Hassan Farooq, MD
The only thing you can definitely predict about earthquakes is, the further you are from the last one, the nearer you are to the next.
—Dr. Edgar K. Soper
Imagine the combined populations of Dallas and Collin counties—approximately 3 million people—becoming homeless in 60 seconds. Such is the scope of the disaster that occurred on October 8, 2005, at 8:50 am local time, when an earthquake measuring 7.6 on the Richter scale devastated large parts of Northern Pakistan and Pakistani-administered Kashmir. Pakistan's earthquake was the worst natural disaster since the December 26, 2004, tsunami, in which 300,000 perished.
The tsunami was caused by a tectonic movement of the Indian plate in the Andaman sea bed. Pakistan's earthquake was also a direct result of the Indian subcontinent's northward movement at a rate of about 1.6 inches per year. This movement pushes the Indian tectonic plate beneath the Eurasian tectonic plate and causes an uplift that has produced the world's two highest mountain peaks: Mount Everest (29,000 feet) in Nepal and K2 (also called Mount Godwin-Austen; 28,200 feet) in Pakistan. Northern parts of Pakistan and Pakistani-administered Kashmir lie over this fault.
The epicenter of this earthquake was located around Muzaffarabad, a city approximately 65 miles northeast of the Pakistani capital, Islamabad (Figure 1). The hypocenter was estimated to be 12 miles below the earth's surface. The duration of 60 seconds was twice that of an average earthquake. Many secondary earthquakes hit the region, mainly to the northwest of the original epicenter, which were strong enough to be categorized as principal earthquakes by themselves: 147 aftershocks were registered on the first day, one with a magnitude of 6.2 (an earthquake of magnitude 6 is considered “strong”); 28 aftershocks with a magnitude >5 occurred during the next 4 days; and major aftershocks were recorded even 11 days later. By October 27, 2005, more than 978 aftershocks with a magnitude ≥4.0 had occurred. The Richter scale is not linear; each 1-unit increase in the Richter scale roughly corresponds to a 30-fold increase in energy release and a 10-fold increase in ground motion at any site. Even with close to 1000 aftershocks within 3 weeks after the principal earthquake, there was no further damage because the destruction due to the principal temblor was absolute and complete.
Figure 1.
The epicenter of the earthquake in Muzaffarabad. Reprinted with permission from the BBC.
This earthquake caused over 73,000 deaths (0.05% of the country's population), with half of the deaths involving children; caused 70,000 injuries; destroyed over 400,000 homes (0.2% of the country's total); and left 3 million people (1.8% of the Pakistani population) homeless. Women and children were largely affected, as they were caught unaware in their homes and schools. A World Bank report estimates that the recovery and rebuilding will take US $5 billion and more than a decade.
Pakistan is located in southern Asia on the Arabian Sea, with India to the east, Iran and Afghanistan to the west, and China to the north. With a total area of 499,247 square miles, Pakistan is 3 times the size of California and almost twice the size of Texas. Pakistan's population is estimated to be 162 million, which is 4.5 times the population of California and 7 times that of Texas. Pakistan's per capita income of US $2400 is 16 times less than that of California and 14 times less than that of Texas. If Texas and California were countries, they would rank seventh and eighth in the world on the basis of their gross domestic product, while Pakistan would rank 28th. The median age of the Pakistani population is 19 years, which is about half the US population's median age of 36 years.
At 7:00 am on October 8 in Texas (5:00 pm in Pakistan), CNN broke the news of the earthquake in Pakistan. A 10-story building in Islamabad had collapsed and at that point 35 bodies had been discovered, 80 people had been rescued alive, and 150 were still trapped. Initially, the damage from the earthquake was thought to be localized to Islamabad, as it was among the handful of Pakistani cities with multistory buildings. I immediately called my cousins in Islamabad and my parents in Lahore, Pakistan, and was relieved to hear about their well-being. During our conversation, my mother hung up the phone due to the aftershocks. Being a parent, I found the images of young children being found alive and dead in the collapsed building to be gut-wrenching. It was the worst disaster to hit Pakistan in my lifetime. My family confirmed my fear of widespread destruction. This was not media hype or the sensationalizing of an event; it was actually happening. Having been born, raised, and educated in Pakistan, I felt compelled to do something to help my country during this disaster; this was my humble way of attempting to pay my dues. I had the advantage of being devoid of lingual or cultural barriers. I was convinced that I could do more good with less effort than individuals with such inherent barriers.
Doctors Without Borders/Médecins Sans Frontières was the first name that came to mind; however, it required volunteers to have prior experience in emergency aid. While searching the World Wide Web, I came across the website of the Association of Physicians of Pakistani Descent of North America and was directed to the Islamic Medical Association of North America (IMANA). About 24 hours after I contacted IMANA, an anesthesiologist from New Jersey gave me the latest update on earthquake relief work. The rest of the planning was done via e-mail, and information was collected about the preparation of the trip from IMANA's website and www.Ready.gov, a US government website for disaster preparation. I was assigned to IMANA Team 6. This team would depart the USA on November 19, 2005, and I would report to IMANA's liaison office located at Shifa International Hospital in Islamabad, Pakistan, to obtain further instructions.
I had 7 days to prepare for the trip. Most of the items on my comprehensive survival list were acquired at the local hunting and camping goods retailers. I contacted my friends (physicians and nonphysicians), 30-plus pharmaceutical representatives, and the central supply department of Presbyterian Hospital of Greenville for any medical or nonmedical supplies that could be donated. Substantial cash donations were made by my friends and family for relief work and especially for helping the orphans of the earthquake. I had to repack the medications, breathing treatment machines, surgical sutures, braces, and cast materials to decrease the bulk. My luggage consisted of one backpack, one large suitcase, and two large cartons weighing 75 pounds each with antibiotics, antipyretics, analgesics, anxiolytics, and antiseptics. I also packed items for my personal use: water, food (1200 calories per day for 10 days), a stove, waterless hand sanitizer, metronidazole and ciprofloxacin, loperamide, a sleeping bag, waterproof clothing (shoes,jacket, pants), thermal underwear, a mess kit, a snakebite kit, a backpack, an LED headlight, batteries, a large flashlight, a compass, a cell phone and handheld two-way radio, a whistle, gloves, and toilet paper.
Pakistan International Airlines airlifted supplies marked for earthquake relief without weight limit. However, the United Airlines connecting flight from Dallas to Chicago allowed only two extra pieces, up to 75 pounds each, marked as relief supplies. It was a 22-hour flight from Dallas to Islamabad. My family picked me up from the airport. The first night was spent at the home of my cousin, Dr. Aly Abrar, a British-trained orthopaedic surgeon who had firsthand experience in treating the earthquake victims. He shared with me the types of injures, the treatment being rendered, and resources available for such patients. IMANA's liaison office at Shifa International Hospital was well organized, with excellent telecommunication capabilities and situational awareness. This office served as a hub for numerous relief workers and agencies. After completing necessary paperwork, I was referred to Major Ron Lain of the US Army for transfer by helicopter to Muzaffarabad from Islamabad. Another cousin of mine, Colonel Salman Qasim of the Pakistan Army, helped me clear the security checkpoint at the Chaklala Air Base on the outskirts of Islamabad to reach the US Army CH-45 Chinook helicopter.
Helicopters were the main mode of transporting relief workers and supplies to the earthquake-affected areas. After the earthquake struck, the USA was immediately able to send helicopters for help because of its presence in neighboring Afghanistan. The number of helicopters gradually increased to approximately 100 at the peak of relief work. The helicopters added later were heavy-lift machines, such as the Mi-26 (the largest helicopter in the world with a payload of 20 tons), CH-53 Sea Stallions (payload >36,000 lbs), and CH-47 Chinooks (payload >10,000 lbs). These helicopters were sent from the USA, United Kingdom, United Nations Humanitarian Air Service, and International Committee of the Red Cross. Also integral to the work were the MI-8 (payload >6000 lbs)and Kamov-32(payload >1700 lbs). These helicopters moved 850 tons of essential supplies in only 6 days. The daily number of sorties varied from 16 to 29, with a peak of 234 tons delivered in 1 day alone compared with 4 sorties and 40 tons per day in the beginning. Approximately 75% of the cargo consisted of building and shelter supplies, such as corrugated metal sheets, tents, blankets, and kerosene stoves, and the rest consisted of food basics, such as high-energy bars, ready-to-eat meals, bags of wheat flour, and cans of cooking oil. This food supply would allow people to sustain themselves over the winter until the reconstruction began in the spring.
I was taken to the Muzaffarabad airfield by a US army CH-47 Chinook helicopter. The largest health care facility, Combined Military Hospital in Muzaffarabad, was completely destroyed (Figure 2), and patients were being treated in tents. The 212th Mobile Army Surgical Hospital (MASH) of the US Army, with more than 100 US soldiers, had already arrived in Muzaffarabad for relief work and brought in an x-ray machine, a portable echocardiography machine, and an operation theater facility. I contacted local Pakistan Army officers and was able to get a ride to Abbas Medical Institute, a small and the sole surviving hospital in the Muzaffarabad area. After evaluating the situation at Abbas Medical Institute in Muzaffarabad, I informed the Islamabad IMANA office that this hospital did not need more physicians; it needed discipline. With the help of a local physician assigned to me for orientation, I was able to reach the next base camp at Ghari Duputta, only 12 miles away yet a 2-hour drive further north in the mountains.
Figure 2.
The condemned Combined Military Hospital in Muzaffarabad. The emergency vehicles parked underneath were crushed as the hospital collapsed.
The Ghari Duputta camp (Figure 3) was situated in front of a completely destroyed girls' school. There were five main tents: a large tent for trauma care (Figure 4), a dispensary, a kitchen, and separate tents to house male and female volunteers. The tent for sleeping was shared with eight other volunteers. I slept on a cot and padlocked my metal trunk containing my personal belongings so it would not be lost or stolen. The temperature during the night dipped to 40°F; my sleeping bag and a gas heater were just about enough to keep warm. Food was high-energy bars, ready-to-eat meals, and bottled water. Our bathroom was about 200 yards from our camp in a partially destroyed house with an intact toilet and no running water. This so-called bathroom was rented for US $20 per month, and several local teens were hired for US $10 per month to replenish the buckets of water daily. Due to the shortage of water, we did not have the luxury of bathing daily. Most volunteers bathed themselves once a week with the use of buckets.
Figure 3.
An aerial view of the base camp at Ghari Duputta.1 indicates trauma unit; 2, kitchen; 3, dispensary; and 4, sleeping quarters.
Figure 4.
The trauma unit in Ghari Duputta. (a) The trauma tent was provided with the help of the USA. (b) Trauma care was provided on wooden tables, lighted with ordinary bulbs that were powered by a generator.
The buildings in Pakistan are usually one-story masonry houses. Walls are built with bricks and stones held together with cement. The roof consists of concrete slab, resembling the driveway of an American home. These homes are not built to withstand even a minor earthquake. The roof of a 2000-square-foot house typically weighs about 220,000 pounds. These buildings lacked cross-braces that would hold the walls together during an earthquake. The collapse of such structures causes multiple fractures, crush injures, and death for the people trapped inside. In the aftermath of the earthquake, resources were too scarce to rescue trapped people even if they had survived the crushing forces. Families could hear the cries of their loved ones buried under the rubble. The destroyed houses scattered all around our camp in Ghari Duputta were a constant reminder of the immense destruction and the wrath of the earthquake. The devastation was absolute. Not one building was left standing; they were all a pile of stones, concrete slabs, and corrugated sheets (Figure 5). Schools were completely destroyed with children buried under the tons of concrete. Mothers continued to visit and wail by the piles of rubble that had engulfed their children.
Figure 5.
The concrete slab roof lying on the collapsed walls of the house. It is impossible to escape from underneath. Collapses like this crushed thousands of people.
My typical day would start at 7:00 am. I would brush my teeth with bottled water, shave, and apply much-needed deodorant. Volunteers met daily in the open field and were briefed about the medical needs of the area. We would get the latest information from the Pakistan military personnel and would communicate via two-way radios and cellular phones to decide where and what kind of medical help was needed. I offered my services to Todd Shae of Operation Heartbeat, a Washington, DC–based organization (operationheartbeat.org). He was already working with several other volunteers and had grouped them in six-member teams. One team consisted of three health providers, including one member who could speak the local language and English; two armed military guards; and a driver who was aware of local road conditions. Each team would travel by road or helicopter to areas with no access to health care.
Initially, our team—consisting of Chris and Ameer (fire fighters from Maryland) along with two army nurses—was asked to staff the outpatient clinic at our base camp. Patients would walk to our tent from surrounding areas to be seen (Figure 6). The next few days we traveled to remote areas and set up medical clinics. Each morning we would pack two to three large metal crates with medications and supplies—antibiotics, antivirals, analgesics, skin preparation for scabies, medication for heartburn, splints, bandages, anxiolytics, and antidepressants. Volunteers were encouraged to return to the base camp at Ghari Duputta every evening so they could receive updates, replenish supplies, and ensure their own safety. After sunset, freshly cooked chicken curry, lentil soup, and rice were served on paper plates. Around the campfire, we would rest our tired feet and work out the next day's details.
Figure 6.
Locals gathering around to be seen by health care providers.
The Pakistani military had set up camps every 30 miles to supply people with food and shelter and to keep the peace. Some of these camps and villages were reachable by road, others by helicopter, and still others only by mountain climbers. The drive was tedious, slow, and risky, as the narrow roads were completely destroyed by landslides (Figure 7). At times we had to backtrack to let an incoming vehicle pass through; due to the excessive load on the vehicles, a vehicle traveling downhill had the right of way. It would take us 2 to 3 hours to cover 30 miles.
Figure 7.
Roads were completely destroyed by landslides triggered by the earth-quake.
The villages were at elevations of approximately 6000 to 8000 feet. In some of the villages, tents had already been erected for clinics, whereas in others we would set up in the middle of an open field (Figure 8). Usually we would start seeing patients about 11:00 am. Since we knew there was a possibility we would not be able to return to the base camp in the evening, we carried sleeping bags, food, and medication for personal use in our backpacks. On our sixth day, we traveled 3 hours by road to get to a village about 30 miles from the base camp, only to see 30 patients. Our team decided to return to the same village the next day, so for security reasons and to save travel time we retreated about 5 miles by a pickup truck to a small army camp to sleep. The next morning we were able to help about 200 patients, ranging from infants to 90-year-old farmers.
Figure 8.
A makeshift clinic. It was not uncommon to set up a clinic in the middle of nowhere with salvaged school furniture.
With their homes destroyed by the earthquake, the local population was forced to live in tents; a large number of the tents were not waterproof or winterized. Most people will call these tents home for several years until they can afford to build new homes. The area has been turned into a massive refugee camp. Winter had already started when we were there, and the weather was getting colder day by day. Because of exposure to the elements of nature, upper respiratory infections were common and were treated with injectable and oral antibiotics, usually second-generation cephalosporins. Since the x-ray facility was in Muzaffarabad, the sickest patients were referred there.
Insomnia and severe reflux symptoms were present in 1 in 10 patients who were symptom-free prior to the earthquake. I was surprised to see the number of patients with gastroesophageal reflux disease. I had reluctantly packed lansoprazole and pantoprazole. The prevalence of Helicobacter pylori infection is reported to be up to 80% in Pakistani patients undergoing endoscopy for various reasons compared with 20% in the US general population. H. pylori infection is acquired in childhood due to poor sanitary conditions in Pakistan. Self-medication is a common problem, and so is drug resistance. Patients with a prolonged history of gastric reflux were empirically treated with combination therapy for H. pylori infection eradication.
To my surprise, diarrheal illnesses were less common. The local health department had already done an extensive awareness campaign on the importance of clean water and sanitation. Locals, especially in the remote areas, were supplied with water purification sets. One water treatment plant in Muzaffarabad was producing 250,000 liters a day to supply 17,000 people. Posters in the furthest areas warned people about the hazard of waterborne diseases. Despite this, an elderly man presented with abdominal pain and a 2-week history of fever. His temperature was 102°F, and his pulse was about 100 beats per minute. He appeared lethargic and wanted to lie still. His abdomen was rigid as a board, and bowel sounds were absent. A tentative diagnosis of typhoid fever was made, with possible perforation of Peyer's patch, and the patient was placed in a nearby tent and started on intravenous ceftazidime and gentamicin. He asked his family not to give him water or food. I had a strong difference of opinion with one local physician over the diagnosis and treatment of this patient. I was able to convince the family in their language to let me airlift him to Islamabad for further surgical intervention. It was difficult to follow up on patients due to a lack of proper recordkeeping and telecommunication.
Even 6 weeks after the initial earthquake, victims were still presenting with musculoskeletal injures. A father carried his 16-year-old daughter in his arms from his village to our clinic, complaining that she was unable to stand up for 6 weeks (Figure 9). She was in the house at the time of the earthquake and the roof had fallen upon her; she was now unable to extend her left hip, and minimal movement caused severe pain. She had marked swelling and anterior dislocation of the left hip with cords in her left calf, as well as swelling, tenderness, and increased temperature representing the onset of thrombophlebitis. She was given intravenous morphine and was also transported with us back to the base camp and then to a tertiary care hospital in Islamabad for open reduction.
Figure 9.
A 16-year-old girl keeping her left leg flexed at the hip joint due to severe pain after anterior dislocation of the hip. She was injured by a fallen roof during the earthquake.
Another young patient with similar problems complained of severe pain in the right leg. There was mild external rotation, deformity, and severe tenderness of the right femur (Figure 10). He was splinted using ribbons made out of old clothing and pieces of cardboard boxes and was transported for further treatment. His x-ray showed comminuted fracture of the right femur.
Figure 10.
This child's right femur fracture being stabilized with pieces of cardboard and strips torn from old clothing. The inset is an x-ray of the comminuted fracture.
We saw several other patients with bruises and blunt trauma caused by falling debris. Puncture wounds and lacerations were very common in patients trying to salvage their homes. Suturing of the laceration was preferred over stapling since sutures can be removed without a specialized tool. The cornerstones of deficiency from lack of iodine in the diet. treatment for these patients were tetanus toxoid, antibiotics, and pain medication. Wound debridements were occasionally performed with local anesthesia; however, several patients with long bone fractures that were treated with external fixators had developed wound infections to the point where pus was visibly oozing out around the screws (Figure 11). All such patients were transported to Islamabad for prolonged antibiotic use and removal of hardware. More than 30% of these patients would end up with gangrene and amputations. All procedures at the base camp were performed under local anesthesia; for general anesthesia, patients had to be transported to Islamabad.
Figure 11.
A patient with an external fixator in dusty conditions ideal for wound infections.
An enlarged thyroid gland was seen in all age groups of the population (Figure 12). The prevalence of goiter is estimated to be 54% in males and 49% in females. Goiter is overwhelmingly caused by lack of iodine in the diet. Unlike in the USA, iodized salt is not widely available in these areas. Fortunately, cretinism—consisting of mental retardation and poor motor function—was uncommon, even though it is caused by a lack of iodine and the resulting thyroid hormone deficiency in infancy (Figure 13). Patients with goiter were provided with iodine tablets and education about the use of iodized salt. In 1993 with the help of UNICEF, the government of Pakistan initiated a campaign to increase the use of iodized salts in these areas, but the effects are yet to be seen. Due to the large number of patients with thyroid problems, a weekly “thyroid bus” service was started to transport these patients to larger hospitals in Islamabad.
Figure 12.
Goiter in a 16-year-old girl with normal intelligence and motor function.
Figure 13.
A child with a thick tongue and poor motor development feared to have cretinism due to thyroid hormone deficiency from lack of iodine in the diet.
Overcrowding had led to skin infections and infestations. Scabies was the most common skin infection and was affecting men, women, and children of all ages. Over 50% of scabies cases were complicated with superinfection of the affected skin. These patients were very difficult to treat due to poor hygienic conditions and a lack of understanding of how the disease was spread. Children, the most vulnerable, were also the most seriously affected. Patients were treated with topical medication and were given detailed instructions about preventing recurrence and spread. Eye infections, especially bacterial and viral conjunctivitis, were occasionally seen (Figure 14).
Figure 14.
A patient with left-sided Bell's palsy, which had led to conjunctivitis and a corneal ulcer and scarring.
Cardiac problems related to overconsumption of food were absent, as was obesity. On the other hand, the prevalence of rheumatic heart disease is about 6 per 1000 in rural Pakistan, and women are significantly more likely to be affected. A 40-year-old woman had a history of progressive fatigue, shortness of breath over the last year, and occasional palpitations and chest pain. On examination, she had an irregular heart rhythm and a holosystolic murmur that was best heard at the mitral area with no radiation to the neck. Her lung auscultation revealed bibasilar crepitations. She could not recall any particular febrile illness without joint pain as a child. This woman was thought to have mitral regurgitation and was transported via pickup truck to the Muzaffarabad MASH for an echocardiogram with a portable machine and further treatment.
After 8 days of work, I was ready for my retreat; however, the weather changed and helicopter flights were discontinued. While stationed at the base camp in Ghari Duputta, a young army officer presented with a 3-week history of exertional substernal pressure with nausea. His vital signs were normal. He was overweight and had recently quit smoking but was physically very active. Considering the risk of acute coronary syndrome, he was given sublingual nitroglycerin, aspirin 325 mg, and carvedilol. I traveled with him for 4 hours to the MASH unit in Muzaffarabad. The electrocardiogram showed normal sinus rhythm without ST changes. Once again, with a portable handheld ultrasound unit with about a 6-inch screen, I was able to see the four-chamber view. There were no obvious wall motion abnormalities. The patient was admitted to rule out myocardial infarction, and stress testing was scheduled at a different facility. While in the MASH, I met an old friend from medical school who is now a major in the medical corps of the Pakistan Army, and I stayed with him.
The next morning, an army truck dropped me off at the Muzaffarabad airstrip. A Russian-made MI-8 helicopter was on its way to drop supplies, and after much discussion the pilot agreed to drop me and other volunteers at the helipad of the Jinnah Medical Institute in Islamabad (Figure 15). I finally returned home to my cousins in Islamabad. Before leaving for Dallas, I contacted SOS Village Pakistan, a worldwide orphanage, and donated enough money to cover 1 year of boarding, lodging, education, and expenses for two children orphaned by the earthquakes.
Figure 15.
Inside view of a stripped-down MI-8 helicopter dropping food supplies on our way back to Islamabad.
It will take decades to rebuild Pakistan after such a massive disaster, yet the victims of the earthquake remain grateful and hopeful. They continue to go on with their everyday lives: children attend school, sitting on the ground in the open air, and adults stay busy preserving and rebuilding their shattered lives. Somehow a sense of peace shows on the faces of the victims, and their faith is even stronger. During my trip, I came to the realization that the natives were not only emotionally strong, they were also physically fit and able; most men in their 60s can carry a 100-kg bag of food on their backs and climb uphill for hours. The people of Pakistan are aware that they will have to continue to depend on foreign aid to get back on their feet; they realize many more lives will be lost in this process as the harsh winter moves in. Kashmir has lost a big part of its generation in this earthquake, yet the victims continue to be adaptable to change. The country of Pakistan (and myself as an observer) has learned a lesson in humility, and the victims of the earthquake know that rebuilding their lives is going to be an ongoing battle filled with life's ups and downs. As Khalil Gibran says, “And when you have reached the mountain top, then you shall begin to climb.”