NATIONAL HEALTH EMERGENCY PREPAREDNESS AND RESPONSE NETWORK (NHEPRN)

HEALTH ASSESSMENT OF HUNZA LAKE HAZARD

Mission members

Dr. Jehanzeb Khan Aurakzai, National Coordinator, NHEPRN Dr. Hendrikus Raaijmakers, EHA Coordinator Dr. Shelina Kiyani, Technical officer, NHEPRN Dr. Asim Niazi, NHEPRN Dr. Saleem‐ ud‐ Din, WHO surveillance officer, Polio, Gilgit ‐ Baltistan

Introduction

The National Disaster Management Authority requested the Ministry of Health to dispatch a team of medical experts to carry out immediate need assessment regarding provision of medical facilities to the affected population of Gilgit – Baltistan in upstream as well as downstream areas of Attabad Hunza landslide. An assessment team from the National Health Emergency Preparedness and Response Network (NHEPRN), Federal Ministry of Health and World Health Organisation therefore visited Gilgit and Hunza Nagar Districts from 27th to 30th May, 2010. . The mission carried out various activities including consultation and coordination with the Government authorities, assessment of health facilities and camps, analysis of the prevailing health situation and the capacity of the health department to cope with the current situation with the aim of identifying the gaps and emerging needs.

Consultation and Coordination

• Chief Secretary Gilgit Baltistan, Mr. Babar Yaqoob Fateh Mohammad • Chairman National Disaster Management Authority ,Lt. Gen (R) Nadeem Ahmed • Inspector General, Gilgit Baltistan ,Mr. Tahsin Anwar • Director Health Service, Gilgit,Baltistan : Dr. Ghulam Ali • District Health Officer, Gilgit,Dr. Ghulam Mehdi • District Health Officer, Hunza Nagar, Dr. Muhammad Iqbal • Health care providers and Camp managers • OCHA representative, Brig (R)Kamran Sharrif • General Coordination meetings with all stakeholders • Health cluster Coordination meetings

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Background

A massive landslide on January 4, 2010 resulted in the formation of an artificial lake in Hunza River at Attabad due to the blockade of the river by debris. The erosion of this debris could lead to collapse of the lake and the resultant water outburst poses a serious threat to a large area up to Diamir. International and national experts have estimated that 400 million cubic meters of water has accumulated in the lake. As per National Disaster Management Authority (NDMA) the height of the lake is 316 feet (approx 100meters) and its length has increased to 19 km This may result in severe consequences including affecting an estimated population of 50,000 individuals directly and 300,000 indirectly. Most of the population in the potentially affected area have been evacuated by the Government with the support of the Pakistan Army. Approximately 25,000 people upstream have been completely cut off from their major supply route threatening shortage of food and other necessities. Ayeenabad area is completely submerged and a substantial portion of the Karakoram Highway (silk route) has been destroyed. Evacuation of areas under potential threat is currently being carried out and all government offices and education institutions have been closed in Hunza Nagar district

Expected Scenario

The water has reached the brim and overflow has started. The Lake outburst is imminent and expected anytime. The resultant flash flood is anticipated to be in two waves, which may affect or damage more than 32 villages. This may destroy the communication lifelines including roads, bridges and electricity poles and will have a prolonged affect on the population. However, the Government of Gilgit – Baltistan in collaboration with NDMA and aid organisations are closely working on the preparedness and response capacities to mitigate the potential damage and loss of life.

Areas and Population affected

An estimated 25,000 people are stranded upstream and may remain isolated for the next one year without access to basic necessities including food, fuel, health and education supplies. The authorities are however looking into the possibility of ferry services across if part of the lake persists. As such, there is a need to strengthen the existing health services in the affected areas

3 to ensure accessibility of essential and life saving services. The areas where these services will particularly be required include Shimshal, Gulmit, Sost, Misgar and Reshit. In addition, around 20,000 people have been displaced downstream of which 12,000 are residing in IDP camps. The presently displaced population needs to be verified by NADRA and the process has commenced in Gilgit district.

Camp Assessment

Presently 26 camps have been established at Gilgit and Hunza Nagar district with a registered population of 12,802 by the Government of Giligit – Baltistan and humanitarian partners (both national and international). The camp population varies from 39 to 1695 individuals. The team visited three of these camps established at Nomal, Chillmisdas and Jutal. The summary of the findings of these camps is as given in the Dr. Aurakzai and Dr. Hendrikus with the camp manager in Jutal table below: Description Chillmisdas Nomal Jutal Date established 18/05/2010 18/05/2010 19/05/2010 Total Population 1698 (803M & 895F) 1615 Total Families 350 197 388 Health service provider DoH and PRCS PPHI PPHI Medicines Available but not all Sufficient Sufficient Clean Delivery kits Not available Not available Not available Sanitary Hygiene Kits Not available Not available Not available Health care providers Sufficient inc Female Sufficient inc Female Sufficient inc Female docs docs docs Services* OPD, MCH, Delivery, no OPD,IP, MCH, Delivery, OPD, MCH, Delivery, no nutrition, no EPI no nutrition, no EPI nutrition, no EPI Vaccination campaigns Measles Measles Measles Water availability Adequate Adequate Adequate Latrines 30(20 F & 10M) 40 (20F & 20M) 40 (26F & 14M) Sanitation conditions Acceptable Acceptable Acceptable Electricity Available Available Available *EPI services are available as outreach services (DoH and AKHSP)

The situation in the remaining camps is summarised in table below: District Camp No of HH Population Health service provider Gilgit Al‐Azhar Model College 221 1589 DoH/ PRCS Gilgit Al Karam Model School, Nomal 46 368 AKHSP

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Gilgit Polo Ground, Nomal 207 1695 PPHI Gilgit Govt High School, Rahimabad 70 352 DoH Gilgit Rahimabad Open 1 44 400 DoH/ AKHSP Gilgit Rahimabad Open 2 AKHSP Gilgit Rahimabad Open 3 DoH Gilgit Jaglote Goro 36 214 DoH Gilgit Jalalabad Girls High School 21 143 PPHI Gilgit G.B High school Oshkandass 24 172 PPHI Gilgit Majukal 1 Qasimabad 120 1060 DoH Gilgit Majukal II Sajadabad 77 632 DoH/ AKHSP Gilgit Jutal camp I 235 1245 PPHI Gilgit Jutal Camp 2 Hussainabad 97 776 PPHI Gilgit Jagote 34 275 PPHI Gilgit FG B Middle School Sultanabad 5 39 DoH Gilgit Chita Colony , Jutial 75 601 PPHI Gilgit Aminabad Nomal 45 360 Hunza Nagar Karimabad Girls College 60 483 DoH Hunza Nagar Altit 175 1400 DoH Hunza Nagar Hussainabad 38 300 PPHI Hunza Nagar Khanabad 40 320 PPHI Hunza Nagar Ghulmet 69 550 DoH Hunza Nagar Skindarabad 26 210 DoH Hunza Nagar Shishkant 57 456 DoH Hunza Nagar Mayoon 25 200 PPHI Gilgit Gojal Colony Helping Hand

It was generally concluded that the health services at the camps were at present sufficient although the following observations were made: ‐ Duplication of services at Chilmisdas and Chita colony ‐ Lack of Disease surveillance (DEWS) and health Information management ‐ Lack of sanitary hygiene kits and clean delivery kits ‐ Lack of Basic EmONC services. ‐ No systematic water quality monitoring system in place ‐ Inadequate referral mechanism ‐ Inappropriate Health care waste management

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Health facilities There are a total of 101 health facilities in the two districts, including 6 hospitals, 24 dispensaries, 1 Rural Health centre(RHC ) , 21 Mother Child health centres (MCHC)and 41 First Aid Posts(FAP) as summarised in the table below:

# Districts Hospitals Dispensary RHC BHU TBC MCHC FAP Total 1 Gilgit 3 11 0 2 2 10 26 54

2 Hunza Nagar 3 13 1 2 2 11 15 47 Total 6 24 1 4 4 21 41 101 Source: Department of Health, Gilgit – Baltistan

The current situation has isolated the Health facilities in Gilgit & Hunza Nagar health facilities above the lake in the Hunza Nagar district from those downstream. The health facilities in the upstream area have no access to supplies unless airlifted. These health facilities require to be strengthened as they will be catering for the cut off population in this area. These facilities include Civil Hospital Gulmit Gojal, FAP Golkin, , FAP Markur, FAP Sost, CD Sost, CD Shimshal, CD Paso, CD Khyber, CD Misger, CD Kirmin and CD Shishkant. As part of the response from the Department of Health, Gilgit Baltistan , Bahria town and Government of Punjab, health care providers have been sent to these health facilities to ensure the provision of essential services. This includes Gynaecologist, Paediatricians, Surgeons, Medical officers and other paramedical staff. Furthermore PPHI and AKHSP are also providing basic health and MCH services respectively. Furthermore, there are a number of health facilities which are downstream. These facilities include, CH Nagar Proper, CH Karimabad , CH Aliabad, CH Gulmit Nagar, CH Juglot , CH Sassi ,CH Danyore, AKHSP FHC, Aliabad, RHC Chalt , BHU Hoper, BHU Khanabad , BHU Nomal , BHU Jalalabad , CD Askardus and CD Sikanderbad.(CH‐ Civil Hospital, BHU‐ Basic Health Unit, CD – Civil Dispensary) There is currently no acute shortage of medicines at most of the health facilities and the Department has sufficient stocks for atleast another month to cater for the needs of the health facilities.

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A total of 6 health facilities have been assessed both upstream and downstream including DHQ Hospital, CH Gulmit Gojal, CH Juglote , BHU Nomal, BHU Jalalabad and CD Danyore .These health facilities were prioritised for the assessment due to their strategic positioning for the patients both in camps and proximity to the host communities.

Findings: 1. District Headquarter Hospital, Gilgit a. Acts as a referral hospital for Gilgit, Ghizer, Astore & Diamer / Chilas. b. 256 bedded hospital with most of the services available including blood transfusion, dental and laboratory services. c. Average consultations / day : 850 to 1000 d. Limited radiology services with no Computer Tomography (CT) or Magnetic Resonance Imaging (MRI) services. e. Essential human resource including specialists (Gynaecologist, Surgeons, Paediatricians, Physicians, Pathologist, Radiologist etc). f. Medicine stock sufficient until the next financial year. g. Ambulance services available 2. City Hospital, Gilgit a. 50 Bedded hospital with functional infrastructure b. Specialists including Doctor at PPHI facility in Jutal Camp gynaecologist, physician, surgeon, paediatrician, orthopaedic surgeon. In addition 10 medical officers and 4 female medical officers available. Ancillary staff including paramedics are available. c. Average number of patients seen is 100 to 200 per day d. Not all medicines from the Essential Drug List are available e. Most essential equipment are available f. No laboratory services and no surgical services g. Ambulance services available 3. Civil Hospital Gulmit Gojal a. 10bedded hospital b. The infrastructure of the hospital is new and intact.

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c. The local staff available include paramedics and were initially supported by a team from Punjab but now the facility is being supported by the medical team from Bahria town d. Sufficient medicines and supplies available e. Lack of equipment f. Ambulance services available 4. Civil Hospital Juglote a. 10 bedded hospital b. Male and female medical officers with paramedic staff, no specialists available c. Medicines available but not all from the EDL d. Most essential equipment available e. All basic services available, no surgical and blood transfusion services available 5. Basic Health Unit Nomal a. Managed by PPHI b. Average consultation/ day 30 to 50 c. Male medical officer, LHV and Dispenser available d. Essential equipment available e. Not all EDL medicines available f. No ambulance services 6. Basic Health Unit Jalalabad a. All essential PHC services available b. Average consultation/ day 80 to 100 c. One medical officer and one Lady Health visitor d. Most essential medicines and equipment available e. No ambulance services 7. Civil Dispensary Danyore a. One Lady health visitor and Dispenser b. Average consultation/ day 15 to 20 c. Not all EDL medicines available and not sufficient equipment d. Only OPD, ANC/PNC & FP services available no EPI services. e. No ambulance services

Disease burden The common diseases in the area as reported by the Department of Health and noted during the assessment include Acute Respiratory Infections, Dysentery, Diarrhoea, Tuberculosis, Hepatitis, Enteric Fever, Accidents, Ischemic Heart Disease, Iron Deficiency Anaemia, Iodine Deficiency Disorders and Trachoma

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The camps are reporting sporadic cases of acute watery diarrhoea and therefore an urgent need to set up the Disease Early Warning System. (DEWS) Response

1. Coordination • Participation in the General Coordination Meeting (GCM) by National Health Emergency Preparedness and Response Network(NHEPRN), Federal Ministry of Health, Department of Health Gilgit – Baltistan and World Health Organization in the to ensure inter‐ sectoral coordination. These meeting were chaired by the Chairman NDMA, the latest situation was discussed and each of the sectors shared their updates including Health. • Introduction to the Health Cluster approach in the Province. Health sector meetings were being conducted but the cluster approach was initiated on the 29th May, 2010. • The concept of Health Emergency Preparedness and Response network was also introduced and its importance in the effectiveness of any response highlighted. • Establishment of the GBHEPRU (Gilgit ‐ Baltistan Health Emergency Preparedness and Response Unit)with the Director Health Services as the Provincial coordinator • Coordination Meetings with Chairman NDMA, Chief Secretary, Director Health services, District Health officers (Giligit and Hunza Nagar)

• Mapping of the partners and W3 matrix is being undertaken 2. Assessments • A rapid assessment to identify the needs of the two affected districts. • Capacity assessment of the local authorities and partners to cope with the current situation • Comprehensive health facility assessment carried out by the NHEPRN, Federal MoH in collaboration with WHO. • A total of 6 health facilities have been assessed both upstream and downstream including DHQ Hospital, CH Gulmit Gojal, , CH Juglote , BHU Nomal, BHU Jalalabad and CD Danyore • Assessment of the health situation in the 26 IDP camps including water and sanitation situation 3. Disease surveillance and Early warning system • Introduction and notification of the DEWS reporting system to all the health facilities and camps by NHEPRN/ GBHEPRU 4. Provision of Essential Health services

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• Provision of health services in the health facilities and camps by the DoH and various partners. • Most of the health facilities are managed either by DoH or PPHI • Maternal and Child health services and Immunisation services provided through Family health clinics of Aga Khan Health Services 5. Provision of Essential Medicines and Equipment • World Health Organisation has provided 6 Mini Emergency Health kits1 & one Cholera Kit2 to the Department of Health • UNICEF has provided 2 Interagency Emergency Health Kit3 & Measles vaccination support to Department of Health, so far 1483 children vaccinated (793 male, 690 female). Cash has also been provided by UNICEF to support immunization and health promotion activities. • Provision of 1500 Sanitary Hygiene Kit4 provided by NHEPRN in collaboration with UNFPA • Provision of 1000 clean delivery kits5 and 2 MCH kits by NHEPRN in collaboration with WHO. Plans and Way forward

1. Coordination ƒ Strengthening (capacity building) of the GBHEPRU ƒ Coordination of all the health related activities in the two districts ƒ Implementation of the health cluster approach ƒ Participation in the General Coordination Meetings ƒ Mapping of all the health partners (W3 Matrix) ƒ Reduce gaps and duplication 2. Assessments and Monitoring ƒ Complete assessment of all the health facilities in the district ƒ Ensure that all health facilities have adequate stocks of medicines ƒ Monitor the situation in all the health facilities in regards to equipment, human resource and medicines ƒ Periodic assessment by NHEPRN and WHO 3. Disease surveillance ƒ NHEPRN in collaboration with WHO to deploy a disease surveillance expert to extend DEWS in the two districts including training of the health care providers on reporting and active case finding. ƒ Establishment of an Epidemic Investigation cell in the Province for the Disease Early Warning System (DEWS). ƒ Develop SOPs for possible disease outbreaks 4. Provision of Essential Health services

1 One MEHK is for 6000 population for one month 2 One Cholera kit is for 100 severe dehydration cases and 600 mild to moderate cases. 3One Inter Agency Health Kit is sufficient for 10,000 population for three months 4 For 3 months for each woman in reproductive age 5 Ensuring 1000 safe deliveries

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ƒ Ensure provision of essential health services according to the basic minimal standards for provision of services in Emergencies including MNCH/ RH/FP and EPI services. ƒ Strengthen the referral mechanism in the two districts and design the referral mechanisms including ensuring the accessibility to ambulances services ƒ Availability of volunteer medical teams from PIMS on standby arrangement to be deployed when and where required. Each team comprises of a Gynaecologist, Paediatrician, Surgeon, male and female medical officers, two nurses and a dispenser. ƒ A need to establish at least one Diarrhoea Treatment Centre (DTC) upstream and downstream 5. Water, Sanitation and Hygiene ƒ Emphasis on inter cluster coordination with the WASH cluster ƒ Inter‐sectoral coordination (Ministry of Power and Development) and other partners to ensure the provision of adequate and appropriate water and sanitation facilities. ƒ Water quality monitoring to be carried out to ensure that the water provided is fit for human consumption ƒ Enhance the availability of sanitation facilities/ latrines as per the sphere standards. ƒ Ensure that all camps have Health and Hygiene corners ƒ Mobilise community health workers for health and hygiene promotion campaigns ƒ Provision of health and hygiene health messages through pamphlets, posters and radio messages 6. Provision of Essential Medicines and Equipment ƒ The current stocks of medicine in the district is available for month, for contingency purposes need to provide medicines for at least the next three months ƒ Ensure appropriate storage and rational use of essential medicines ƒ Gaps in equipment and medicines may be filled in coordination with the health partners 7. Psychosocial support and Mental Health services • Provision of psychosocial support for the three populations categories , those affected by the lake formation, those that have been isolated from the rest and those displaced and living in IDP camps Challenges

ƒ Capacity of the Department of Health: Especially District Health Officer Hunza Nagar who has no staff, running costs etc ƒ Lack of appropriate infrastructure and human resource at the health facilities ƒ Accessibility to the upstream population ƒ Communication : email / telephone networks

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