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Cuban Doctors Offering Massive Relief in Pakistan

Text and Photos by Conner Gorry

Purchased from Norway, the Cuban Hospital at Muzaffarabad is one of the busiest, seeing some 600 patients a day.

Islamabad, Pakistan - A week after the October 8th earthquake leveled large swaths of northern Pakistan, the dead were still being pulled from collapsed houses, hospitals and schools. In the small town of Balakot - 110 miles from Islamabad and very near the epicenter of the 7.6 quake - rubble and ubiquitous dust mingled with the odor of death and the shocked air common to post-disaster scenarios. These were the conditions encountered by the first of Cuba’s medical relief specialists as they arrived in towns throughout Pakistan’s North-West Frontier Territory and the Azad Jammu and Kashmir areas.

Part of the Henry Reeve International Team of Medical Specialists in Disasters & Epidemics, the initial group of medical professionals and coordinators traveled halfway around the world days after the quake to offer medical relief to the more than 100,000 injured and 3 million left homeless by the natural disaster. The Henry Reeve Contingent, as it’s known, was formally constituted in a ceremony on September 19th in Havana and was pressed immediately into action – first in Guatemala following Hurricane Stan and now in Pakistan and Bolivia (see MEDICC Review, Vol. VII, Nos. 8 & 9, 2005).

This 14-year old boy received an 11,000 volt electric shock, fell 30’ and suffered a brain hemorrhage. He was in stable condition at the Muzaffarabad hospital ICU after six days on a ventilator.

While the team in Guatemala returned to Cuba in early December, the contingent in Pakistan has grown to over 2,000 and includes all manner of specialists – gynecologists, cardiologists, dermatologists, physical therapists, etc. The Pakistan mission has proven a minefield of challenges due to the scale of the destruction, religious, cultural and language differences, the pre-earthquake health picture and above all, climate.

“Everything was totally chaotic when we arrived on October 14th,” says Dr. Gerardo García, an anesthesiologist from Matanzas and member of the first group to arrive in Pakistan. “We had to circle for 45 minutes before landing at the airport and when we did, there wasn’t even a stairway for us to descend from the plane; the pilot had to shout from the open door to the authorities on the ground below.” Since then, Pakistani and Cuban officials have worked together to streamline the process so by mid-January, Cuba had 2,378 medical personnel (doctors, nurses and other paramedical staff) working in 44 locations throughout the earthquake-affected areas.

In December, MEDICC Review had the opportunity to witness in action these health care workers who have been voluntarily helping hundreds of thousands of Pakistanis since the earthquake. (For further details, see International Cooperation Report: Touring Cuban Field Hospitals in Post-Quake Pakistan).    

Establishing Hospitals & Treating Survivors

A baby receives treatment for polidermitis of the scalp at Hospital 26 near Abbottabad. Her eyeliner signifies she’s in mourning.

Imagine you’re dropped in a cold, mountain town where half the population has perished in a natural disaster and the other half – many without food, water, heat or shelter – are suffering from broken bones, fractured skulls, respiratory infections, and festering wounds. You don’t speak the language, can’t drink the parasite-infested water and have no experience with Islamic custom, which requires you to cover your head (if you’re a woman) or refrain from talking to strangers of the fairer sex (if you’re a man). It’s the middle of Ramadan, so 96% of the population is fasting from sunrise to sunset, making it hard to find food. Disturbingly, aftershocks shake the ground daily, causing landslides and roadblocks and injecting an element of fear into your mission: staff a field hospital receiving masses of quake victims.

This approximates the scenario in many locations, including Hattian Bala, a picturesque, riverside site in Pakistan-administered Kashmir where a team of Cuban doctors arrived on October 24th. A field hospital with an operating room, post-op ward, consultation areas and pharmacy had already been established by the local Bilal Hospital, to which the Cubans added 10 specialists, plus equipment and medicine.  In those first weeks they were treating mostly compound fractures, infected wounds and women giving birth in a region where more than 90% of all housing was destroyed. Since then, the number of Cuban doctors at the hospital has swelled to 26 and, except for expectant mothers (of which there are no shortage in this country where scant reproductive health services and birth control combine with religion to raise birth rates), the pathologies have changed.[1]

A charpoy – traditional rope bed – serves as the pharmacy for the field team in Tori.

“At first we were concerned with saving lives. Now it’s different. Now we’re treating pre-existing conditions,” Dr. Carlos Herrera, Director of the Hattian Bala hospital told me in December. The most common among these are acute respiratory infections, scabies, polidermitis, parasites and gastrointestinal illnesses. “This is a working hospital and even though we don’t have all the equipment of a regular hospital, we keep on working hard,” he said. This includes an average of three major surgeries a day, a vaccination campaign that had inoculated 1,898 people by mid-December and hundreds of daily out-patient visits.

One indication of the importance of the Cuban presence is the nearly complete responsibility for primary and secondary care these doctors have assumed in affected areas like Hattian Bala. This field hospital and surgical unit, for example, is now the referral hospital for the region. On the afternoon MEDICC Review visited, the Cuban doctors had just received, treated and evacuated several victims of a major traffic accident in which 40 people died at the scene. Also that day, a child was born and the first EKG ever in Hattian Bala was performed by the Cuban team managing the hospital. 

Treating Remote Communities

Equitable, compassionate health care is a pillar of the Cuban medical philosophy that has been translated as coherently as possible to the Pakistan relief effort. In the aftermath of the quake, attending remote communities – especially those located above 5,000 feet – has proven problematic. Cold, inhospitable locations make it hard to establish hospitals at higher elevations, which combines with an unwillingness of many homeless quake victims to descend to the cities and valleys in search of care.[2]

Anesthetist Tomás Romero of Havana injects a patient before surgery at Hospital 26 near Abbottabad.

The solution the Cuban team applied was one they brought from experience in their own mountains: if people can’t reach the health services, then doctors go to them. To this end, each hospital dispatches daily teams of four or five doctors (or more depending on need), to attend to people that can’t get to one of the 30 field hospitals. Sometimes they set out on foot, carrying medicine and equipment in a backpack or in a Jeep, loaded down with a pharmaceutical cornucopia so complete they’re essentially arriving in these rural villages with a portable doctor’s office. The latter is the strategy employed by the mobile team based at the Garhi Habibullah field hospital in Pakistan-administered Kashmir.

The hospital at Garhi Habibullah had treated over 23,000 patients by late December and was the first field hospital established entirely by the Cubans. Easier said than done: the doctors arrived on October 22nd to find little more than a dusty open plain abutting a ribbon of river in the middle of nowhere. Squaring off a large corner, they set to erecting their camp, bathrooms, water and light services, plus all the necessary consultation rooms, sterilization facilities and operating theaters needed to treat the local population. Here, as elsewhere, the Cubans have counted on major logistical support from the Pakistani armed forces.

This, and many other of the practical details of how the Cuban doctors successfully help so many people in such difficult circumstances became clear on the mobile team visit to Tori. This cluster of mud houses and a few tents is in that part of the Pakistani mountains still disputed by politicians and cartographers alike, about 20 miles from the Garhi Habibullah base hospital.

Dr. Milagros de Armas treats a foot infection in Tori.

The mobile team is comprised of four doctors, all Family Medicine specialists, with the team evenly split along gender lines to accommodate Pakistani religious-cultural norms that female patients can only be seen by female doctors. The white-knuckle ride along a ribbon of cliff-hugging road; the big rifle carried by our guard/translator; and the gorgeous mountain scenery that makes the area a summer vacation hot spot were all taken in stride by these doctors who head into the farthest mountain reaches around Garhi Habibullah six days a week to treat hard-to-reach patients.

After about an hour of the hair-raising ride, we could proceed no further. Escorted by a town elder, we walked the last five minutes to the village, our knees buckling under the weight of the medicines. In a small clearing, a table and chairs were set up to see patients. A couple of charpoys, typical rope beds, appeared and were pressed into service as the pharmacy, with antibiotics, pain relievers, cough syrup, topical ointments, gauze, gloves, syringes, and alcohol lined up for use. Surgical masks were passed out. “You better use this,” Dr. Alexis Rodriguéz from Bayamo told me. “There’s a lot of tuberculosis here; we’ve already seen many cases.”

Two nearby tents - one for men and one for women - were commandeered for shots and more thorough examinations. Slowly but surely, the townspeople started drifting out of their homes and relief agency tents to be attended by the Cuban doctors; this was their first visit to Tori and probably the first time some of these people had ever seen a doctor.

The same pathologies seen in field hospitals everywhere in the affected areas were here too: scabies, pyoderma, acute respiratory infections (ARIs), gastritis and gastroenteritis, hypertension and parasites mostly. But there were also other conditions in Tori: adolescent girls with anemia eating dirt for the iron, an inner ear infection so advanced pus was oozing from the man’s ear, a young woman suffering from hyperthyroidism and an elderly woman with a grotesquely swollen ankle. “Here’s something we don’t see in Cuba: leishmaniasis,” explained Dr. Rolando Carballo, a family doctor and resident in cardiovascular surgery from Havana.

At the end of the day, the doctors had examined and treated 103 patients, making a point of distributing Urdu-language flyers describing health measures for pregnant women and the importance of treating drinking water. Nutrition and basic hygiene are two of the most pervasive challenges for the post-disaster Pakistani health picture.
 
Though the doctors valiantly wielded basic Urdu vocabulary and sign language to make diagnoses and prescribe medicine, and the army-provided translator scooted between out-patient stations, language barriers remain one of the major difficulties for the Cuban doctors here, as well as for other outside relief workers.

There are about two dozen languages (with more than 300 dialects) spoken in Pakistan and although an Urdu-Spanish-English guide to medical terms was compiled through Cuban and Pakistani collaboration and has been distributed to all the hospitals, this is of little help when the patient is a Pashto or Shina speaker. What’s more, conservative religious and cultural codes prevent women from discussing certain matters (e.g. gynecological problems) with men outside their families - like translators.

Contextual Challenges

The Cuban contingent in Pakistan is a healthy mix of recent graduates who had never before been out of the country and sage old hands with many international missions under their belt. All of the four doctors with whom I visited Tori had previous international experience in places as varied as Honduras and Ethiopia, but when asked how this one compared, said in unison ‘it’s harder!’ In every field hospital I visited, there was consensus on this point, whether the people had previously served in the Venezuelan Amazon or the villages of Mali. 

Even anesthesiologist Tomás Romero who braved sand storms and blistering heat in the western Saharan territory of the Saharawi Arab Democratic Republic and treated war-wounded in Angola says “the conditions here are the most difficult of all the places I’ve been.” Why? The weather, say the Cubans, each of whom received close to 40 pounds of winter weather gear - from socks and long underwear to sleeping bags and coats. “Of all the times I’ve served abroad, this is the hardest because of the cold,” said Idarmis Sánchez, an oncological nurse from Havana who has worked in Haiti and Angola. “It’s very cold and it gets into these old bones,” said the 56-year old who will celebrate her next birthday in Pakistan.

The mental toll on the Pakistani people is incalculable and, in some sense, beyond reach of any doctor. The women and children instantly made widows and orphans when over 75,000 died, the destruction of home and hearth, and the interminable aftershocks requires a healing process that will extend long beyond the projected spring departure of Cuba’s Henry Reeve International Team.

Still, in the quake’s aftermath, Pakistanis see possibilities: “Disaster recovery presents opportunities for restructuring,” according to Dr. Farzana Bari, chairwoman of a Gender & Disaster Management workshop held in Islamabad recently.  “We have the chance to increase participation and restructure social life so it presents more opportunities like property rights for women and greater employment.” Even with so much destruction and the harsh winter upon them, hope springs eternal in Pakistan.

Notes & References

  1. Pakistan has a total fertility rate of 4.3 births per woman, compared to 3.2 for the South Asian region and 2.9 for developing countries overall. The contraceptive prevalence rate in Pakistan is 28% and only 23% of births are attended by skilled health personnel (UNDP, Human Development Report, 2005).
  2. Land deeds are largely non-existent in Pakistan, meaning people who lost homes in the quake are reticent to leave plots unattended for fear they’ll return to a battle over land rights. Indeed, unofficial estimates indicate most of Balakot has already been occupied by squatters after half of that town’s 25,000 people perished and survivors fled to safer areas.
 
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