and the North West Frontier Province of Pakistan and the
adjoining areas of Indian administered Kashmir.
The districts of: Poonch, Baramulla, Jammu, Udhampur, Ramban Kathua, Srinagar,
Budgam, Anantnag, Pulwama and Kupwara are the districts which have been
reported to be worst affected in India
administered Kashmir. The Armed Forces, the
state and provincial administration conducted rescue and relief operations
and also provided immediate medical care.
The districts of Baramulla, Poonch, Kupwara and Srinagar are the worst
affected districts. As per the official reported figures, 1308 persons have
lost their lives and 6,622 are reported to be injured. 33 persons are
reported to be missing in the State. The injured persons are being cared for
at the Army and Civil hospitals at various locations in the State. Army
personnel have evacuated injured persons from Baramullah and Tangdhar to Army
hospital Srinagar, SMHS hospital Srinagar, Bone and
Joint Hospital Srinagar and the Sher-e-Kashmir Institute of Medical Sciences.
Makeshift hospitals have been set up and doctors were flown to Uri and
Tangdhar to attend to the injured.
Tented accommodation with kitchen facilities have
been established at Uri to provide food and shelter to the affected persons.
Truckloads of medicines and blankets have been sent from Pattan to Uri.
Blankets and essential equipment have also been
airlifted from Kanpur
by the Govt of India. The Directorate General of Health Services MOH&FW
is coordinating medical relief and has deployed a medical response team of 30
members comprising of physicians, surgeons, anesthetists and orthopedic
surgeons. Stocks of essential
medicines- IV fluids, antibiotics, syringes, dressing materials, etc have
been mobilized and flown to Srinagar
and affected districts.
Mission
objectives
A mission from WHO country office (Dr Sampath
Krishnan, National Professional Officer CDS, and Dr Pranay Dutta, National
Consultant HAC) visited Kashmir valley (after
obtaining the necessary security clearance) from 24th to 30th October 2005 to
carry out a Rapid Health Assessment of the affected districts in the
aftermath of the earthquake. Considering the difficult terrain and
sensitivities of the affected area the mission had a limited TOR of:
 Assessment of the response of the state and
central government (including armed forces) and identify areas of technical
support.
Provision of technical support to the state
government in the relief and recovery phases especially in the areas of:-
 Strengthening disease surveillance and
implementation of effective prevention and control strategies for prevention
of epidemic prone diseases.
Support implementation of measles immunization
campaign.
Carrying out an injury survey to assess the
extent of injuries suffered and plan effective rehabilitation strategies
(immediate, long-term and future).
Support provision of psycho-social counseling
to reduce post traumatic stress disorders.
Any other area if requested by the govt. of J
& K.
Day 1 (24th October 2005)
Immediately on reaching Srinagar the mission met Dr Muzzafar Ahmed
Director of Health Services Kashmir on 24th October and held
detailed discussions on the objectives of the mission, and the areas where
WHO could provide necessary technical support.
 
WHO India officials in discussions with DHS Kashmir & briefing of team carrying out injury
survey
Injury Survey:
The DHS deeply appreciated the injury survey format (adapted from WHO-CDC
Injury surveillance guidelines) and immediately detailed a team of four
Medical Officers under Dr Shafi A Wani Dy CMO Srinagar. These doctors were
briefed in detail about the objective of the survey (assessment of extent of
injuries suffered and planning for future rehabilitation needs) and the
methodology for filling up the format. The DHS instructed the team to carry
out the survey on 25-26 October and complete the data compilation and
analysis on 27 October with the assistance of State epidemiologist Dr Basheer
A Gash. The majority of the seriously injured patients are/were admitted in
SMS Hospital (Medical College), Bone & Joint Hospital, SKKM Hospital and
Base Hospital Srinagar (army).
Psycho-social
counseling: The DHS informed that a central team would be arriving
on 25th October for psycho-social counseling. He was provided with
the Framework for psycho-social counseling and Training manual for
psychosocial support in emergencies (prepared for Tsunami relief) which he
felt would be very useful for training his MOs and Health workers.
Disease Surveillance:
The DHS informed that disease surveillance was on-going in all the districts
of Kashmir for the following
diseases/syndromes-fever, diarrhea, jaundice and ARI. Following the
earthquake daily reporting was being followed in the affected districts. So
far no outbreak of epidemic prone diseases has been reported. The IDSP
(Integrated Disease Surveillance Project) format for Syndromic reporting was
explained to the DHS especially since it covered a wider range of diseases
and the DHS agreed to implement weekly reporting on the new formats in
affected districts.
Measles immunization:
The DHS had already been informed about WHOs recommendation for immunizing
all children between 6 months to 10 years of age (recommendation was for 14
years but DGHS, MOH&FW decided on 10 years based on logistics and
operational reasons) in Baramullah and Kupwara districts of Kashmir. He was
advised to provide the epidemiological data which would be required for
planning and implementing an effective immunization campaign. A central team
from Dept of Family Welfare, WHO (NPSP) and UNICEF would be arriving shortly for
micro-planning for the same.
Documents:
The team from WHO also provided folders containing important guidelines for
public health activities during emergencies including Infant Feeding in
Emergencies (WHO), Module for training of nurses in providing outreach
services during emergencies (developed by Indian Nursing Council, Tamil Nadu
Nursing Council and WHO, post-tsunami), Integrated Management of Neonatal and
Childhood Illness in Disasters, and other relevant WHO documents. 5 CDs of
WHO-PAHO disaster library was also handed over to the DHS for future use
during training for disaster management/preparedness.
Day 2 (25th October 2005)
Local Army Headquarters, Srinagar:
Discussions were held with Brigadier KVS Rana, Deputy Director Medical
Services (Head of Army Medical Services in the Kashmir
valley). The mission conveyed the WHOs appreciation for the prompt and
effective efforts by the army especially during the early rescue phase. The
mission was briefed about the various activities during the aftermath of the
earthquake. The armed forces lost around 30 personnel and a significant
number were injured due to the earthquake. Since the presence of doctors and
health staff of the J&K government were limited all the existing medical
teams from the army were immediately deployed including 12 teams from outside
the zone consisting of four persons including a Medical officer each, to
strengthen the medical care in the remote areas. These teams were largely
responsible for providing emergency health care and evacuating patients from
the remote villages located in the high altitudes to health facilities. He
had an excellent power-point presentation of the activities carried out by
the army including recommendations like requirement of air ambulances,
resuscitation trainings, etc which he had used to brief General NC Vij
(retired Chief of Army Staff) who is presently Deputy Chairperson of the
recently constituted National Disaster Management Authority (NDMA). The
mission briefed the Brigadier on some of the areas of WHO involvement with
the Directorate of Health Services which included:
Injury survey: The
Brigadier was quite appreciative of the format provided for conducting the
injury survey and asked for the soft copy to be provided which was
immediately given. He instructed the army hospital to carry out this task on
priority for both army and civilian casualties. An interesting observation
from him was that the format did not have a mention of falling boulders
(landslides) as a major cause of injury in earthquakes in hilly areas. This
was obvious when the mission met the doctors who were filling the formats and
patients as a significant proportion of injured were due to falling boulders.
Disease surveillance: He was also happy about
the simplified disease surveillance format and wanted copies of the same to
be provided so that he could instruct his Medical officers to report on this
format for all civilian patients attended by army MOs in their locations.
Measles immunization: He expressed concern
that fixed booth campaign would not serve the purpose of immunizing children
in remote inaccessible areas and felt that WHO/UNICEF/State govt should send
teams to these villages if measles immunization has to be effectively carried
out. He expressed willingness to issue instructions to army personnel to
provide details of each and every village with population details and provide
assistance in the form of one BFNA (Battle
field nursing assistant) to accompany the teams. However security constraints
of house-to-house immunization in border areas should also be kept in mind.
Psycho-social support: He was appreciative of
the manual prepared for psychosocial support and wanted a soft copy of the
same (as downloading from internet was difficult in this region) which will
be provided. He committed to deploying two Psychiatrists from the army
hospital to each of the districts to train the MOs and Health staff of the
army to provide the necessary psycho-social support to civilian populations.
Documents: Various WHO documents were provided
including CD of PAHO guidelines for disaster management.
Army Hospital Srinagar: The
mission met Brigadier Dutta Gupta, Commandant of the hospital who briefed
about the activities of the hospital. All patients who required immediate
life and limb saving surgery were evacuated by helicopter directly to the Base Hospital
at Srinagar.
All these patients were surgically treated and only after stabilization were
transferred to the civil hospitals. More than 178 (seriously injured)
civilian patients were treated by the army hospital. Presently about 30
civilian patients are still admitted in the army hospital apart from the army
casualties. The hospital transferred out armed forces patients to other
referral hospitals (Udhampur, Jammu and Chandigarh) to increase
availability of beds for civilian patients. The mission visited the surgical
and family wards of the hospital and interacted with the injured patients. It
was a poignant moment to see a two-month old infant who had sustained
fractures on both lower limbs recuperating in the ward. The mission also
interacted with some of the armed forces personnel who were injured in the
earthquake. The Commandant also showed the mission the state-of- the- art
Trauma Care Centre which could immediately attend to 12 casualties at any
given time which clearly highlighted the excellent state of preparedness for
any eventuality. The injury survey format including soft copy was handed over
to a lady medical officer who went about the task of filling the details
immediately.  
WHO Mission members examination civilian patients
admitted in Army Hospital, Srinagar
Bone & Joint Hospital, Srinagar: The mission next visited the B&J Hospital and interacted with some of
the patients admitted there. The two doctors (Dr Mariam Rashid and Dr Amreen
Magray) who were detailed to enter the data in the injury format were also
met and monitoring of the activity was carried out. They had completed the
task for this hospital which had presently 41 patients admitted. The mission
also met Dr Abdul Raseed, Superintendent of the Hospital and discussed the
purpose of the visit.  
WHO Mission members monitoring injury survey in Bone & Joint Hospital,
Srinagar
Sher-e-Kashmir
Institute of Medical Sciences/Hospital: The mission also visited
the SEKIMS and were informed that presently only 15 patients were admitted in
the hospital and majority of the others (over 100 patients) have been treated
and since been discharged. The lady doctor (Dr Kausar Jabeer) had already
completed filling the injury formats.
Youth Hostel: The
mission also visited the youth hostel which has been converted into a
half-way home for the recuperating patients who only required change of
dressings and other minor treatment. The hostel had so far received 110
patients from different hospitals and presently around 30 patients were still
being housed in the hostel. The mission interacted with these patients and
they were quite comfortable with the facilities which included free meals for
them and their attendants. Dr Shafi A Wani Dy CMO Srinagar had also completed
the format of injury survey of these patients.
Day 3 (26th October 2005)
Uri Sub-district Hospital: The WHO mission traveled by road
(by govt vehicle) to Uri Tehsil which is located about 100 Km from Srinagar and passes through Baramullah (District
headquarters), Rampur
and Mahura (refer to map of the area attached). The mission visited the
hospital and held discussions with Dr Salman Officer from DHS and Dr Karim
Block Medical Officer. The hospital (on the pattern of Community Health
Centre) covers 35 Halqua’s (community blocks) with 130,000 population. The
hospital was totally destroyed in the earthquake so they were forced to occupy
their newly constructed hospital building (which incidentally also suffered
structural damage and is also presently unsafe). The hospital is usually
manned by one surgeon and one gynecologist. Since the earthquake it has been
strengthened with 2 orthopedic surgeons and few MOs. They have so far treated
175 patients who required immediate surgery or orthopedic treatment. 120
patients who required major surgery where evacuated to Srinagar. Presently 8 patients were
admitted in the make-shift ward and a large number of out-patients have been
attended by the OPDs and mobile teams (14297 patients till date). This sub-district hospital has three PHCs
located at Buniyar, Bijana and Mahura, six allopathic dispensaries, 5 medical
aid centres and 21 sub-centres of which more than 85 percent have been
damaged. Since the earthquake, 54 medical/mobile relief teams (with
ambulances) are deployed. The mission briefed the available doctors about the
necessity of disease surveillance and also on filling the injury formats.   
Damaged Sub-district
Hospital in Uri (left)
now functioning from new building (middle) which also suffered damaged
Village Salamabad:
The mission then visited the villages around Uri Tehsil including village
Salamabad. Most of the villages have suffered varying damage including the
towns and army cantonment. One village visited in Salamabad was totally
destroyed and the villagers reported that 3 deaths and 30 were injured from
their village alone. The mission also met one child who was recuperating at
home with lower limb fracture (with Plaster of Paris cast). The mission also
observed large number of clothing strewn along the road sides as the
villagers had no need of used clothing. Different relief camps were observed,
where distribution of relief materials like metal sheets, tents, rations and
other necessities was on-going. Few NGOs were seen providing necessary
assistance. No major relief camps were present as most of the villages had
makeshift shelters near their villages only. Though some of the villages were
located in the hills (through treacherous and tortuous roads) yet aid seems
to have reached them as temporary shelters and tents could be visible in
these villages also.  
Affected
villagers including an injured child with POP in Salamabad village, Uri
CMO Baramullah:
The mission also met the Dr Mir Manzoor Chief Medical Officer of Baramulah
district, Dr Shafi Dy CMO and Dr Rashid Dhar Block Medical Officer. The CMO
explained that he was personally monitoring the situation at Uri by camping
out there, post-earthquake. He directed the BMO to arrange for completion of
the injury surveillance formats and also inform the MOs in the district to
report weekly on the suggested disease surveillance format which was provided
by the mission. The framework and training module for psycho-social support
during emergencies was also handed over to him.
Days 4 & 5 (27th & 28th
October 2005)
Chief Medical Officer
Kupwara District: The mission visited the office of CMO but could
not personally meet Dr Ghulam Mayuddin Wani who was visiting Sogam, but held
discussions with Dr Ali Mohd Sheikh, Physician of the sub-district Hospital
Kupwara (District Hospital is located at Handwara). The district covers 6.4
lakh population with eight Tehsils- Handwara, Kupwara, Karalpora, Vilgam,
Sogam, Langate, Zachaldera and Tangdhar. The sub-district hospital Kupwara is
50 bedded hospital having 3 surgeons, 3 physicians and 2 gynecologists and
presently had only 3 patients from Tangdhar admitted.
Tangdhar Tehsil: The WHO mission then visited Tangdhar, the
worst affected area by the earthquake and took a round of the affected
villages. The village is remotely located about 170 Km away from Srinagar and its Teethwal block, borders Muzzafarabad in
POK (Pakistan occupied Kashmir). The approach is treacherous and requires
crossing the Sadhana
Pass located at an
altitude of 10417 feet. The pass has already received its first snowfall of
the winter and would shortly cut of the area from road traffic for almost six
months in the year. Entire villages have been completely destroyed by the
earthquake. The villagers were grateful to the army who immediately came to
their rescue by clearing roads, air evacuation of patients, emergency
life-and limb saving surgery, setting up temporary camps, providing food and
essential supplies in spite of themselves suffering major casualties and
damages also. Relatively few aid agencies were seen in the area like MSF,
Radhasaomy Satsang Mandal, as this region is less accessible compared to
Poonch and Uri.   
Damaged building along the roadside on way to Teethwal,
Tangdhar. Reconstruction work (right) in progress by an NGO
Tangdhar Hospital
(which is a CHC) which caters to approximately 55000 population and covers 45
villages was itself damaged (70%). According to Dr Nazeer Awan, the BMO
(surgeon) over 8000 patients have been treated till date. More than 400 major
and minor surgeries were done after the first week once the OT could be made
functional. More than 100 patients were given POP casts. About 200 serious
patients have been referred to Srinagar
as they required further treatment. Presently 22 patients are hospitalized.
One Surgeon, one Physician (Dr Naseer Ahmed Mir), one Anaesthetist (Dr Mohd
Yusuf) and one Gynecologist (Dr Mohd Farooq Quereshi) are posted in this
hospital. Presently additional MOs and orthopedic surgeons are also deployed.
The doctors being localites are revered by the public. The WHO mission
briefed the doctors about injury survey and disease surveillance. Formats
were discussed and were assured by the BMO that they would start both these
activities without any delay. The mission also handed over 20 Chloroscopes
and 40,000 Chlorine tablets for strengthening water quality monitoring. The
mission also reviewed the ongoing IEC activities in the area. The hospital
also has 2 New Type PHCs, 3 medical aid centres, 4 sub-centres and 8 family
welfare centres of which only Teethwal sub centre miraculously remains
undamaged.   
Damaged Tangdhar
Hospital with
inpatients and Control Room for
Disease Surveillance providing chlorine tablets and IEC material
Day 6 (29th October 2005)
Measles Immunization: The mission briefly met Dr
Pradeep Haldar Assistant Commissioner (UIP) MOH&FW and Dr S Sengupta from
UNICEF who had come to Srinagar for micro-planning for Measles immunization
and also visited Tandhar and Uri Tehsils. The mission conveyed WHOs concern
due to non-availability of AD/disposable syringes for measles immunization
and that it would be better for the state government to wait and immunize
children later only after proper micro-planning, especially in the affected
blocks of the two districts. Dr Haldar personally intervened and the AD
syringes have now been made available and measles immunization along with
Vitamin A administration has since started.  
Discussions of Assistant Commissioner (UIP),
MOH&FW, GOI and DHS for measles immunization campaign in affected
districts
Debriefing of DHS Kashmir
The mission conveyed WHOs appreciation of the
efforts of the state under the able guidance of DHS in providing timely
critical health care in the aftermath of the earthquake.
Rapid Health Assessment
The team carried out a rapid health assessment of
the affected districts (Kupwara and Baramullah) from 25th to 29th
of October 2005.
The salient findings of the mission are given
below:-
The earthquake of 8 October 2005 measuring 7.6
on the Richter Scale with epicenter at Muzaffarbad caused large scale damage
to human life and property in the districts of Kupwara, Baramullah and Poonch
(not visited) which border Muzzafarbad in POK. In these districts the Tehsils of Tangdhar
and Uri were most severely affected.
Around 1308 were killed and more than 6622
were injured of which about 1000 were seriously injured. An injury survey is being carried out
(using WHO adapted format). The survey
for patients admitted in hospitals of Srinagar have been completed (SEKIMS, Bone and Joint Hospital, SMS
Hospital, Youth Hostel and 92 Base Hospital)
Information from patients treated at Uri and Tangdhar Sub district
hospitals are also in progress.
Detailed analysis of the data would reveal the extent of injuries
suffered and enable planning for rehabilitation.
Almost 100% of the health infrastructure in
these Tehsils has also been severely damaged.
In Uri Tehsil 22 health institutions including sub district hospital
and 3 PHCs have been damaged.
In Tangdhar 17 of the 18 health institutions
have been damaged. Health
infrastructure of the armed forced in these tehsils have also been severely
damaged.
In spite of the damage to physical structure
the hospitals, PHCs and SCs continue to function from alternate
locations. This has been strengthened
by deployment of additional health teams/ mobile teams. The significantly large number of patients
attended to in the post-earthquake scenario attests to the effectiveness of
the health services provided. Most of the patients came for change of
dressing, follow-up, and for minor ailments.
Visits to villages/ towns revealed large scale
damage to buildings. Significantly
well constructed buildings (with bricks, cement) survived the
earthquake. Majority of the buildings
which were totally destroyed were of poor construction with stones, little
mortar, mud and wooden beams.
Though a large number of villages were almost
completely destroyed people have put up simple temporary shelters (tents,
polythene sheets, tin sheets) in the villages itself and large temporary
shelters were hardly visible.
Impressions
The affected populations have suffered loss of life,
limb, shelter and livelihood. They
thus have the following immediate needs:-
Water proof and winterized shelters as winter
has set in.
Food supplies for six months as all their
winter reserves have been wiped out.
Winter clothing, footwear and blankets being
located in snowbound areas.
Effective health care to prevent further
morbidity and mortality.
Health risks and interventions
Management of injuries and rehabilitation: The
mission observed that excellent health care to the injured has been provided
under the circumstances. The injury survey once completed and analyzed would
serve as a baseline for planning and provision for rehabilitation. The survey
would also enable the state to plan for future disasters.
Prevention and control of communicable diseases:
Though the state has been carrying out surveillance for important epidemic
prone diseases it was felt that weekly reporting for a broader range of
diseases (as under IDSP) could be covered and the syndromic format for the
same was provided and recommended for implementation in the affected
districts. The format included cold injuries (chilblains and frost bite) as
the affected districts would be snow bound for the next six months. IEC
activities had already been carried out for common outbreak diseases.
Water borne diseases- There seemed to be no
increased risk of water borne diseases following the earthquake as the
population continues to reside in the same area with the same water supply
(natural springs) and sanitation (local made toilets which are unsanitary). However
chlorine tablets were being distributed to ‘displaced’ families after
explaining how to use the same.
Vaccine preventable diseases- The immunization
status in the affected districts could not be ascertained but is likely to be
below 70% because of the inaccessibility of the region. Measles immunization
and vitamin A administration through campaigns to all children from 6 months
to 10 years has been started and this would definitely prevent outbreaks and
morbidity due to measles.
Vector borne diseases- Though the area is
endemic for malaria, because of winter setting in there are no significant
risk of vector borne diseases for the next six months. Hence no intervention
is recommended.
Post traumatic stress disorders (PTSD): The
mission explained the importance of basic counseling for the victims and
survivors of the earthquake to prevent PTSDs. A central team has arrived in
the valley and training of health staff is underway to provide basic
psychiatric counseling. Material prepared for Tsunami was also provided to
the doctors by the mission.
Others-Nutritional anemia, scabies and worm
infestations are common in these areas. These health problems require to be
managed by local health authorities in a routine manner.
Recommendations
Based on the rapid health assessment, the identified
health risks and available interventions the following recommendations were
given to the DHS Kashmir by the mission:-
Strengthen disease surveillance especially in
affected districts. The team also recommended speedy preparation of the
Project Implementation Plan (PIP) for the state of J & K to be included
in the next phase of the Integrated Disease Surveillance Project.
Strengthening of water quality monitoring in
the affected villages.
Completion of the injury survey and planning
for rehabilitation of the injured.
Intensified Measles immunization and Vit A
administration to all children from 6 months to 10 years of age.
Psycho-social counseling of the affected to
prevent PTSDs.
Disaster preparedness planning
Human capacity development of staff by detailing for
various courses/trainings conducted at WHO collaborating centres like FETP,
EPR and Disaster Management.
Support Provided
(through Centre) by WHO
Immediately following the earthquake the WHO kept in
close contact with the Director Emergency Medical Response, MOH&FW and
provided the following:
Four
emergency surgical kits for 400 surgeries (US$ 60000) provided to army
hospitals in the affected area.
Support
to activities by Indian Red Cross in affected areas (US$ 12000) who are
supplying blankets, mattresses and other relief material.
Provision
of technical guidelines on Mass Casualty Management, Medical Supplies for
Crisis Situation, Post Disaster Disease Surveillance, and Water Quality
Surveillance.
Development
of a Reporting Format for Suspected cases of Communicable Diseases and Cold
Injuries.
Development
of a Post Earthquake Injury Surveillance Format.
Rapid
Health Assessment carried out by mission and feedback provided to DHS
Kashmir.
Facilitated
injury survey.
Facilitated
strengthening of disease surveillance.
20
Chloroscopes and 40000 chlorine tablets distributed in affected districts.
The
mission also provided folders containing important guidelines for public
health activities during emergencies, including.
Infant
Feeding in Emergencies (WHO)
Module
for training in Psycho-social counseling
Module
for training of nurses in providing outreach services during emergencies
(developed by Indian Nursing Council, Tamil Nadu Nursing Council and WHO,
post-tsunami)
Integrated
Management of Neonatal and Childhood Illness in Disasters
5
CDs of WHO-PAHO disaster library
Other relevant WHO documents were also handed over
to the DHS for future use during training for disaster management/
preparedness.
Further technical support by WHO
The mission held discussions with the DHS Kashmir
and offered WHOs continued technical support for the relief and
rehabilitation phase. The following areas could be considered for further
involvement of WHO.
Psycho-social counseling (team from centre
already in Srinagar
and trainings of Doctors and health workers in progress).
Coordination of rehabilitation of those with
residual disability with other partners like Handicapped International, MSF,
Care India, etc (partners
already in Srinagar).
Acknowledgement:
The mission gratefully
acknowledges the excellent cooperation and support received from the
Directorate of Health Services Kashmir and
the army which made it possible to carry out the rapid health assessment in
the short time available.
|
