Interview with WHO country head, Khalif Bile Mohamud

Pakistan's healthcare system took a direct hit in this month's devastating earthquake in Pakistan's North West Frontier Province (NWFP) and Pakistan-administered Kashmir, which killed over 53,000 and injured thousands more. In a comprehensive interview with IRIN, country head for the World Health Organization (WHO) in Pakistan, Dr Khalif Bile Mohamud, offered his insight into the disaster. QUESTION: In terms of the health sector, what is your assessment of the situation on the ground? ANSWER: With an estimated 80 percent damage of the total infrastructure in the earthquake-affected areas, the health sector has been equally affected. Of the 564 health facilities in the eight affected districts, 291 (52 percent) have been totally destroyed, while 199 (31 percent) are still functional. Of all hospitals, 41 percent have been completely destroyed. In comparison, 99 percent of all first aid posts have been devastated. With the overwhelming number of injured (an estimated total of 72,000) the burden on the remaining health facilities is enormous. Thanks to the arrival of over 50 temporary field hospitals and mobile teams mobilised by numerous countries and international NGOs and the large number of hospital-based and rural medical teams organised jointly by the Ministry of Health and the WHO, the capacity to treat the injured has increased significantly. One of the main priorities two weeks after the earthquake is the strengthening of the severely weakened human resources capacity of the health sector. Although estimates of the total number of health staff that have died in the quake are still awaited, it is clear that the impact on the health sector is vast. Although many health workers have experienced losses of their homes and family members, the majority have already reported back to work. The solidarity among the affected population is extremely generous. The number of medical doctors who have voluntarily come to support their colleagues in the affected areas is another example of the existing solidarity within Pakistan as a nation. The Ministry of Health (MoH) and the WHO have mobilised over 200 medical doctors, surgeons and health workers from all over Pakistan to support the health sector, including remote areas only accessible by helicopter. Q: What is your prognosis for that infrastructure's recovery? A: According to estimates by the MoH, the reconstruction and rehabilitation of the health system will cost US $651 million. This includes the reconstruction of hospitals and rural health centres (RHC), provision of medical equipment and ambulances; restoring laboratory systems, blood banks, and nursing schools; and manufacturing artificial limbs. Thorough assessments of the damage and needs of the health system will be carried out before initiating the rehabilitation activities, which could take years before being completely restored in permanent facilities. However, the WHO will support temporary tented or pre-fabricated structures to replace urgently needed district level hospitals and first-level care facilities as soon as possible. Q: Logistically speaking, how are you coping with what undoubtedly must be one of the most challenging humanitarian efforts ever? A: Thanks to generous donations and the possibility of procurement of essential necessities on the local market, there is at present no shortage of medicine or any other medical supplies. Indeed, the challenge is to provide the supplies that are pre-positioned in Islamabad to the affected areas. Logistics operations in disaster response situations have a dual function. One is obviously the efficient management of incoming humanitarian supplies to the most affected areas. Another important area is transparency and information exchange towards donors on where the donated goods have been distributed for continuous donor support and trust. The WHO/United Nations humanitarian supply management system, i.e. the Logistics Support System (LSS), is currently being implemented for the health sector. LSS registers all incoming donations and monitors their distribution to warehouses in the affected areas. The software system enables information exchange between disaster response organisations and enhances transparency and efficiency in humanitarian logistics coordination. In order to avoid duplication of efforts and improve coordination, information regarding all health-related activities needs to be shared with the MoH. In view of the approaching winter, field-level warehouse facilities (five hubs) are being established to preposition essential supplies and equipment to facilitate their immediate use. Q: On the health front, what are your primary concerns and why? A: Because of the winter approaching quickly and temperatures at night going below zero, the main concern at present is the lack of proper shelter (tents and blankets) for the affected population. Cold exposure reduces defence against respiratory infections and hypothermia is deadly for infants and the elderly. Thanks to the fact that Pakistan has an important tent-manufacturing industry, the initial provision of tents was addressed efficiently. In view of the large number of people who have lost their homes, the amount of tents available remains insufficient. In addition to the expected local production of 200,000 tents by mid-November, the UN agencies and NGOs have appealed to the international community for a rapid mobilisation of more tents. With the majority of the health system collapsed and numerous NGOs coming to temporarily provide emergency medical aid and basic healthcare, the WHO aims to assist the government in streamlining the provision of primary healthcare services in all the areas, so as to ensure continuity in the provision of basic healthcare in the earthquake-affected areas. Lack of safe drinking water has been a concern and several NGOs have installed water purification plants while the WHO is monitoring environmental health at the major sites and training national sanitation officers to take over this work. The WHO is assisting in the promotion of general hygiene education, solid waste disposal and hospital/health facility level water supply and sanitation. A lack of water for washing at community level is currently creating problems with skin diseases such as scabies presenting at all health centres in the affected areas. The WHO is providing health and hygiene messages on the radio, partnering with other agencies on provision of soap, and supporting government facilities and mobile teams with medications to answer the need. The mental health consequences of the population having experienced the stress of an earthquake, and the loss of many beloved ones, are tremendous. In addition, severely traumatised earthquake survivors are continuously being confronted with their losses as the disposal of the dead bodies still covered under the rubble is an extremely slow process. Further daily recurrence of tremors and aftershocks (about 900 since 8 October) are also worrisome for the people. Sustained emotional reactions, not timely treated, may handicap the recovery and rehabilitation. The WHO wishes to emphasise that dead bodies do not transmit diseases. According to ICRC (International Committee for Red Cross and Red Crescent Societies) and WHO international guidelines, all dead bodies should be identified before burial so as to enable family members to adequately cope with the loss of their beloved ones and settle their affairs. ICRC will provide additional refrigeration for dead bodies, to enable identification of all deceased by their family members. Burial of the deceased earthquake victims should be at a distance of at least 1.5 metres of any water source. As the odour spread by those dead bodies still covered under the rubble is becoming more unbearable with time passing, spraying with chlorine solution or bleach has been widely implemented by the MoH. The Ministry of Health and WHO are disseminating these and other health promotion messages on the importance of hygiene through FM radio, banners, leaflets and brochures to the affected population. Q: Following the earthquake of 8 October, how did the WHO respond and what is it doing now? A: The WHO's role in the response to the earthquake disaster affecting Pakistan at this point in time, is to support the Ministry of Health by providing technical advice and coordination of the "health cluster" that brings together all the health relief partners, by assisting the MoH in health relief delivery and in improving the quality and access to healthcare services by the disaster-affected population. Technical issues such as environmental health, disease control, mental health and management of medical and other supplies are crucial. Almost two weeks after the earthquake, it is expected that relief assistance will continue for a period of at least six months. Rehabilitation and recovery of the health sector are foreseen to take years, but are already addressed as key priorities. According to estimates by the MoH, more than 65,000 have been injured by the earthquake, requiring immediate medical treatment. The collapsed health facilities in the affected areas, as well as the difficult accessibility by road and air, are posing a challenge to all medical and surgical teams mobilised to the affected areas, as well as those hospitals in Islamabad and Rawalpindi receiving over 18,000 patients from the earthquake affected areas. The first collaborative action undertaken by the MoH and the WHO was the establishment of a joint Health Emergency Operation Centre (EOC) at the Pakistan Institute of Medical Sciences (PIMS), the main hospital in Islamabad. The centre aims to coordinate health actions among all governmental organisations, UN agencies, donors, and NGOs. A clear picture of the magnitude of the earthquake and the required response could be drawn and an additional 250 national public health and medical experts were mobilised by the MoH and the WHO to strengthen the seriously weakened human resources capacity for all health-related activities. These were deployed in teams of five persons to provide minor surgical and primary healthcare in the area of destroyed rural health facilities. The WHO has mobilised more than 50 kits, including surgical and trauma kits and New Emergency Health Kits to supply the mobile teams and health facilities re-establishing services. Two weeks after the earthquake, the WHO has mobilised experts to field offices in five of the most affected locations: Mansehra Balakot, Muzaffarabad, Bagh and Rawalakot. The WHO presence in the field has been appreciated by health partners for their efforts at organising airlifts, daily meetings to share surveillance information and providing key health information on the health status and needs of the affected population. The WHO's main activities are divided in the following technical areas: Disease surveillance and control; environmental health; DEWS vaccination against measles and tetanus; primary care, hospital referral, and mental health. Q: Reportedly there have been no disease outbreaks in the affected areas, but the risk remains very real. Can you update us on those risks and what you are doing to mitigate them? A: All health partners who are providing treatment and care to the affected have been sharing information on the number and type of cases treated, as well and deaths, as part of the active sentinel communicable disease surveillance system. A rapid flow of information on disease patterns will enable the WHO to rapidly respond to and control any outbreak, such as measles, meningitis, acute watery diarrhoea and acute respiratory infections. A total of 106 cases of tetanus and 22 related deaths have been reported so far. In other emergencies it has been documented that about 3 percent of earthquake injuries are susceptible to develop tetanus, especially in situations where wounds are left untreated for an extended period of time. The Pakistan Ministry of Health received more than 15,000 doses of anti-tetanus globulin (ATG) channelled through the WHO and donated by the United Kingdom, United States and Canada. UNICEF has also procured ATG from India. In Battagram district of NWFP, 13 cases of measles and one death were reported, and measles vaccination of all children six months to 15 years is now ongoing in the area. In Bagh district of Pakistan-administered Kashmir, one case of suspected hemorrhagic fever was identified. The WHO sent a team of international level epidemiologists to investigate the case and potential risk factors. Blood samples were drawn from the index case and close contacts and the patient was brought by helicopter to Islamabad for further investigation and treatment. All WHO offices are briefing the health agencies working in the affected area about the guidelines and precautions in management and control of Congo Crimean hemorrhagic fever. Q: There are reportedly many pockets of people or communities that have still not been reached. What specifically is the WHO doing to address the health needs of these people? A: Due to the large extent of damage to the road infrastructure, those areas that have become inaccessible by road can only be reached by foot or by helicopter. Slowly, thanks to gigantic efforts of the Pakistan authorities, the Ministry of Health and many NGOs, inaccessible areas are now being reached by medical and other health teams. With the winter approaching, the need for shelter is the main priority. The entire UN system and all NGOs providing aid to the affected communities are doing their utmost to get sufficient tents and blankets to all of the population in need of appropriate shelter. Also winter snows will close most of the roads in about three weeks. The bulk of supplies needed for the next three to six months should be pre-positioned close to the population centres as soon as possible. Q: Given the devastating blow this has had on the health sector in both affected regions, what are your primary needs at the moment? Do you have the material, resources and staff you need at this point? A: The WHO strategy to respond to the crisis, in close collaboration with the Ministry of Health, is continuously adapting to the changing situation. Thanks to a vast experience with health response in all kinds of natural disasters, including earthquakes, the WHO is well prepared for the task to ensure most health needs are met and the main health risks are avoided. Reactivation of PHC first-level care facilities and community-based interventions will have the greatest priority. Q: Donors have been slow to respond to this crisis. As a health expert on the ground, what message do you have for them? A: Through the mechanism of the UN flash appeal, the health sector is seeking tangible funding. With time passing quickly and the winter approaching, acceleration of the relief response will be critical to the success of these interventions.