When Mountains Fall

When the Kashmir earthquake struck nearly a year after a long succession of disasters at home and abroad (Asian tsunami, Hurricane Katrina, etc.) it was just one disaster too many. And this one was too far away, too remote, with no tall buildings, no tourists, no compelling video. But our group of paramedics and doctors wondered if we could do something to help. One phone call led to another.

BACKGROUND
For 50 million years, inch by inch, the Indian subcontinent has pushed up against the Eurasian plate, launching the jagged Himalayas above the mounting tension. On the morning of Saturday, October 8, 2005, most people were home, napping after the pre-dawn Ramadan meal, resting for another day of work and fasting. Then the weight of the earth slammed down and the mountains crashed. The 7.6-magnitude earthquake claimed lives in three countries. Most of the devastation occurred in the area closest to the epicenter in the city of Muzaffarabad, in Pakistan-administered Kashmir.

In a land of towering mountains sheltering slender forest valleys, Kashmir was already one of the most inaccessible places on earth. Divided between India and Pakistan in two wars along a contested dissection known as the Line of Control, the earthquake roughened the landscape further.

Jan Egeland, the United Nations' emergency relief coordinator, says, "We have never had this kind of logistical nightmare, ever. We thought the tsunami was the worst we could get. This is worse."

Entire mountains disappeared, sliding down and coming to rest on the floors of valleys, wiping out roads and telephone lines. In the first days after the earthquake, severe thunderstorms and hailstorms pounded the region, grounding helicopter flights and, for the thousands buried alive, wiping out hope that rescuers could reach them. For the next three weeks, nearly 1,000 aftershocks-many of them large earthquakes in their own right-continued to jolt the area. By that time, however, there was nothing left to destroy. More than 80% of all structures in Kashmir were completely demolished, approximately 90,000 people died, and close to four million were left without shelter for the brutal winter.

In the initial aftermath of the earthquake, separate groups led the local response. The Pakistan military heroically pulled itself from the rubble to save hundreds, while, at the same time, Muslim extremist groups quickly raised their flags under which they set up makeshift shelters and clinics. The government allowed them and other volunteers to continue until humanitarian groups could replace them. While large, slow-moving international agencies like the International Committee of the Red Cross dispatched their assessment teams, other groups were already delivering relief supplies from pre-stocked warehouses. The United States sent helicopters and troops engaged in antiterrorism maneuvers in Afghanistan. In less than 24 hours, search and rescue, as well as medical teams from around the world, landed in Islamabad. No agency wasted time wrestling for command. In the first few days, saving lives came first, no matter who was in charge.

Stakeholders in the Pakistan relief effort created a structure that maximized collaboration between the federal government and the humanitarian community. President Pervez Musharraf appointed a Federal Relief Commission, but coordination was never unilateral. The Commission, in collaboration with the more than 200 United Nations agencies and hundreds of NGOs, drafted a bold National Response Plan, which organized 10 "clusters." The clusters were not intended to command NGO efforts, but rather to encourage and set standards for facilitating rescue, relief and reconstruction. Each cluster was co-chaired by the international humanitarian agency and the Pakistani government ministry best suited to carry out the cluster's mandate. Gathering all agencies and groups working in a specific field, the clusters aimed to share information, prevent duplication of efforts and strengthen communications between agencies' headquarters and operatives in the field. The National Response Plan had only one absolute: maximum flexibility for the greatest positive impact.

Despite the well-orchestrated response, inadequate funding condemned the relief effort. The international response to the United Nations' flash appeal of roughly $550 million fell embarrassingly short. Ten days after the Southeast Asian tsunami, 80% of the money needed had been donated; 10 days after the earthquake, barely 12% had been received.

HALFWAY AROUND THE WORLD
In the hours following the Kashmir earthquake, dozens of doctors and paramedics began calling each other, wondering how they could help. A core of providers emerged and spent the following days persistently glued to phones, speaking with humanitarian agencies from New York to Geneva. They all insisted a team like ours was desperately needed, but they were too overwhelmed to make decisions. At the same time, the team of 10 paramedics and two doctors, many who'd never met, began to obtain enough supplies to deploy as a self-sustained unit. Generous donations in kind provided us with enough food, water and shelter to be independent overseas. Finally, the World Health Organization (WHO) coordinators on the ground in Pakistan directed our team to deploy to the town of Ghari Dupatta, approximately 25 km southeast of Muzaffarabad, where we'd provide forward triage for the thousands of patients coming to the newly established field hospital. A couple of days after the earthquake, we had everything except plane tickets.

It wasn't until two weeks later that a United Kingdom-based NGO, Islamic Relief, offered to pay for our flight and provide us a satellite phone. When we arrived in Islamabad, we discovered that, while our luggage had arrived, our cargo was lost, despite our best efforts to prevent that from occurring. Airport personnel were working overtime or volunteering, and ours wasn't the only lost humanitarian cargo. Islamic Relief sent vans and drivers, but no officials and no satellite phone. Our contacts in the government were unable to make progress in the chaotic cargo offices. We waited in the hot cargo docks surrounded by tens of thousands of relief boxes, none of them ours.

A few hours of telephone calls later, the United States Army agreed to provide us with water and meals-ready-to-eat (MREs) to last us a few days until our cargo arrived. They offered a helicopter to Ghari Dupatta, so long as we were on it within 10 minutes. Islamic Relief, which had a base of operations in Ghari Dupatta, said they would provide us shelter and a satellite phone when we landed. One member of our team stayed behind in Islamabad to make certain our cargo followed us.

We managed to convince soldiers at the Air Force base that they either had to break the rules and allow our vans onto the tarmac, or we were going to run across it carrying all our supplies to the waiting U.S. helicopter. Forty minutes later, we touched down in a small landing zone in the middle of what appeared to be an improvised military tent camp, which the helicopter pilot said was Ghari Dupatta. He was wrong.

We had landed in Sawan, a small military outpost in the Jhelum River valley. A Pakistan Army colonel explained to us that Sawan had been unreachable by road since the earthquake, being located far beyond several colossal landslides that had barred access to the larger relief agencies. Ghari Dupatta was several hours on foot behind us. Further to the southeast, almost no aid had arrived. People carried patients on heavy, improvised litters through dangerous mountain switchbacks to reach the closest medical attention hours away at a clinic in Sawan being run by a small medical team of Afghani military doctors who were, coincidentally, leaving the next day. No replacement team had been scheduled.

During the first days after the earthquake, the Afghans saw several hundred patients daily and had performed hundreds of fracture reductions and amputations. The daily patient count and severity index had since decreased, but it was difficult to learn how much. Likely fearing that telling us a number either too high or too low would mean we'd refuse to stay, the Afghanis were hesitant to reveal specifics. As far as medical supplies, the clinic-four beds, some chairs and strewn rubble underneath a tarp next to a semi-demolished clinic-while terribly disorganized, was sufficiently stocked for several days.

We had no means of communication and no means of getting out. We had tents and supplies for three or four days. Our principal concern was that we were in the wrong place-potentially a place where we were either not needed or were incapable of providing the necessary level of care.

The next morning, patients poured in. As the Afghani team helped carry a patient with a spinal injury to the landing zone on an improvised stretcher-a door from a collapsed home-we saw a sign along the road that we'd missed the night before, which declared: "Warning! Journey ahead prohibited for foreigners!" The Afghanis thanked us for coming and took off, leaving the clinic at Sawan in our hands.

Three team members trekked back for hours to the closest town with a satellite phone to let the relief effort know where we were and that more help was needed. One agency told us we were too far from the epicenter and there would be no patients to treat. But as word spread, our patient load doubled. The most seriously wounded had been evacuated on foot or had died already; left were the patients who had been too sick or not yet sick enough.

Our mission had changed, and we changed our attitudes to meet the situation's demands. We cleaned up and organized the clinic, creating a fast-track area, a wound-care area and a resuscitation area. We also created a female-only section staffed by women, but male providers never encountered problems in treating females. Three team members, as well as the Pakistan Army's officers, spoke fluent Urdu and taught us how to ask basic questions. We learned the capabilities of different hospitals where we could evacuate patients by air. The two-and-a-half doctors-one pediatrician, one wound-care specialist and a paramedic who was finishing a physician's assistant program-trained the paramedics to care for wounds.

Although many patients had horribly infected wounds, theirs were not the only medical problems. Patients with grossly angulated closed fractures, who had received no care since the earthquake, were common. Acute traumatic injuries were also numerous as patients slipped and fell in the shifting, treacherous terrain. We stabilized the most critical patients-from severely dehydrated babies and traumatic brain injuries to wounds so infected that only hospitals in Islamabad could handle them--and then we prayed for a helicopter. A great number of our patients were suffering from pneumonia, upper respiratory infections, dysentery, parasites or scabies. Patients coming from miles ahead spoke of no water, no medicine, no shelter and hundreds of people too weak to climb down.

Despite the strong aftershocks, we sent a four-man team with an army escort to trek to a town further up the mountains. The town, located at the point of convergence of three valleys, had enormous medical need and was a perfect place to set up a second clinic. Although we'd agreed earlier not to split up, we recognized that the immediate need to move forward had to be balanced against the need to continue providing care in Sawan. Half of our team continued forward, where they would set up at an artillery base located only a few kilometers from the Line of Control. They loaded Pakistan Army mules with enough medical supplies for a few days. We prayed for our cargo, which still had not arrived, and for more help.

Our only contact with the rest of Pakistan was a shaky field telephone line that we shared at night with dozens of soldiers trying to call home. We used what precious minutes we had to try and secure more help for our region. Only hours after our team members left, a landslide knocked out the telephone line ahead of us, preventing our split team from communicating with each other for days. Finally, our efforts began to pay off. Two doctors and four nurses volunteering from the United Kingdom were flown in. The road had opened, and two nurses from Doctors Without Borders arrived with supplies. Minutes later, a crew from CBS's 60 Minutes arrived (who would eventually profile the work of the NYC medics on the show) with cameras and a satellite phone. We finally called our families. On the last helicopter, the final member of our team arrived, along with our hundreds of pounds of supplies and medicine.

The next morning, the telephone between our two camps was restored, and we learned that the forward camp was out of supplies. No helicopters had come, and they were treating nearly a dozen patients who would die within hours. With the satellite phone, we alerted the military in Islamabad of the situation. Before noon that day, helicopters flew in to evacuate those patients.

As we hiked away from Sawan into the mountains, we saw that someone had painted, in English, the message 'Wel Come' on a pile of rubble. With the team all together and a satellite phone in hand, we advocated for the tens of thousands of people who'd been forgotten. In the following days, more helicopters flew overhead toward the forgotten valleys. Two field hospitals sprang up, and we were asked to identify villages where small medical teams like ours could deploy. Massive relief drops were occurring ahead. On the roads, we saw many of the patients we had seen only days earlier, coming back for follow-up care. The wounds were healing, but our time in Kashmir was running out.

The first moments after
massive disasters are too
precious to waste.

The day before we left, we heard that the villages in front of us had been taken care of and we could go home happy with our job. But as we waded toward the landing zone through the maze of ruined houses, through the scent of death and incense burned to hide it, through the wreckage and the stares of children, through the smiles and gifts of the people we'd helped, in the face of such annihilation, it was hard to feel good about leaving.

LESSONS LEARNED
Our team did many things wrong and many things right. We learned four key lessons from both.
1. Communication is a critical factor during a disaster. Not surprisingly, standard forms of communication fail. They failed on September 11, 2001, and they failed us in Pakistan.
2. Information needs to flow along well-established pathways-from small units that can see specific details to the person or persons in the best position to see the bigger picture. When this doesn't happen, wrong decisions are made and the neediest areas are forgotten. The neediest were forgotten in New Orleans and almost forgotten in Pakistan.
3. The first moments after massive disasters are too precious to waste. If there's no pre-existing plan, or it's clear that a plan will fail, everyone involved needs to communicate, coordinate and create a realistic plan based on the immediately identified needs and the immediately available resources.
4. An attitude of flexibility, creativity and collaboration is the single most critical factor for success. Ego and blame have no role in relief. Unfortunately, when things fall apart, blaming someone or something is easier than getting tasks done.