Foreign Field Hospitals in the Recent Sudden-Onset Disasters in Iran, Haiti, Indonesia, and Pakistan

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1 ORIGINAL RESEARCH Foreign Field Hospitals in the Recent Sudden-Onset Disasters in Iran, Haiti, Indonesia, and Pakistan Johan von Schreeb, MD; 1 Louis Riddez, MD, PhD; 2 Hans Samnegård, MD, PhD; 3 Hans Rosling, MD, PhD 1 1. Division of International Health IHCAR, Karolinska Institutet, Stockholm, Sweden 2. Department of Molecular Medicine and Surgery, Karolinska Institutet 3. Independent Consultant, Stockholm Sweden Correspondence: Johan von Schreeb Division of International Health IHCAR SE Stockholm, Sweden johan.von.schreeb@ki.se Funding/Support This study was funded by a grant from the Swedish National Board of Health and Welfare. Keywords: disaster; foreign field hospital; Haiti; Indonesia;Iran; Pakistan Abbreviations: FFH = foreign field hospital GDP = gross domestic product ICRC = International Committee of the Red Cross IFRC = International Federation of the Red Cross MSF = Médecins sans Frontiéres OCHA = United Nations Office for the Coordination of Humanitarian Affairs PAHO = Pan-American Health Organization WHO = World Health Organization Received: 29 May 2007 Accepted: 03 August 2007 Revised: 10 September 2007 Web publication: Abstract Introduction: Foreign field hospitals (FFHs) may provide care for the injured and substitute for destroyed hospitals in the aftermath of sudden-onset disasters. Problem: In the aftermath of sudden-onset disasters, FFHs have been focused on providing emergency trauma care for the initial 48 hours following the sudden-onset disasters, while they tend to be operational much later. In addition, many have remained operational even later. The aim of this study was to assess the timing, activities, and capacities of the FFHs deployed after four recent sudden-onset disasters, and also to assess their adherence to the essential criteria for foreign field hospital deployment of the World Health Organization. Methods: Secondary information on the sudden-onset disasters in Bam, Iran in 2003, Haiti in 2004, Aceh, Indonesia in 2004, and Kashmir, Pakistan in 2005, including the number of FFHs deployed, their date of arrival, country of origin, length of stay, activities, and costs was retrieved by searching the Internet. Additional information was collected on-site in Iran, Indonesia, and Pakistan through direct observation and key informant interviews. Results: Basic information was found for 43 FFHs in the four disasters. The first FFH was operational on Day 3 in Bam and Kashmir, and on Day 8 in Aceh. The first FFHs were all from the militaries of neighboring countries. The daily cost of a bed was estimated to be US$2,000. The bed occupancy rate generally was <50%. None of the 43 FFHs met the first WHO/Pan- American Health Organization (PAHO) essential requirement if the aim is to provide emergency trauma care, while 15% followed the essential requirement if follow-up trauma and medical care is the aim of deployment. Discussion: A striking finding was the lack of detailed information on FFH activities. None of the 43 FFHs arrived early enough to provide emergency medical trauma care. The deployment of FFHs following sudden-onset disasters should be better adapted to the main needs and the context and more oriented toward substituting for pre-existing hospitals, rather than on providing immediate trauma care. von Schreeb J, Riddez L, Samnegård H, Rosling H: Foreign field hospitals and the recent sudden-impact disasters in Iran, Haiti, Indonesia, and Pakistan. Prehospital Disast Med 2008;23(2): Introduction Earthquakes, tidal waves, tropical storms, volcanic eruptions, and landslides are sudden-onset events that have killed an estimated 800,000 people, injured more than one million, and affected the lives of approximately one billion people during the last 30 years. 1 Proportionately, the human toll from sudden-onset events and the disasters they produce is 100 times higher in lowincome countries (gross domestic produce (GDP) <US$85 per capita) than in high-income countries (GDP >US$10,726 per capita). 1,2 After a sudden-onset disaster in a resource-poor area, national and international humanitarian assistance may be needed to meet urgent, vital needs such as shelter, water, food, health care, and long-term recovery. Funding for international humanitarian assistance has more than doubled each decade since 1975, and the United Nations Financial Tracking System indicates that Prehospital and Disaster Medicine Vol. 23, No. 2

2 von Schreeb, Riddez, Samnegård, et al 145 foreign governments for humanitarian assistance contributed US$7.6 billion during disasters associated with natural hazards around the world in The major healthcare needs following a sudden-onset disaster are: (1) emergency medical trauma care; (2) care for secondary effects such as wound complications; and (3) regular healthcare needs following the damage sustained by health facilities and the loss of staff. Foreign field hospitals (FFHs) can satisfy each of these needs, but have been criticized for being too focused on emergency trauma care. 4 6 In addition, the relevance, timing, and cost-effectiveness of FFHs in the aftermath of sudden-onset disasters have been questioned. Studies of FFHs mainly have assessed services at a single hospital in one setting One article describes aspects of several FFHs in Bam, Iran, and another reports on a few in Aceh, Indonesia. 5,14 Another article broadly analyzes the role of surgeons following a sudden-onset event, 15 but no study that systematically describes and analyzes how FFHs were used in recent disasters due to sudden-onset events was found. The aim of this study was to assess the timing,activities,and capacities of the FFHs deployed during the first four weeks after four contemporary and prominent sudden-onset events, and the extent to which World Health Organization/Pan- American Health Organization (WHO/PAHO) essential requirement for FFHs intended for early emergency medical care and follow-up trauma and medical care were met. Methods Four recent, prominent disasters due to sudden-onset events were studied: (1) the 2003 earthquake in Bam, Iran; (2) the 2004 tropical storm in Guanavaca, Haiti; (3) the 2004 earthquake/tsunami in Aceh, Indonesia; and (4) the 2005 earthquake in Kashmir, Pakistan. The WHO/PAHO definition of a field hospital; a mobile, self-contained, selfsufficient healthcare facility capable of rapid deployment and expansion or contraction to meet immediate emergency requirements for a specified period of time was used. Domestic field hospitals were not studied. Secondary Data Review For each disaster, researchers searched the Internet for information on the context, local pre-disaster availability of hospital beds, the impact of the sudden-impact disaster, the human toll in each affected area, the number of FFHs deployed, the date of arrival and length of stay and country of origin of each FFH, as well as its location, number of beds, activities and cost from the onset of the disaster to one month after each disaster.the search engines Google, Google Scholar, and Pub Med were used with the keywords field hospital, Aceh, Bam, and Kashmir, alone or in combination. For the disaster in Guanavaca, Haiti was used as the search word. The search was conducted between January and December Additional information was retrieved from the Humanitarian Information Center homepages for each disaster, WHO operational updates, the emergency-related postings at Reliefweb, and the homepage and database of the Organization for Coordination of Humanitarian Assistance (OCHA). Key Informant Interviews Semi-structured questionnaires were used to interview decision-makers involved in the deployment of FFHs by the Norwegian Red Cross and the International Committee of the Red Cross (ICRC). The interviewees were asked for personal experiences from each disaster, and copies of all available statistics on FFHs deployed during the four disasters were requested. In December 2004, two of the researchers visited Iran and interviewed key informants in Tehran and Bam. National decision-makers involved in the Bam relief work were asked specifically for information on the FFHs. Observations The authors are surgeons with experience in international humanitarian emergencies, and two have field experience from either work in the ICRC field hospital in Aceh or the Médécins sans Frontiéres (MSF)-supported hospital in Kashmir. Analyses The retrieved information was read, compiled, and listed. For all of the disasters studied, except Haiti, the period of deployment, number of beds, and country of origin for each FFH were plotted in Figures 1, 2, and 3. To judge whether the timing of the FFH deployment was according to the expected needs, a conceptual model based on the empirical experience of the authors and the available literature, was used. 16 In the model, (Figure 4) the first phase lasts about three days and is dominated by immediate hospital care needs due to injuries. The second phase is dominated by an increased need for the care of secondary complications caused by delayed initial injury treatment. The third phase is characterized by an increased need for hospitalization due to regular health problems such as obstetric, pediatric, and psychological conditions exacerbated by the disaster. During the last phase, an accumulated need for elective care is noticeable. It should be noted that routine medical emergencies must be treated during all of the phases. The conceptual model was compared with the retrieved data on FFH deployment, length of stay, and activities. Service output was calculated by dividing the total number of surgeries and the number of outpatient visits with the number of active FFH days. Validation of the results was done by triangulation. Only information that was consistent and reported from at least two different sources was included. Identified FFHs were compared with the WHO/PAHO first essential requirements for: 1. Early emergency medical care (48 hours), which states that to provide life-saving emergency medical care for trauma, foreign field hospitals must be onsite within 24 hours of the impact of the event; 2. Follow-up trauma and medical care (days 3 15), which states that in order to provide hospital care that meets the immediate needs of the affected population, FFHs must be operational three to five days following the disaster impact. 16 March April Prehospital and Disaster Medicine

3 146 Foreign Field Hospitals Figure 1 Foreign field hospital deployed in Bam, Iran and number of beds available before and after the earthquake Figure 2 Foreign Field hospital deployed in Aceh Indonesia and number of beds available before and after the earthquake/tsunami Prehospital and Disaster Medicine Vol. 23, No. 2

4 von Schreeb, Riddez, Samnegård, et al 147 Figure 4 Foreign field hospital deployed in Kashmir and Northwestern Province Pakistan and number of beds available before and after the earthquake Results The Google Internet search yielded approximately 10,000 hits for both Haiti and Bam, 20,000 for Aceh, and 23,000 for Kashmir. The top 200 Google hits for disasters due to sudden-onset events were examined for relevance, and 50 documents per disaster were read. Google Scholar and Pub Med yielded 25 and two articles, respectively. Searches on Reliefweb yielded 40 operational updates from OCHA and WHO, while the Humanitarian Information Center homepage for Aceh and Kashmir generated 15 documents. These 82 documents were read to search for FFH information, which was retrieved and compiled. A striking observation was the scarcity of detailed information, especially numerical data for input, output, and cost. Most documents were quotes from press releases concerning spectacular activities that occurred at individual FFHs. The operational updates from OCHA and WHO provided some non-systematic information on FFH presence. Key informant interviews with agencies did not provide any additional information. There were missing data on cost in 80% of the FFHs, on the number of operations in 82%, and on the number of consultations for 86%, respectively. The limited availability of data only allowed calculations of crude daily costs per FFH bed (Table 1), which did not allow for detailed assessment. Comprehensive data were found for four of the 43 foreign field hospitals. More than half (24) of all FFHs were of military origin. The sudden-onset disaster context and pre-disaster infrastructure in each affected area varied considerably (Table 2). The urban city of Bam had paved roads and an airport in contrast to the mountainous and rural Kashmir, which had a limited road network. In Aceh, Indonesia, the affected area was a thin strip of a 600-km-long coastline, and only one main road. Bam, Iran At 05:30 hours on 26 December 2003, an earthquake measuring 6.5 on the Richter scale struck the area of the ancient city of Bam (Table 2). Approximately 80% of hospital capacities were lost. Within hours, domestic rescue services, headed by the military and the Iranian Red Crescent 17,18 started relief operations and mass evacuations. During the first days after the earthquake, approximately 10,000 injured persons were evacuated by air and road to 72 unaffected hospitals in Iran. 19,20 The eight hospitals in the neighboring city of Kerman (bed capacity = 1,500) admitted approximately 6,500 patients during the first two days. On the evening of the earthquake, Iranian authorities requested international assistance and asked specifically for field hospitals. An open sky policy was adopted, allowing anyone with a relief mission to enter the country. Within the first week, an estimated 1,800 aid workers arrived from 44 countries. 19 On Day 3, a Ukrainian field hospital was the first to arrive. In total, 11 FFHs (five military) were deployed, with a maximum of 550 hospital beds on Day 8 March April Prehospital and Disaster Medicine

5 148 Foreign Field Hospitals Figure 4 Conceptual model for the variation over time of needs/use of hospital resources for non-trauma emergencies, trauma complications and elective surgery before and following a SID Iran Haiti Indonesia Pakistan GNI per capita in US$ (Atlas Method) 2, , Population (in millions) Human Development Index Table 1 Demography of countries included in the study (GNI = gross national income) (Figure 1). A majority of the FFHs were erected next to one another, and five were operational for <7 days. One year after the earthquake, the International Federation of Red Cross and Red Crescent Societies (IFRC), the only FFH had been upgraded to a 100-bed container hospital staffed with domestic staff. Two articles 21,22 report on surgical activities at the United States field hospital that arrived one week after the earthquake. During their four-day mission, the staff of 80 did two caesarean sections, one appendectomy, and four minor operations. Since priority was given to surgical trauma equipment, they lacked obstetrical surgical instruments. The maximum occupancy rate at the 200-bed IFRC hospital during the first two months was 25%. During this time, 818 patients were admitted, and 34 caesarean sections were performed. The cost per hospital bed per day was at least US$1,700 (Table 1). One report estimated the cost for all FFHs in Bam to be >US$10 million. 23 Guanevaca, Haiti Between 17 and 19 September 2004, Tropical Cyclone Jeannie caused torrential rains in northeastern Haiti. The two main hospitals in the city of Gonaives were destroyed. Local and international agencies, including a Cuban team, supplied human resources and supplies for trauma care without deploying specific hospital facilities. On 14 October, four weeks after the tropical storm, the Norwegian Red Cross and the IFRC opened a 100-bed capacity field hospital (Table 1). By the middle of November, an improved health situation was reported. Following two months of activities, the hospital was dismantled, and at the end of February, the equipment was transferred to the repaired main hospital. Output activities were low for surgery, while about eight deliveries were performed per day during the first two months following the event. Aceh, Indonesia On the morning of 26 December 2004, an earthquake measuring 9.0 on the Richter scale struck an area off the western coast of Sumatra, Indonesia. The earthquake caused destruction and triggered a tsunami that devastated the coastline (Table 2). The main road was destroyed, and helicopters or boats were the only means to reach the affected areas. Hospital capacity in the area was reduced to <25%. An estimated 10% of all wounded persons (7,200) were reported to be severely injured and requiring hospitalization. 14 Prehospital and Disaster Medicine Vol. 23, No. 2

6 von Schreeb, Riddez, Samnegård, et al 149 Sudden Impact Disaster Country Days on site Number of daily consultations Number of daily operations Beds US$/bed/day France ,700 Belguim ,800 Bam United States India IFRC Haiti NRC Denmark ,000 Aceh Portugal ,000 Australia/NZ ICRC Czech Republic ,300 Kashmir NATO ,600 Belguim ,600 France ,500 Table 2 Foreign field hospital service output during first month, number of beds, length of stay, and estimated cost per bed per day (ICRC = International Committee of the Red Cross; IFRC = International Federation of the Red Cross; NATO = North Atlantic Treaty Organization; NRC = Norweigan Red Cross) International assistance was requested on 27 December, but response initially was slow due to a lack of information and access problems. On Day 5, naval vessels from three countries arrived to assist with helicopter evacuations, while international relief teams began to provide assistance. On Day 8, a FFH from Singapore was the first to become operational (Figure 2). Soon, there was an oversupply of trauma surgical services. By Day 15, the WHO officially declared that no more FFHs were needed, but they continued to arrive until Day 20. By then, a total of nine (five military) FFHs were operational in three districts. The occupancy rate generally was <50%. Six weeks after the tsunami, a US hangar ship with 12 operating rooms and a 1,000-bed capacity arrived at the coast of Aceh. A lack of health sector coordination severely limited the efficiency of the relief work. One study concluded: It was a matter of guesswork which facility had beds or surgical capacities available. 14 The Australian and New Zealand Defense Force Field Hospital (ANZAC) reported 173 operations on 71 patients starting on Day 15 and for two months onward. A total of 70% of the interventions (42% of all patients) were for injuries caused by the tsunami, while the rest of the operations were for unrelated emergency conditions. No elective surgeries were reported. 9 The ICRC hospital performed 355 surgical interventions during its first two months of activity. A total of 30% of the operations were tsunami-related, 30% were elective hernia operations, and the remaining 40% were regular surgical interventions for obstetric emergencies, non-tsunami trauma, and other common surgical conditions. 7 Nine weeks after the tsunami, the same hospital reported that of the 120 outpatients seen daily, 12% experienced at least one problem directly related to the disaster. 24 The 53 tsunami victims who were hospitalized during the first six weeks required 103 operations and an even larger number of wound dressing changes. 7 The Danish field hospital reported 385 operations, but the type of operations and diagnoses were not reported. The Independent State of Azzad Jammu and Kashmir (AJK) and the North Western Frontier Province (NWFP), Pakistan On 08 October 2005, an earthquake measuring 7.6 on the Richter scale struck Azzad Jammu and Kashmir and the North Western Frontier Province of Pakistan (Table 2). It reduced hospital capacity by 75%. The Pakistan Army and other local and national agencies began to provide care at several locations in the affected area immediately, but access remained difficult and transportation largely was dependent on helicopters. The Army quickly started air evacuation of the wounded, and within 10 days, 10,000 were transported to towns in northern Pakistan for care. After 10 days, trauma patients continued to arrive at health facilities. International assistance was requested on the day of the earthquake. During the first nine days, the WHO highlighted the need for light and mobile FFHs. A Turkish March April Prehospital and Disaster Medicine

7 150 Foreign Field Hospitals FFH was the first to arrive, and was operational early on Day 3 (Figure 1). A total of 150,000 outpatient consultations and 1,500 operations were reported from 10 FFHs during the first three months of the post-earthquake period. The ICRC hospital reported 379 operations, 142 of which were wound-debridements. 8 The North Atlantic Treaty Organization (NATO) FFH opened one month after the earthquake. It initially was staffed with four male trauma surgeons. It took several weeks before a female gynecologist became part of the team. The daily bed cost at four FFHs was approximately US$2,000 (Table 1). The occupancy rate at the FFHs varied substantially with regard to time and location. During the initial first weeks, it remained >60%, since it was difficult to discharge patients because they had nowhere to go. Two FFHs opened temporary hotel structures in order to discharge patients. Several agencies supported damaged hospitals, such as MSF s support of the district hospital in Bagh. No detailed information on capacities, time of arrival, activities, location, and cost of the so-called Cuban FFH has been found. One month after the earthquake, 1,200 Cuban health professionals reportedly provided in-patient care at about 38 FFHs. Although extremely rudimentary in terms of equipment, Pakistan s authorities highly praised this contribution. Observations in three of the sudden-onset disasters indicate that most FFHs were equipped and staffed to care for emergency trauma rather than to provide care for the most common disease burden, routine medical emergencies Adherence to WHO/PAHO Essential Requirements None of the 43 foreign field hospitals fulfilled the WHO/PAHO essential criteria for FFHs emergency trauma care deployment, while 9% of the FFHs in Bam, and 23% of the FFHs in Kashmir fulfilled the essential criteria for deployment for follow-up trauma and medical care. None of the FFHs deployed in Aceh or Haiti met these essential criteria. Discussion Lack of Information A striking finding is the lack of detailed information on the service output and costs of FFHs. Surprisingly, agencies were unwilling to share internal reports. It may be that the reluctance to provide information on services provided because FFH agencies are aware of the discrepancy between the expectations and realities of intercontinental emergency trauma care and do not wish to make it known to the general public. Timing None of the 43 FFHs were operational early enough to provide life-saving, emergency trauma care.the first FFHs to arrive came from neighboring countries. It is noteworthy that the high-income countries of West Europe and North America with well-organized military and plenty of development resources were unable to provide services within the first three days in any of the sudden-impact disasters. A Bam earthquake study concludes: However large the number of casualties, life-saving trauma care should be provided by local or national health services and not by outside rescuers. 6 The ICRC and IFRC deployed FFHs in all of the studied sudden-impact disasters, but were never operational before Day 7. The reason may be logistical and human resource problems associated with deploying a large, multidisciplinary, FFH that is to stay for a long period. Activities, Capacities, and Cost Despite a thorough search on the Internet, repeated inquiries to agencies, key informants interviews, and onsite visits, the authors only could retrieve basic activity output data from 14% of all of the FFHs. Undoubtedly, most FFHs focusing on emergency trauma in all sudden-onset disasters arrived too late (except in Haiti). This is supported by the short stay of FFHs in Bam, especially the low surgical output activities at the US FFH. Clearly, there was a competition for patients. A similar scenario was noticed in Aceh, even though the needs were larger. In Kashmir, the situation was different, due mainly to the large area and vast number of people affected as well as the massive destruction and lack of infrastructure. Therefore, the WHO asked for mobile FFHs to facilitate transportation to remote areas. In Kashmir, the need for multidisciplinary FFHs remained for a significantly longer period than in the rest of sudden-impact disasters. It could be that in this setting, the basic Cuban foreign field hospital was better adapted to provide cost-effective, long-term FFH care. More evaluations and studies are needed to determine how to most effectively cover long-term hospital care needs following sudden-onset disasters in low- and middle-income settings. Within days following a sudden-onset event, the needs for hospital care returns to normal (mainly caring for routine medical problems). Nevertheless, it is important not to neglect the resource burden of disaster-inflicted injuries. This was experienced in Aceh, where tsunami victims required repeated operations and wound dressings, as well as anesthesia and long hospitalizations. 7 One task for FFHs that arrive more than a week after the precipitating suddenonset event is to care for such victims, while its main role is to substitute for the damaged hospitals. It is likely that the daily bed cost is higher than the estimated US$2,000. This crude estimate was based on a 100% occupancy rate, and did not allow for the inclusion of military FFH costs. 14 In Aceh and Kashmir, helicopter evacuations were of considerable importance, but it took longer to get them started compared to Bam. Studies are needed to define the optimal balance between transporting the wounded from and bringing FFHs to the affected area. In some contexts, it may be better to send helicopters than FFHs. Adherence to WHO/PAHO Essential Criteria for Deployment The fact that none of the FFHs adhered to the first essential criteria for emergency trauma care deployment must be studied further. It is vital that the objective for deployment matches the time of arrival, equipment, and staff. Based on the Kashmir experience, the 15-day exit deadline suggested in the criteria for follow-up trauma and medical care deployment must be re-evaluated, as the hospital needs Prehospital and Disaster Medicine Vol. 23, No. 2

8 von Schreeb, Riddez, Samnegård, et al 151 during this sudden-onset disaster remained for a considerable time. It seems relevant to regularly update the WHO/PAHO guidelines for the use of FFHs following sudden-onset disasters. Limitations The conceptual model used in this study only provided a simplified overview. Depending on the type of precipitating event, there may be an overlap between Phase 2 and Phase 3, and the level of secondary infections also may vary. Most information was retrieved from non-peer-reviewed sources (primarily the Internet and situation reports). Some FFH activities may have been missed, and the exact timing of when each FFH began and ended its activity may deviate slightly from the findings. Hopefully, such limitations will stimulate for increased transparent reporting. Conclusions The lack of available information and the reluctance to share data on the activities of FFHs following sudden- onset disasters due to natural hazards was the most striking finding of the study. Efforts must be made to make data available and encourage further studies on the use of FFHs during sudden-onset disasters. All of the FFHs in this study arrived too late to provide emergency trauma care. The main task for a FFH arriving later than three days after the precipitating event is to substitute for the collapsed healthcare system. Therefore, the FFH should be multidisciplinary equipped and staffed for the optimal provision of such services. In addition, information on the predisaster context, the damaged caused by the precipitating event, and the available national capacities and international responses should be used to guide appropriate deployment of FFHs. 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