INTERNATIONAL COOPERATION REPORT Touring Cuban Field Hospitals in Post-Quake Pakistan Text and Photos by Conner Gorry Fast Facts:

Northern Pakistan Earthquake

as of December 31, 2005 Epicenter: Gori, 12 miles northeast of Muzaffarabad in Pakistan-administered Kashmir

Magnitude: 7.6 on moment magnitude scale

Fatalities: 75,000+

Wounded: 120,000+

Homeless: 3.3 million

International aid pledged: US$6.2 billion

Number of temporary shelters erected: 250,000

Refugees in 37 planned camps: 57,742*

Refugees in 335 spontaneous camps: 126,718*

Number of international field hospitals: 44

*Source: UNHCR On October 8th, when a devastating earthquake ripped through northern Pakistan claiming upwards of 75,000 lives, leaving 100,000 injured and more than 3 million homeless, Cuba couldn’t count one Urdu speaker in its ranks. On that day - now historical for the scale of the disaster and the international relief response - Cuba had no embassy in Islamabad. Nevertheless, there are now over 2,300 Cuban doctors, nurses and medical technicians working throughout the earthquake-affected areas. Cuba’s disaster response team, the Henry Reeve International Team of Medical Specialists in Disasters & Epidemics, was created last August in response to Hurricane Katrina (see MEDICC Review, Vol. VII, Nos. 8 & 9, 2005). Designed as a specialist team that could be moved into post-disaster situations to effectively treat survivors and prevent and control epidemics, its volunteers commit to go wherever in the world they’re needed. On that fateful Saturday in October, it became clear they were needed desperately in the Kashmir and North-West Frontier Province (NWFP) areas of Pakistan. The Post-Quake Scenario The post-disaster health and hygiene situation is made more complex for several reasons. First, 80% of health centers in the affected areas were destroyed, so even if those suffering from fractures, head trauma and other event-related injuries could get past the landslides and roadblocks in search of care, there were few places they could go in the direct aftermath. Many of the health centers demolished were public facilities, further placing the most vulnerable at risk. Several towns near the epicenter including Balakot, Muzaffarabad and Garhi Habibullah were the hardest hit, with water and electricity services completely interrupted, making safe food and water virtually impossible to find. This was particularly dangerous for the 17,000 pregnant women in the affected areas due to give birth in December, an estimated 1,200 of whom would face major complications. Of these, some 400 would require surgery.[1] As winter approached, food and water were key health issues which continue to present complicated logistical problems since mountainous areas above 5,000 feet have become increasingly inaccessible with each snowfall. Although relief agencies began airlifting food to those areas in mid-December, there is no guarantee it will prove sufficient for the tens of thousands of victims, particularly if the winter is especially harsh.[2] Add to this the aftershocks - some qualifying as strong earthquakes themselves (over 6.0 in magnitude) - that cause continual landslides and interrupt aid delivery. Cuban Relief Mission – What it Looks Like Into this scenario, scores of Cuban medical professionals of the Henry Reeve International Team began arriving in Pakistan on October 14th. Together these doctors, nurses and technicians came to Pakistan with an average of 10 years clinical experience, specialized training and medicines for treating epidemics and other post-disaster health threats; collectively they have served in over 40 countries. They also came with the understanding that if not designed correctly, disaster relief has the potential to do more harm than good. “We knew this had to be a closed-loop relief effort,” says Dr. Juan Carlos Martín, Director of the Cuban field hospital in Muzaffarabad. “Not only did we have to bring the medicines and the doctors, we had to provide everything – the hospital, the electricity, the plumbing, the beds – to run that hospital.” Easier said than done when your aim is to equip, staff and run 30 field hospitals spread throughout a mountainous, earthquake-stricken region where the populace is in desperate need of primary and secondary care. Add to this cultural, language and climatic differences and the task looms large. Each of those 30 field hospitals (in addition to another 14 locations throughout the affected regions where Cuban doctors are working, including refugee camps and Pakistani hospitals), has distinct conditions which come to bear on the delivery of health care. It became evident during MEDICC Review’s visit to several different types of hospitals that the Cuban team has adapted to these particularities with grace, treating their Pakistani patients with a professional, human approach. “They treat patients like people, not just cases,” said Khalida Ahmad of UNICEF in Islamabad. “Everyone I spoke to from the affected areas was so grateful. They felt they could always go to the Cuban doctors to ask a question, despite language difficulties.” Two of the field hospitals - Hospital 20 in Muzaffarabad and Hospital 26 in Abbottabad - were purchased by Cuba from Norway and Spain/South Korea respectively, costing around half a million US dollars each. These units are designed for extreme events and circumstances and come equipped with space enough for out-patient, operating, ICU, diagnostic and recovery services. But these are in no way ‘one size fits all,’ and the Cubans have had to customize these hospitals to fit local needs and provide the best care possible. Moments after I arrived in Muzaffarabad for example, two accident victims were rushed into the emergency area, one with internal bleeding and the other with massive head trauma. As a team of specialists set to stabilizing them, it became clear that the present set-up was not sufficient for running several IVs concurrently, should multiple emergency patients arrive at once - not uncommon in Pakistan, where traffic accidents can instantly fill an ER. By the next morning, the two men were stable in the ICU, and a hook and line system for hanging multiple IVs was being set up. Similarly, in the Abbottabad hospital, crowd control barriers had to be erected at the entrance to the out-patient tent to maintain an orderly procession of the 500 patients seen daily. Other adjustments made by the Cubans in these and other hospitals include securing X-ray developing areas, devising dividers to separate the male and female patients according to religious custom, and providing running water to operating rooms. The Cubans have assembled other field hospitals from components purchased from Russia and elsewhere that function much like the pre-fabricated units in Muzaffarabad and Abbottabad. However, not all are the same in terms of working conditions, as I learned upon visiting Hospital 5, located within the Data refugee camp. In addition to the ER, operating room, and laboratory and X-ray capabilities, doctors from the field hospital here mimic the Cuban family doctor system, going into the “community” of tents to provide evaluation, care and follow-up to the 350 or so living in the camp, remitting patients to the on-site hospital if necessary. Every day, several pairs of doctors – always one male and one female – fan out among the 80 or so tents with a backpack of medicines and a good working knowledge of Urdu. I’m awestruck watching young Family Medicine specialist Yudelkis Noa Hernández of Havana asking an older gentleman about the location, tenor and duration of his pain in Urdu while she examines him. Moreover, the relationships the Cubans have with the Pakistani people here are apparent in the familiarity between doctor and patient - Dr. Noa is diverted several times during her rounds to say hello or provide some quick follow-up – and the fact that most men are not shy about being treated by women doctors. “I’ve lived here for a couple of months already,” she tells me when I compliment her on her Urdu skills. “It’s not easy, but I like it. It’s like camping and I’m a trooper!” she laughs. The Director of the hospital, Dr. Barbara Haliberto, a general surgeon from Cuba’s Holguín Province says, “this field hospital and camp hasn’t had the same support from the army as others. We’re relatively far away [from the affected areas] and there’s been some support, but limited, so resources and services are different.” Still, the Data field hospital, with a staff of 55, is offering the same primary and secondary services as other hospitals including minor and major surgery, physical therapy, and rehabilitation to the increasing number of people who arrive daily at the camp. Pathologies & Challenges Although the Cuban hospitals initially treated their fair share of disaster-related injuries including fractures and infected wounds, the care now being delivered is largely of a different nature. “The most frequent pathologies we’re seeing now are acute respiratory infections, skin problems and other primary care conditions,” says Dr. Haliberto of the Data field hospital. These include scabies, parasites, sepsis and gastroenteritis. Many times these cases are painfully advanced or chronic, like the child who had such a bad case of pyoderma she couldn’t walk, the little boy who had system-wide sepsis that had penetrated his bones, and entire families with scabies. Hepatitis, TB, tetanus and typhoid are also present. There is also a high prevalence of burn victims, caused by accidents from heating elements in homes and refugee tents. With the 17,000 pregnant women delivering in December and 9,000 more each month thereafter, pre- and post-natal care including ultrasounds and caesarean sections are always in high demand. Meanwhile, routine surgical procedures include removal of tumors and hernias, appendectomies, and amputation of gangrenous lower extremities and other orthopedic procedures. Poorly knit post-earthquake fractures also see their share of OR time. Over several weeks of treating 500 patients daily at the busiest hospitals, including those in Muzaffarabad and Abbottabad, patterns of pathologies emerged for which the Cuban team has customized their relief effort. Roughly a third of out-patient consultations were for scabies, for example, signaling the need for dermatologists and a continuous supply of benzyl benzoate. Likewise, the number of people requiring physical therapy and rehabilitation due to earthquake-related trauma alerted Cuban officials that those specialists were needed. The number of pregnant women, coupled with the religious norm of female patients only seeing female doctors, meant female ob-gyns were in high demand. The Cubans have responded by sending dermatologists, physical therapists and female doctors of all specialties to better serve the local population.[3] It hasn’t all been smooth sailing, however, and mounting and maintaining a relief effort of this magnitude has involved a precipitous learning curve. Gathering reliable statistics has proven a challenge for example - not surprising, given the thousands of daily consultations spread across 44 locations, plus the service in remote mountain villages, where mobile teams treat upwards of 100 people a day. The importance of accurate statistics was underscored in a December meeting in Islamabad that brought together directors of field hospitals, logistical coordinators and other Cuban decision makers to streamline statistical gathering mechanisms. This has resulted in statistics being gathered and analyzed more consistently (see box) which should translate to even more effective resource allocation. Statistics for Cuba’s Relief Effort in Pakistan

(October, 2005-January 24, 2006) Number of medical personnel: 2,378 (including doctors, nurses and other paramedical staff)

Locations in which they serve: 44

Number of field hospitals: 30

Number of lives saved: 1,315

Number of consultations: 601,369 (276,491 women)

Number of surgeries: 5,925 (2,819 major)

Births attended: 125

Caesarean sections: 24 A whole host of other contextual factors specific to Pakistan are presenting difficulties for which no amount of training in Cuba could prepare these medical practitioners. The cold weather - and snow in particular - are the enemy, both to the doctors and quake survivors. Cultural differences, from strict gender roles to religion and language, come into play in the doctor-patient relationship, the delivery of emergency care, and broader medical ethics concerns. Finally, a reliable blood supply – integral to the efficient functioning of any hospital – has proven another hurdle in post-disaster Pakistan. Update: Cuba’s Disaster

Response Team in Bolivia In late January, torrential rains in Bolivia caused landslides and flooding, severely affecting several regions, particularly in the east. Over 12,000 families lost their homes and entire towns were cut off due to collapsed and inundated roads as the rain continued unabated. The natural disaster triggered a call for international aid by President Evo Morales to which Cuba responded on February 2nd with a relief effort comprised of 15.7 tons of medicines, 20 field hospitals and 150 volunteers from the Henry Reeve International Team of Medical Specialists in Disasters & Epidemics. The Silver Lining The earthquake has sparked debate on the national level about structural fundamentals in Pakistani society that contributed to the magnitude of the destruction. The hope is that through adjustments, a repeat event might be averted. Poverty reduction, a greater investment in the public health system and a concerted effort to educate more female doctors have all been discussed by government officials in the aftermath. Increasing participation by women in Pakistani political and social life is another opportunity seen by local gender and development specialists represented at a Gender and Disaster Management seminar in Islamabad this December. There are also great expectations for future collaboration between Cuba and Pakistan, including medical education. Indeed, many medical students, acting as translators for the Cuban doctors, expressed an interest in studying there. According to Cuba’s Vice Minister of Foreign Relations Bruno Rodríguez, Cuba is offering full scholarships to young Pakistanis to study at the Latin American Medical School in Havana. Training new doctors committed to practicing medicine in underserved communities is key to any strategy for providing sustainable health care in Pakistan, where the “brain drain” of doctors to developed countries is particularly acute.[4] In the meantime, Cuba continues to look for ways to further extend health services to the people of the earthquake-affected areas. “Thirteen amputees have already completed their pre-prosthetic rehabilitation,” Vice Minister Rodríguez told MEDICC Review in an exclusive interview. “We are now preparing to transfer them to Cuba to be fitted for prosthetics.” Moreover, Cuba has pledged to donate their field hospitals to Pakistan once the disaster response team departs (date to be determined), provided they remain in the same locations and continue to function as public health facilities.



Notes & References United Nations Population Fund, December 17, 2005. In the final days of December, for example, the World Food Programme had provisioned 68 tent warehouses with food enough for 45-60 days in regions above 5,000 feet. Furthermore, the new year dawned with heavy snowfall that isolated two Cuban field hospitals for a week and caused the collapse of two dozen tents, according to Cuban officials in Pakistan. Fully 48% of Cuban medical personnel serving in Pakistan is female. Pakistan ranks fourth among low-income nations for number of physicians working in the United States, Canada, the UK and Australia combined, with 12,813 doctors of Pakistani origin practicing in those nations. This means 11.7% of Pakistani doctors are practicing outside Pakistan (Mullan, Fitzhugh. “The Metrics of the Physician Brain Drain,” N Engl J Med, Vol. 353: 1810-1818, 2005).