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Aftershocks

Medical and mental health needs of quake survivors require long-term care

by Wendy Driscoll, Press Officer

KOTDA VILLAGE, Gujarat, India (February 12, 2001) -- The child is hysterical as he is led through the dusty streets of what once was a village. The village is no more --shaken to grotesque piles of rock and dust in the massive January 26 earthquake that even today sends periodic ripples of aftershock up from the earth. The quake crushed not only the houses of this village of 2,000 people, but also 34 people, including this boy's father. And now the boy -- Parveen is his name - is crying and saying that the left side of his body has gone "numb."

CARE medical staff -- on the ground in the worst-hit areas of Gujarat since February 1 -- think the cause of his distress might lie elsewhere.

'This is psychosomatic,' says Dr. Anubha Ghose, team leader for the two mobile CARE medical teams that have treated more than 600 quake victims over the past ten days. 'This is because his father is dead.'

The toll of the dead and injured is so enormous in this landscape of apocalypse that medical workers have had little time to concentrate on anything but urgent cases. But everywhere in Kotda Village people lie nursing damaged bodies or, in the case of Parveen, damaged psyches -- and CARE staff warn these less apparent victims must be assisted as well.

A young girl is treated for a swollen ankle by a CARE emergency medical team. Photos: Wendy Driscoll © CARE 2001.

The medical team is busy today. Their truck filled with medical supplies stands in a dusty courtyard and next to it a small camp bed is placed, shaded from the glare of the sun by the arching branches of a tree. It is on this camp bed that they treat the long line of patients who have come to see them.

First in line is a man whose knee was knocked by a falling rock and has since swollen and turned a jaundiced yellow from the constriction of unreleased pus. Then a young woman in an impossibly optimistic pink head scarf pulls back the dainty frills of her robe to reveal her monstrously huge, bandaged ankle. CARE doctors work quickly, swabbing the wounds, injecting anti-inflammatory medicines, bandaging the victims. The injuries here are less serious, as evidenced by their patient's ability to walk to this mobile clinic. More serious cases lie in the village, in the makeshift tents and shelters erected next to demolished homes. Each day, CARE doctors make the rounds.

"I remember three earthquakes [in my lifetime]," says a 90-year-old woman, Baina Bahen, lying prone on a woven bed between heaps of broken cement. Her son fans the buzz of flies away from her parchment-like skin. "This was the worst. The others knocked down some buildings, but they did not kill so many people. This one killed."

Bahen cannot walk; her spine was bruised by a falling rock on the day of the earthquake, but because her injury was not bloody, her family delayed bringing her for treatment. Such cases are typical, says CARE's Ghose.

"Very obvious injuries such as fracture or bleeding wounds were attended [in the first days]," she notes. "But there could be some very serious injuries like internal fracture that are overlooked."

So Bahen has languished in her house, her internal injury worsening until villagers whispered to CARE doctors about the old woman who could not get up. Since then, CARE staff have visited and done what they can. "They are my mother and my father," says Bahen devoutly, clasping her hands together in the Indian namaste - the traditional sign of greeting or thanks.

Children of Kotda Village with CARE relief truck.

There are other unseen victims who will require assistance over the long term. Two hundred people from this village alone went to the hospital, and at least 80 had injuries severe enough to be admitted. It is too early to tell who will be permanently disabled by their injuries, but CARE staff say there are "many" -- here in Kotda and across the quake zone.

"Follow-up is the main problem now," says Ghose. "Over the long term, we need to look at rehabilitation of people who have become disabled. Especially those who are the primary earners for their families. Now their family members need to be given support on how to treat these people, and given income-generating assistance. These are people who do not have disability and now they suddenly have so much disability."

Health staff are only now beginning to think about what happens to quake victims over the long-term. Hospitals and health workers have been consumed by the volume of serious injuries, of amputations and dislocations, of shattered bones and crushed internal organs.

"[The main city of Bhuj] could not handle the injuries," notes Ghose. "The hospital was totally demolished and had to be rebuilt in tents." This is not criticism, she is swift to point out. "Nobody has ever seen, has ever dealt with anything like this."

Almost every building in the 6,000 square-mile 'worst-hit' area of the quake will have to be pulled down and rebuilt to earthquake-proof specifications. Until then, the almost total absence of permanent health infrastructure presents a serious challenge to health workers and their scarred and traumatized patients.

"It is easy to say 'take them to the hospital' -- but where is the hospital?" says CARE's Ghose.

CARE's job in the meantime is to catch the cases that "fall through the cracks." Today, Ghose and her CARE colleague Dr. M. Srinath are visiting such a case: a young woman who is critically ill from internal bleeding following the birth of her child on February 5. A local tradition in this remote corner of India encourages women to avoid breastfeeding in the first days after childbirth. The woman, Lakshmi, 23, followed this stricture and consequently her uterus has not contracted. For four days she lay bleeding in her hut, gripped with fever. By the time CARE staff found her, they feared only a blood transfusion could save her.

By afternoon, they are more optimistic. Lakshmi's tongue is still milky white -- the sign of severe anemia-- but she has taken iron pills and antibiotics and, on the advice of Ghose, started breastfeeding. She now has strength enough to sit up in bed and hold her child. She smiles and says she feels much better.

When asked why she did not go to the hospital, she points out that in this village there is no transportation. More to the point, CARE staff note, where would she go?

Dr. Anubha Ghose asks Parveen to flex his fingers.

On the way back to the mobile clinic, the little boy Parveen appears with his uncle. The child already has been seen once this morning at the clinic, and is returning for a follow-up visit. His face is pinched; his expression that of a wounded animal. His uncle stands one pace behind him, his eyes full of tenderness. Parveen is clutching the arm he still claims is paralyzed, but CARE's Srinath holds his shoulder gently and asks him to move his fingers, which he does.

Parveen is the youngest of four children, and because he was not physically injured villagers say he was "neglected" in the days following the quake.

"People just assumed he was okay," says Ghose. "His mother had enough just coping with the loss of the husband. [This boy] held his grief in so long he finally did something to get attention. So we of course check the physical symptoms, but we also talked with him about his school and his family, and gave him some attention."

Such mental health counseling is often overlooked in the early days of disaster response, but is an important part of longer-term recovery efforts.

"Everyone is going through the same misery. Some people are not injured but they are suffering," says Anu John, a CARE medical and psychiatric social worker. "Sometimes they just want to speak out."

Mental health care is not a priority for relief workers schooled in the emergency drill of food, water and shelter. But CARE staff say that mental health care should go "hand in hand" with other services after such a devastating disaster.

"Everyone here is going through the same misery," says John. "You can't say do this thing [food, water and shelter] and do another [mental health.]"

The medical and mental health needs over the next months will only grow as local government authorities struggle to reconstitute themselves. Most attention in the relief effort so far has focused on the urgent needs for temporary and permanent shelter, and many relief officials feel this will remain the emphasis over the months ahead.

Boxes of relief supplies being unloaded at CARE's warehouse in Anjar.

CARE, however, is looking at a "complete package" of assistance that includes not only shelter but considers medical and mental health care and other services (such as credit programs). CARE staff discuss the possibility of working with local health workers to train them in health and psychological assistance.

Without long-term care, women like Lakshmi and Bahen might die, and little boys like Parveen will continue to suffer -- or worse.

"They feel sympathy for him now, but if he continues to behave like this people will say hi is crazy," notes John. "And he is not crazy. He is just sad."

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