Pakistan: MSF Expands Emergency Response Into New Flood Zones

Pakistan 2010 © Jean-Marc Jacobs/MSF

MSF water distribution point in Khyber Pakhtunkhwa province.

More than five weeks after flooding began to overwhelm Pakistan's northern regions, Doctors Without Borders/Médecins Sans Frontières (MSF) emergency medical and water and sanitation teams are continuing to work in the north while also expanding operations to the southern provinces of Punjab and Sindh, where millions of people have been displaced by additional floods.

The prevailing concerns are the spread of waterborne diseases, malnutrition, and the lack of shelter and clean, safe water. Teams are rushing to establish new bases in the southern towns of Hyderabad and Sukkur, part of the effort to access flood-affected communities on either side of the Indus River. MSF is focusing on the water supply, shelter for the displaced, medical care for dehydration and acute watery diarrhea, and the distribution of essential non-food items (NFI).

SINDH PROVINCE

Sukkur

Officials report more than 4.5 million people displaced in Sindh province alone, including those who left their homes during mass evacuations of regional centers last week. MSF is planning further assessments to identify pockets of vulnerable people.

In Sukkur, in northern Sindh, MSF has been operational for four weeks, providing support to the intensive therapeutic feeding center (ITFC) ward of the Railway Hospital. The ITFC provides treatment for severely malnourished children under the age of five who have medical complications. Thirty children were admitted to the ITFC in the first five days it was open. MSF is conducting two nutrition-focused mobile clinics in surrounding areas and camps and distributing NFIs and hygiene kits. Work on Sukkur’s water plant has been completed, and now 80,000 liters of water are being distributed per day.

Last week, 110 consultations were completed in mobile clinics in a displacement camp in Sukkur and 24 of those patients were admitted to Railway Hospital with serious medical conditions. Oral rehydration therapy for diarrhea and dehydration was provided to 1,247 patients, and 2,561 people received health education in camps and at the hospital throughout the week.

NFI distributions also took place last week outside Sukkur. The result was that 265 tents, 453 hygiene kits, 539 cooking sets, 539 tarpaulins, and 539 jerry cans were handed out in the following locations: Sukkur Old Airport Road, Shara-e-Abassi Sukkur, C-Government High School, and C-Government College Pir Illahi Bux.

Hyderabad & Jamshoro

In southern Sindh, MSF has set up a base in the town of Jamshoro on the western side of the Indus River, near Hyderabad. MSF started up its activities in the area this week after identifying pockets of displaced people on both sides of the Indus who had received almost no assistance to date.

The main focus is the water situation; the aim is to provide five liters per day per person. On August 27, MSF distributed 30 cubic meters of chlorinated water in Jamshoro town. In the three days that followed, MSF’s distribution capacity grew to 180 cubic meters per day in six locations serving approximately 10,000 people.

Pakistan 2010 © Jean-Marc Jacobs/MSF

An MSF water bladder that was set up in Mingora.

Also this past week, mobile clinics were conducting 130 consultations a day per site. An additional 500 tents were ordered for NFI distributions that will begin this week and that will target between 5,000 and 10,000 families.

Going north along the western bank of the Indus, MSF located more than 10,150 people living without shelter and at least seven small pockets of displaced people living by the side of the road. Only one of these groups had received any assistance. Shelter is clearly a high priority—people are struggling just to find shade—along with access to clean water and medical services.

Approximately 50 percent to 70 percent of the villages MSF has encountered have been evacuated with the displaced populations taking up residence in camps. Some residents, however, have gotten little assistance and have very limited access to drinkable water or medical care. It seems clear that resettlement will take quite some time due to flood damage. Nonetheless, MSF has been able to identify abandoned structures in flooded districts that could potentially serve as locations for a diarrhea treatment center (DTC) if needed.

Around Jamshoro, there are two types of displaced people: those who’ve moved to relocation centers and those who are living out in the open. Four relocation centers are currently located inside government high schools, in extremely unhygienic conditions similar to those seen in northern Sindh. These centers have received some assistance, but MSF intends to monitor them and to provide hygiene kits if necessary. Clean water supply might be an issue in coming weeks as well.

There are several sites around Jamshoro where people are living out in the open. One is near a university medical college, where approximately 2,000 people from as far away as Jacobabad and Baluchistan province are gathered for the time being. Relief teams from the university are already providing food, water, and health care. There are other camps around Jamshoro, however, where needs remain high and tension exists amongst a population frequently desperate for help.

In Hyderabad, one main camp has been identified, the New Sabzi Mandi camp, where approximately 10,000 people have settled. Local organizations have already responded, so it remains to be seen whether MSF needs to support their efforts.

South of Jamshoro, on the road headed towards Karachi along the west side of the river, a large displaced population is staying in the Khuda Ki Basti Colony, a huge compound with around 300 blocks with four houses on each of them. The complex is completely occupied by approximately 6,000 to 8,000 displaced people, but sanitation and hygiene are poor. Two other tent camps are nearby, each with a population of approximately 1,000 people.

BALUCHISTAN PROVINCE

Nasirabad & Dera Murad Jamali

In Dera Murad Jamali (DMJ) in Nasirabad district, MSF continues to operate a DTC that had 46 admissions on August 28 alone. More information is also coming in about additional flooded towns and villages—places like Tambu and Babhakot—where people remain stranded.

More reports are likewise coming in about diarrhea-related deaths in displacement camps near DMJ such as Pat Feeder Canal, Degree College, Notal, and Model College camps. Clean water is still a major problem in DMJ and non-MSF tankers continue to supply water that is below emergency standards. MSF will not start distributing water until it is allowed to purify water sources first.

Pakistan 2010 © Ton Koene

MSF staff tending to a patient in Nowshera.

MSF is conducting several mobile clinics in the area and carried out 1,047 consultations in the past week. The mobile clinics are treating cases of acute watery diarrhea, skin infections, and malnutrition and distributing supplies for women. Malnourished children are being given a seven-day supply of ready-to-use therapeutic food (RUTF) and get follow up consultations a week later.

In the coming week, MSF mobile clinics will focus more on nutrition, antenatal care, and lactating women. Forty new cases of severe acute malnutrition were recorded in the past week in DMJ. Ten were referred to the hospital ITFC and 30 were tended to in the mobile clinic, along with 23 follow-up cases from the prior week.

MSF believes it can more effectively address morbidity through a more focused approach to nutrition in its mobile clinics. Pregnant women will also be offered limited antenatal care (including ferfol, albendazole, and a safe delivery kit) and supplemented with BP5 high energy biscuits.

In the meantime, following negotiations with local authorities, MSF should soon sign a contract to build 250 latrines in the same camp. MSF also plans to build more than 125 latrines and a 15 cubic meter water bladder for the 2,500 displaced people in Barchoki, in the Mangoli Camp, as soon as our tanker arrives and we produce enough water from the water plant.

There is currently one small filter plant In Mangoli Camp that has a capacity of about 300 liters per hour and can run for 12 hours a day. Three deaths related to diarrhea have been reported in this camp over the past week. Health educators have been dispatched in camps around town and soap will be distributed starting this week.

MSF tested and treated the water tank in DMJ last week; it was found to be acceptable and thus all tankers were re-rerouted to it on August 28. During the past week, 265 tents were distributed and the MSF team employed 20 day laborers to pitch 150 tents at the Degree College. The water and sanitation team will also provide 30 latrines and ensure water is delivered to the site as soon as possible.

Since the intervention in DMJ began on August 10, MSF has carried out 5,117 consultations, distributed packets of 100 aqua tabs to 551 families, and supported 1,050 consultations with Ministry of Health clinics.

PUNJAB PROVINCE

Kot Addu

On August 24, MSF’s 35-bed DTC in Kot Addu was fully occupied with severely dehydrated patients. MSF therefore expanded the center’s capacity to 75 beds. Additional personnel were brought in to augment the effort. More patients are still arriving, however—some referred by health centers in neighboring villages and transported by MSF ambulances—so it may be necessary to expand again in the near future.

MSF currently receives 150 patients a day in the DTC, 45 of them as inpatients. In total, 1,138 patients were treated for watery diarrhea last week; 338 were severe and 446 were children under five years of age. More patients with malaria, presenting with fevers, are being seen as well. And a small number of severely malnourished children are also presenting and being treated with therapeutic feeding.

MSF is also considering installing oral rehydration points in other health facilities in the area to ensure that dehydrated patients receive treatment quickly.

Places where internally displaced people (IDPs) have settled have been assessed north of Kot Addu. More than 2,000 flood-affected families were found who had not received any relief support so far. MSF is planning to assist them with NFIs and tents.

Rajanpur

This week, MSF teams are assessing the Rajanpur district in southern Punjab, a district bordering Sindh that was hard hit by the flooding. Medical teams are observing dozens of IDP settlements that have received very little assistance, if any. A significant upsurge of diarrhea and malaria cases has been recorded over the last few weeks at local health facilities, along with a worrisome number of malnourished children under the age of five. Based on the results of this assessment, MSF is considering opening a new project in this area.

KHYBER PAKHTUNKHWA PROVINCE

Peshawar

MSF performed 845 consultations in the last week at the three supported basic health units (BHUs), mainly for skin diseases and watery diarrhea. MSF may hand over daily activities of some health facilities to the Ministry of Health or another organization in order to focus solely on case management of malaria and watery diarrhea.

MSF is also continuing to distribute NFI and tents where flood-affected populations are not benefiting from the assistance of other organizations. Approximately 2,500 families received NFIs and tents last week in settlements near the river and in the north of the district, as well as in Afghan refugee camps south of Peshawar. Since the beginning of the flood response, MSF has provided NFIs and tents to more than 7,000 families in Peshawar district. New distributions are likely in the coming weeks in order to cover the needs of people who were living in schools but may have to find another refuge, since school is scheduled to open soon.

Charsadda

Mobile clinics in Charsadda have conducted 7,191 consultations since the flooding began. The main maladies are skin diseases, acute watery diarrhea, and respiratory infections. Four new sites were identified this week as well. Mobile clinics in Charsadda will reduce their activities in the coming weeks as more people return home and can will be able to more easily access primary health care facilities. Nevertheless, MSF is still working on emergency preparedness plans that include setting up a DTC should that be required in the second phase of the disaster.

MSF distributes an average of 93 cubic meters of water per day in Charsadda. From August 15 to 25, more than 10,000 cubic meters of water were distributed in Charsadda. Overall, MSF has distributed 2,250,000 liters of water in the towns of Painda Khel, Babra, Zoor Bazar, Giddra, and Shulgara.

MSF has installed 27 500-liter tanks in the so-called “Motorway camp” situated on the highway between Peshawar and Islamabad. MSF will provide 14 cubic meters of water per day there, 19 cubic meters per day in Hizara Camp, and 15 cubic meters per day in Utmanzai Camp

A well-cleaning program was started last week with two teams working on the periphery of Charsadda. The first team is working in Zoor Bazar, Babra, and Shulgara. The second started cleaning wells this week in the villages in the Tangi area. The hygiene promoters will also join the well-cleaning teams to conduct information campaigns.

NFI distributions in Charsadda will be finished this week; in total, 4,870 NFI kits have been distributed since the beginning of the intervention. Villages will also be assessed in coming weeks for distribution of reconstruction kits designed to help 2,500 families begin their return home.

Nowshera

At the beginning of last week, MSF performed 170 consultations at Nowshera Hospital's outpatient department and 474 at the emergency room. MSF has since handed management of the hospital back to local health authorities so that resources can be applied to regions experiencing more urgent medical needs, particularly in the south of the district. However, MSF will set up an epidemiological early warning system in order to follow up the evolution of acute watery diarrhea and to counteract a waterborne disease outbreak, should one occur.

As other medical organizations arrive in the area, MSF has decided to focus on water and sanitation activities, increasing daily the amount of chlorinated water it is providing to the populations and continuing to conduct NFI distributions. From August 9 to August 22, MSF distributed 903,000 liters of chlorinated water. In the past week, MSF provided almost 240,000 liters of water per day in 10 locations, including Pir Sabak, Akora Khatak, and the town of Nowshera itself. Three other water points were rehabilitated with automatic chlorination in Pir Sabak. Last week, MSF provided NFI distributions to 1,780 families and tents to 350 families. Since the beginning of the flood response, MSF has provided NFIs to almost 5,800 families in Nowshera district.

Swat

In Mingora hospital, there is a slight decrease in emergency room traffic, but MSF expects the numbers rise again after the bridges are repaired and people currently isolated are able to access health care services. MSF has trained senior nurses and laboratory technicians in blood bank management and the care and transport of blood and transfusions.

Mobile clinics continue in the Mingora area. MSF has started to refer surgical patients from mobile clinics to Timurgara because its more easily accessible from towns such as Kabal and Matta. As other actors return to Swat’s health structures, MSF is spreading its mobile clinics to areas where no other actors are present. The new locations include Manja, Kalagei, and Tarkani, all near the border of Dir district.

MSF plans to extend mobile activities for two more weeks, or until would-be patients who are still cut off can access Mingora hospital. All told, MSF has conducted 1,600 consultations in the region since the beginning of the flood intervention.

Mingora’s DTC was still receiving close to 100 patients a day last week, most suffering from watery diarrhea and mild to moderate dehydration. The emergency phase is most likely winding down in the DTC, but MSF is still sharing data with its health promotion and water and sanitation teams in order to respond to suspected cholera cases. Since the beginning of the flood response, MSF has treated 1,262 patients.

MSF’s water distributions continue in Swat, where a total of 4.5 million liters have been distributed. MSF’s water treatment unit has also provided 2 million liters of water that was distributed by other non-government organizations (NGOs). MSF’s health promotion team continues to join water and sanitation teams that are cleaning wells, carrying out hygiene promotion and education, and distributing hygiene kits around Mingora. Thus far, MSF’s water and sanitation team has cleaned 26 wells.

Timurgara (Lower Dir)

Last week, MSF conducted an assessment of the DTC at District Headquarters Hospital in Timurgara and plans to assist by supplying drugs and human resources, improving hygiene and rehydration capabilities, and providing infusions.

MSF is supporting the emergency room at the Rural Health Center in Munda and managing suspected cholera cases, which average six per day. MSF mobile clinics are ongoing in Summerbagh and Tauda China, and in Tauda China, MSF has distributed NFI kits to 55 families and 8,000 liters of water at the Khazana bypass.

Dargai (Malakand)

The acute phase of the emergency is over in Dargai, where the DTC now averages just two cases of acute watery diarrhea per day. NFI distributions have been completed in Malakand after 466 kits were handed out to families in the region. Mobile clinics have conducted 624 consultations, and 450,000 liters of water have been distributed.

In the past week, mobile clinics in Kalangi performed 105 consultations for diarrhea, respiratory infections, skin infections, and malaria. The mobile clinic found no serious medical conditions that cannot be treated by mobile clinics working on the other side of the river, in Dir, which is reachable via a traditional suspended chair. Some medical staff have been sent to Sindh to reinforce efforts there.

Hangu

In Hangu, MSF has been responding to an outbreak of acute watery diarrhea since July, treating more than 1,800 cases in an 80-bed DTC. The outbreak appears to be almost over, since MSF was seeing 55 patients per day two weeks ago but is now receiving only five patients per day.

FEDERALLY ADMINISTERED TRIBAL AREAS (FATA)

Sadda, Kurram Agency

In Sadda, Lower Kurram, where MSF has run a project since 2006, MSF set up a 30-bed DTC after an acute watery diarrhea outbreak was confirmed. The facility currently receives 20 patients per day, roughly a quarter who are severely dehydrated and need hospitalization.

Since 1988, MSF has been providing medical assistance to Pakistani nationals and Afghan refugees suffering from the effects of armed conflicts, poor access to health care, and natural disasters in Khyber Pakhtunkhwa, the Federally Administered Tribal Areas, Baluchistan, and Kashmir. MSF does not accept funding from any government for its work in Pakistan and chooses to rely solely on private donations.