Pakistan Flood Relief: Field Notes from Doctors to District Khairpur – Day 1

Dr. Nighat Shah’s brief about our trip:

Khairpur at this moment is housing huge bulk of displaced people from Larkana, Jacobabad, Shikarpur, and many smaller villages like thul, ghouspur etc. The registered displaced people are more than 50,000. Around 120 camps are housing people in small clusters. These range from 250-300 people in smaller schools to 5000-8000 in bigger schools.

In all camps, the majority is of children and the  statistics are mind boggling! In a camp at Ghari Mori, district Khairpur,  housing 280 people, there were 44 men, 67 women and 169 children. Almost all children are sick, ranging from stunted growth, severe malnourishment, diarrhoea and skin problems. Almost all women are anemic, weak, malnourished, perpetually pregnant or breast feeding, and the sad part is that there is no milk but the baby is still latched, always! More than 20-25 percent are pregnant.

Brief review of our activities- Day 1

As a team comprising of a retired pediatrician (working at SOS villages), a local gynecologist / obstetrician, 2 soon to be graduates from AKU and I, a recent Masters in Public Health graduate from Harvard and an instructor in the Dept. of General Surgery, AKU, Karachi, visited displaced peoples camps in District Khairpur.

We left around 7 a.m. for the visit but worked early in the morning to organize the medicines available in boxes so prescription would be faster. The hospitality of our hosts is of tremendous. I had to have two cups of tea in the morning (that is more than I drink in a year :-). They do not let you work until you are well provided for and do not stop asking you to drink up and eat up.

Our first stop was the APWA school where around 400 people mostly from Thul are housed. It was nice to see displaced people having shelter from rain and the hot weather and a place to rest. The schools have lots of open space so the camps are not very congested. However, this is coming at the cost of education of the local children. Schools are closed.

I hope alternate efforts are planned – The IDPs are not suiting the schools well and the furniture and facilities are taking a toll.

There were no toilet facilities available – the school’s toilet was clogged so the openess of the grounds was being used as a substitute. Upon inquiry we found out that sanitation work is underway and they just havent reached this school yet. Yes, we saw pit latreens in all of the other places we visited today.

It was also nice to see that handpumps were being constructed – almost all of the camps we visited had them. How potable that water is something requiring thought. We plan on taking a few samples with us back to khi to be tested – we have to keep in mind the arsenic incident in Bangladesh.

But atleast that water is fit for washing and showering and we did see lots of showering as we went along. The problem was the choice of place to construct the hand pump – it was not rare to see water having standing on the ground. No drainage was thought of while contructing these – we provided these observations to authorities who instructed those planting these pumps to do something about the standing water. Standing water is an issue that needs to be taken care of urgently.

This camp was clean, the headmistress was paying the kids to clean up – but the garbage was being collected at one place in a heap – no city truck ever came to take this away – and as is the garbage disposal system of most of Pakistan – this garbage was scheduled to be burnt.

As mentioned before – problems are not only due to the flood – but the baseline itself is a low health state.

We divided ourself in two teams and began seeing all kinds of patients – women , children and men. I was surprised to see that even the men were so anemic – women and children always are, this is the first time I saw such a high proportion of men being anemic. Gastroenteritis, skin conditions (scabies, impitigo, fungals) were expectedly quite common. There was high volume of URTI and LRTI prescriptions were mostly, amox, cipro, ORS, vitamins, benzylbenzoate, FeSO4. However, a feeling of helplessness was frequently encountered when we encounter patients with epilepsy, angina, Colon Ca (most likely), Nephrotic (most likely), Hypertension.

What does one do about these patients in a camp? we tried sending them to hospitals but common complaints were,

‘they prescribe meds that we cannot afford’, ‘ we cannot affort tests’, ‘doctors are never available’, ‘doctors do not treat us’.

Some of these complaints are not appropriate. Many had cannulas in their hands, meaning they were going to hospitals regularly and receiving IV fluids – sent back to the camps for the night to return the next day (not an ideal way to deal with things – but a good way to deal with the high volume of patients and lack of resources).

The teachers of the school were a huge force – educated women who understood and spoke Urdu. They were coming  everyday on duty, however, they were not doing much. We encouraged them to teach the children running about (atleast teach poems etc.) We encouraged them enforce handwashing, general hygeine and cleanliness. They are definitely a force to be utilized in the right way – dispensing ORS and maybe vaccination?

Of mention is a vaccinator who was idly sitting at the school. We asked her to administer polio to all children and TT to all pregnant women (she actually had those vaccines), but her reply was, ‘but they are pregnant’ to the TT request. We explained to her what she can do – her response was ‘acha’. I hope she does some vaccinations tomorrow (she needs to bring the shots from storage).

Our next stop was Salimabad.

The condition there was terrible. Almost 50% of the displaced people there had watery diarrhea. We sent two patients immediately to the hospital in our ambulance. In one of the rooms was a dead body of a 20 year old female who died of watery stools. She had died in the morning. They were around 250  people and had been staying there for 10 days. What is this besides cholera?

I certainly fear more deaths will occur here.

Our treatment was based on IMCI – ciproflox for 3 days and ORS.

We immediately got them to fill three water coolers (half of what they had) and filled these with ORS. We adviced everyone with diarrhea to immediately drink plenty from those coolers. ORS is life saving in these situations! Handwashing with soap was emphasized. We heard of another neonatal death in another one of the camps. Of note: In this camp there was no one incharge – these people were just brought here and left on their own – there was no one there to look after them, but it seems like they were supplied with water and food. There were pit latrines made by UNICEF, however, feces was piled in these pit latrines. The people of camp said that someone used to come everyday to maintain this latrines but after a ‘foreigner’ came and looked at them no one has come back even once. The last visit was 5 days ago.

An appeal to those deploying the pit latrins. Please educate people on how to use them and maintain them – the latrines are really good and are an amazing help but that benefit is severely stunted if feces is lying open to the millions of flies buzzing around.

From there on we went from camp to camp repeating the same. Taking a look at water sanitation and hygeine and seeing if we could do something, treating patients, educating on handwashing with soap and improving health and hygiene awareness. We have brought soap with us and will be distributing it tomorrow. We understood the issue of intestinal worms is an endemic problem , however we had no medicines for that purpose. Instead of asking about we thought we would buy Albendazole and give stat doses to everyone we enounter. We aim to deworm all camps.

Many organizations are setting up medical camps in various camps – we faced a bit of disorganization today and some time was wasted in looking for camps without doctors. We are meeting with the EDO health tonight and hope to resolve this issue and make full use of available resources

What is needed:

• ORS, Amoxcillin, Vit B complex, scabies and deworming medicines.
• Water jugs and utensilts to make ORS in  (cant put it in the hand pump).

Education material

• pictographs of flies sitting on feces and going and sitting on hands and food.
• benefits of handwashing (pictographs).

Health and Hygiene workers (more important than doctors at the moment.)

• They must be sindhi speaking
• LHWs, medical students, nurses, doctors  (any educated person with a bit of training)
• Need to promote and ensure hand washing with soap (provision of soap)
• availability of ORS (made – not only powder) and education to use it in case of diarrhea. As expected we got the sense that people were not satisfied with just ORS – they need to be explained the benefits of this and encouraged to NOT DELAY ORS. Cholera is a killer and it has already begun.
• getting rid of stagnant water

Note: there is not much need of doctors in the camps at the moment. But local hospitals are understaffed and in need of trained personnel and equipment. There are many many lessons to be learnt from Bangladesh. We should make use of the experience, expertise and material available there.

Food was not a problem in the camps we visited today. Although they found the food too spicy.

But there are a number of people in tents (not schools). They crowded around us expecting food. They had been left there with no one to supervise them. The local government is extending us great support and we also crossed paths with high officials in the field a number of times who were doing visits and trying to solve the numerous problems.

Signing out for today

Syed Nabeel Zafar

MBBS, MPH
Instructor (Research)
Department of General Surgery
Aga Khan University.