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This falling off of support is not surprising — 2005 was an uncommon year for disasters. The tsunami, famine in Niger, floods in Guatemala, three major hurricanes in the United States, and man-made disasters in such countries as Uganda and Sudan put enormous demands on the world's capacity and willingness to respond. In addition, more than six months have passed since the quake occurred. There are no more tales of dramatic rescue, televised scenes of devastation, or high-profile visits by politicians. Why should we be concerned with the ongoing relief and recovery efforts? For disaster-relief professionals, the answer is obvious: the scale of need remains enormous.
In addition to those who died, more than 76,000 people were injured, 2.8 million were left homeless, and 2.3 million have insecure access to food and other essentials. And the affected population is spread over 30,000 km2 in impoverished, mountainous, and difficult-to-reach areas. Once the bitterly cold winter set in, it became clear that the earthquake would continue taking its toll for months to come.
The first priority of rescue teams was, appropriately, rescue and the provision of emergency care for physical trauma. There was much early criticism of the Pakistani authorities, who struggled to deploy military aircraft and mule trains to remote mountain villages. International urban search-and-rescue teams arrived within days, but their heroic efforts probably saved relatively few lives: such interventions are generally responsible for only a small part of the public health effect of relief efforts after major disasters, since most survivors are rescued by community members in the first hours or days.1 Other international teams provided invaluable helicopter airlift to retrieve the injured and deliver aid to remote villages.
Pakistani authorities estimated that of 564 health facilities in the affected area, 291 (52 percent) were totally destroyed, including the district hospitals in Muzzafarabad and Mansehra, and an additional 74 (13 percent) were seriously damaged. Health-sector coordination meetings during the first two weeks, under United Nations leadership, focused on the reestablishment of hospital-based surgical care. The need for continual review of health-sector priorities prompted by the rapid evolution of public health threats was not initially recognized by some health officials. Overcrowding, poor sanitation, limited access to clean water, environmental exposure, and the widespread disruption of health care services quickly superseded surgical services as primary considerations.
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Despite the overwhelming needs, it is naive to rely on altruism alone as the basis for foreign assistance. When natural disasters occur in countries in which the United States believes it has a national-security interest, a strong case can be made for long-term involvement. The U.S. government, including its armed forces, has already made important contributions to the relief effort in Pakistan, as have many nongovernmental organizations based in the United States. The same was true in Indonesia after the tsunami, and polls have shown that U.S. assistance improved Indonesians' opinions about the United States.4 Many observers would consider continued contributions by the U.S. government to recovery efforts in Pakistan an appropriate demonstration of solidarity with an ally that has provided highly valued assistance in the search for Al Qaeda.
Many lessons may be learned from the earthquake and the response to it — the first response to a large international disaster in which the United Nations implemented its new "cluster" approach. This approach entails the identification of a lead agency within each sector to improve coordination among responding agencies, as well as the quality, consistency, and predictability of the relief effort. In Pakistan, 10 main cluster working groups were established, focusing on health, emergency shelter, water and sanitation, logistics, camp management, protection, food and nutrition, information technology and communications, education, and reconstruction. The approach had an uneven start, largely because of a general lack of understanding about the objectives, procedures, and responsibilities, as well as inconsistent leadership. A disaster of this scale warranted the deployment of lead-agency professionals trained not only in technical areas of expertise but also in the science and practice of disaster management and, especially, the art of coordination, the lack of which has been said to be a leading cause of death in disasters.5 Too many of the lead-agency coordinators in Pakistan appeared to be poorly equipped and lacking in the skills required to chair a meeting, set a strategy, and articulate priorities.
Fortunately, under the leadership of the World Health Organization, the Health Cluster Working Group in Geneva has initiated a process for training future sector leaders, with an emphasis on both technical and management skills. It is in the interest of all future victims that an "A team" be consistently deployed to manage large-scale disasters.
Source Information
Dr. Brennan is health director of the International Rescue Committee, New York. Dr. Waldman is a professor of clinical population and family health in the Program on Forced Migration and Health at the Mailman School of Public Health, Columbia University, New York.
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