15 May 2006

1. REVITALIZATION OF PRIMARY HEALTH CARE FACILITIES

The refurbishment at the Soli dispensary is almost complete. A water tank has been built and the bathroom is under construction. Painting has been finished inside the main building with only the roof repairs remaining.

Soli clinic a pleasant transformation!

The 600 Gallon water tank being constructed...

2. INCINERATORS RUNNING HOT

10 of the 12 brick incinerators for clinic infectious waste have been constructed. Only the installation of steel lids remaining. The incinerator lids have a large bore 1.2 meter flu to discharge smoke at a safe height to avoid public inhalation. The steel has been difficult to source, and finally AAI has supplied local the welder with 12, 3mm steel sheets to finalise the project.

The incinerator almost finished at Soli...

An incinerator being constructed in Hillan...

3. AAI GOES TO THE REMOTE AND ISLOATED REGION OF BEHEDI

With the road to Behedi finally opened this month after being blocked by snow and landslides since December, the AAI team at Kahuta packed up the office for three days, taking along all staff. Also along for the ride was Behdi's Lady Health Supervisor, Arifa, who had not been back to Behedi since the earthquake. Whilst at Behedi the AAI team carried out the last of the deliveries of DRI donated medicines and equipment. Whilst the deliveries were taking place the training team held training sessions for 7 Lady Health Workers (LHW) covering Hygiene and Sanitation, Disease Surveillance and bird flu information. This was a significant achievement as these were all the LHW's in the local area and this was the first training they had received since well before the earthquake.

The AAI team carrying medical equipment to the clinic at Kwaja Bandi...

4. MEDICAL DISTRIBUTIONS

DRI donated medicines and AAI purchased medical equipment deliveries were completed to the 8 remaining clinics, bringing to total of 18 clinics that received medications from DRI and medical equipment purchased from AAI funds. The team at AAI is in the process of distributing medical equipment donated by DRI to 19 clinics in the local area.

The Civil Dispensary at Hillan...

5. CELEBRITY CHEF

On the 6th and 7th of this month AAI hosted the famous Pakistani TV chef, Madam Fawzia Tariz in Kahuta. Madam Fawzia was kind enough to donate her time to present three sessions including two sessions of cooking demonstrations and nutritional information and one session on tie-dying as an income generating activity. In total 75 women from the Kahuta area attended the two day activities. This was well received by the local community and an event of such that has never occurred before in this remote region.

Madam Fawzia presenting her lessons...

6. HYGIENE KITS

The long awaited UNICEF 3400 hygiene kits were delivered to AAI for distribution this week. AAI has arranged the distribution in collaboration with union councils and other Community Based Organisations (CBO's). AAI will start delivery in the coming week to an eagerly awaiting community of whom have already completed hygiene training by the AAI training team.

7. VOLTAGE STABALIZERS

AAI provided twelve voltage stabilizers EPI vaccination centers to enable them to operate their medicine fridges at constant temperature. AAI was approached by Sub-district Hospital (THQ) to fill the funding gap, which would have seen the centers go without functioning fridges essentially rendering the vaccination program for the district non existent.

Dispensers receive EPI Voltage Stabilizers at THQ from AAI...

Gugdar BHU Dispenser receives 3000W Stabilizer from AAI Staff members Karen and Basit...

AAI Staff Karen, Basit and Qamar deliver essential 7000W Voltage Stabilizer to Mr Aslam EPI THQ...

8. AAI PREPARES TO LEAVE

AAI 's current DFID funded program for Community Health Initiatives is due to finish on the 31 st May 2006 . Whilst AAI are awaiting the outcome of additional proposals to potentially extend our stay, with no definite funding to extend the program the Kahuta office will complete operations on Thursday 25 May 2006 , centralizing in Islamabad until our future in Pakistan is decided.

30 April 2006

1. REVITALIZATION OF PRIMARY HEALTH CARE FACILITIES

•  AAI has selected the clinic at Soli to refurbish. Soli, a Civil Dispensary, which was not covered by Pakistan Government reconstruction and rehabilitation program (ERRA). Many clinics that AAI chose to rehabilitate were covered by ERRA and therefore would have to wait for lengthy approvals before works could begin. A building contractor is currently rendering the walls, repairing the earthquake damage and repainting. AAI is will also supply a permanent water system, re-equip the clinic with new beds, desk and all new medical equipment.

•  In terms of the problems with solid waste management and infection control AAI is in the process of finding constructing brick incinerators at 12 of the clinics in the district. This will greatly assist with more sanitary disposal of medical waste and providing a clean environment around the clinics.

•  AAI is also investigating the possibility of providing to the Sub-district Hospital (THQ) Kahuta with 1700 meters of ½ inch pipe to provide the hospital with constant running water through the summer period.

Soli clinic before rehabilitation works

Soli clinic on day 3 of rehabilitation works

Click here to view a map showing clinic locations.

The remaining 8 major clinics in the Haveli Tehsil will be visited in the upcoming fortnight. The donations are being well received particularly from the clinics that are not accessible by road.

Delivery of medical supplies and equipment to Degwar clinic

2. COMMUNITY HEALTH

•  In this two week period AAI held 4 Hygiene and Sanitation training sessions in Changal, Kahuta and Soli, with 50 Lady Health Workers (LHW) and 1 Lady Health Visitor (LHV) being trained in the delivery of hygiene and sanitation education to their communities. In these sessions four new master trainers were involved in presenting the training to the other LHWs.

•  AAI attended the inaugural meeting of the Women's Community Based Organisation (CBO) in Kalsan, set-up by 2 LHWs as part of the hygiene and sanitation program. The 15 women at the session received hygiene education and discussed their role in assisting the LHWs to deliver hygiene education in the Kalsan community.

•  AAI circulated updated information on Bird Flu to the health facilities in Haveli and was invited to present a Bird Flu information session to 16 LHWs in Soli.

•  All training sessions for reproductive health, family planning and primary health have been cancelled, as directed by DHO and WHO, while they develop a more coordinated program with partners.

AAI interpreter Mr Basit, leading an education session

Education of Lady Health Workers in Soli.

1. Hygiene and Sanitation

2. Bird Flu information sessions

4. DISEASE SURVEILLANCE

Havali Tehsil enjoys the highest reporting rates in the Bagh District (10 out of 12 reporting stations).

With the arrival of the warmer weather AAI have seen an increase of suspected malaria cases.

16 April 2006

1. REVITALIZATION OF PRIMARY HEALTH CARE FACILITIES

•  The AAI Field Site received a mass delivery of priority medicines , equipment and supply essentials thanks to AAI procurement and DRI donor support. Equipment includes sterilizers, syringes, IV sets, kidney dishes, antibiotics, topical scabies treatments etc.

•  AAI 's medical team will now gear up to deliver the much anticipated goods to the 12 Haveli Sub district health clinics over the next fortnight.

•  AAI team members continued to work with local providers in assessing the nutritional status of Haveli children. AAI teams are in the first round of gathering and analysing data on the height and weight of children entering local clinics. The analysis of such data will be passed on to District health officials and UNICEF to monitor trends and support nutritional supplementation where needs are identified .

•  AAI 's training programme and initiative for capacity building has received much attention from national and international partners. The awareness of the need for education revitalization to national providers is rapidly being identified as the relief effort and international community begins to pull out of the Bagh district. In response, AAI has been asked to facilitate our training theories and actual trainings to partner organizations. Liz Headley, AAI 's public health nurse, conducted training in disease surveillance and outbreak control for the staff of Quetta Red Crescent who currently run a remote tent hospital.

•  AAI continues its efforts in bridging the gaps between the Ministry of Population Welfare and the District health authorities in an effort to create and sustain a collaborative effort in preventative and curative MCH and family planning health initiatives. AAI continues to advocate for both parties and is working with the WHO in linking the efforts of the two health networks. As a first step, the providers will be brought together in a joint training session to be held in Bagh in the coming weeks.

•  The director general for livestock in Azard Jammu and Kashmir hearing about AAI 's educational information about bird flu requested AAI 's materials be disseminated thorough all of AJK in health facilities and among his staff to further enforce essential preventative measures.

•  AAI staff member Liz Headley on a visit to the Cuban tent hospital met the arrival of a trauma case. At that time most of the Cuban doctors were involved in meetings leaving only one on duty for such cases. Immediate attention was needed, as such, Liz jumped in and aided the Cuban physician in the assessment and stabilization of the 12 year old girl who fell from a Kahuta cliff side suffering multiple crushing head injuries, and a severely broken arm among other injuries.

•  AAI have done extensive surveys and structural assessments of health facilities in the Haveli Tehsil. In close collaboration and partnership with the DHO, local government and ERRA AAI have chosen to do a number of small scale rehabilitation projects. The first project to commence will be the Soli BHU. AAI have committed to fully rehabilitate and beatify the building including development of a water system and construction of incinerators. Furthermore AAI will be supplying medicines, medical supplies and equipment and furniture for the clinic.

2. TRAINING PROGRAM

•  AAI in partnership with UNICEF continues Hygiene and Sanitation education sessions. AAI master trainers are working through sub-district clinics providing training to all local Lady Health workers. AAI continues to monitor and support the master trainers in organizing and implementing the workshops. Future training sessions are scheduled throughout April to follow Polio NID programs with an expected involvement of 100 LHWs.

1. Hygiene and Sanitation Training Statistics

Click here to see results.

2. Maternal and Child Health Training Statistics

Click here to see results.

•  AAI facilitated the attendance of 9 female health workers from Haveli sub-district to the WHO/DHO Phase 1 training, in Bagh, for MCH/Family Planning Train the Trainer workshop. Three Master Trainers are now providing training to LHWs in Haveli Tehsil. During this training the topics covered are

•  Maternal and Child Health
•  Family Planning
•  Disease Surveillance
•  Newborn Care and Resuscitation
•  HIV / AIDS and STI's
•  Adolescent Health Issues
•  Introduction to IMCI, EPI diseases and gender issues.
•  HIS Health Information System

•  AAI attended the planning session of the training in Bagh on 7 th April to be involved in planning of support to the step-down training program to other health workers in Haveli in the following months.

3. COMMUNITY HEALTH

Hygiene Kit Distribution

At the Health and Hygiene UN cluster meeting lead by UNICEF, AAI was identified as being a forerunner in our efforts to identify utilize and strengthen local infrastructure and government systems by the facilitating and mobilising local community based organizations in the distribution of hygiene kits.

•  The Hygiene Kits comprise of soap bars, towels, toothbrushes, toothpaste, lavatory wash jug, cottonwool, cloth, cotton gauze and other hygiene items. Each household in Haveli will receive one hygiene kit.

•  AAI continues to strengthen relations with local government officials through our distribution efforts supporting and empowering the people of Haveli to get involved with supporting their own communities.

•  AAI have distributed all of 2500 received Hygiene Kits from UNICEF in 4 of the 6 AAI supported Union Councils;

AAI will now await the second delivery of 3500 kits from UNICEF to deliver in the coming month.

•  For a database of the distributions, please refer to Attachment 2, Distribution Plan, and Distribution Timetable.

•  AAI has completed hand washing station water tank distributions to the local schools which have had little or no access to running water. In combine efforts, UNICEF has donated large scale water storage tanks to further support access to clean water.

Hygiene Kit Distribution  

DISEASE SURVEILLANCE

•  ARI, watery diarrhoea, fever of unknown origin and injury continue to be the major contributors to overall consultations.

•  Haveli sub-district reported two deaths over the past two weeks; neither related to communicable disease.

Attachment 1. AAI Supported Health Facilities

Click here to see results.

Attachment 2. 1.1 Hygiene Kit Distribution Timetable

Click here to see results.  

1.2, Hygiene Kit Distribution Plan

Click here to see results.

19 March 2006

AAI ACTIVITIES PER PROGRAM AREA:  

1. REVITALIZATION OF PRIMARY HEALTH CARE FACILITIES

•  AAI facilitated the delivery of paediatric and other priority medicines (ie: antibiotics) to 12 Hevali Sub district health clinics from the DHO and WHO. Click here to view the Clinic Details.

•  AAI teams continue to distribute the educational materials mentioned in previous reports to all levels of health care workers including key community members. Recent materials and support have concentrated on providing information regarding Bird Flu since the confirmed presence in areas of the NWFP. In fear of spread to an already vulnerable population, most chicken distribution pipelines have been stopped into these areas. However rumour has sparked concern with in all areas of Kashmir including Kahuta. The aim of these educational materials is to educate the local community on prevention, identification and management measures.

•  Education materials continue to be created concentrating on tropical illness suspected to be seen as spring and summer approach.

•  AAI team members have distributed both standing and baby scales along with tape measures to begin assessing the nutritional status of Hevali children. AAI will facilitate gathering and analysing data on the height and weight of children entering local clinics and or seen by local health care professionals. The analysis of such data will be passed on to partners supporting nutritional supplementation and will be used to watch trends for the future.

•  AAI's community team has completed assessing the 126 health houses from which the lady health workers provide their services. AAI intends to disseminate the assessment information through the UN teams and local partners facilitating the acquisition of support and assistance where possible. AAI is currently prioritizing need and evaluating where our team can help.

•  In follow up to the last situation report, the UN special operations team has successfully reopened the road to Behdi. This task was by no means an easy feat. The team suffered set backs including a vehicle break failure that due to JC's cunning judgment resulted in an accident seeing only minor injuries for two of the UN ops team members. AAI thanks them for their perseverance and dedication. AAI wants to also take this time to send our most sincere condolences to UN ops for the loss of their brother and our dear friend Paul.

•  Danger is a reality that AAI may face everyday in Kashmir . On that note, AAI sends our love and respects to the Haveli Cuban field hospital team who were involved in a tragic accident when a landslide slammed into their mobile medical team vehicle injuring many and claiming the life of one doctor.

**AAI will remember fondly our friends and co-workers for their commitment to providing AID to the people of Kashmir in this remote and often unforgiving region of the world.

2. TRAINING PROGRAM

•  AAI in partnership with UNICEF has begun implementing Hygiene and Sanitation education. Progressing into a more natural and sustainable system, AAI is facilitating master trainers in attending the initial training sessions. AAI will then monitor and support the master trainers in organizing and implementing community level workshops through Haveli health clinics to the remaining health care providers.

Hygiene Sanitation Workshop

•  Of the targeted health care providers, AAI only had one missing Master Trainer due to weather constraints. Snow high in the Kahuta hills made travel impossible.

•  For both days of the workshop, participants completed evaluations which identified and reinforced topics and their importance in combating public health issues.

•  The AAI training team, assistant district health officer, local medical technician and master trainers have completed the design of an IMCI adapted program. IMCI training is programed to commence in the coming week.

•  AAI will continue to be a resource, providing educational materials, as well as general support and supervision where necessary.

•  A new member has joined the WHO team specializing in Reproductive health. Currently Anna, AAI's training coordinator, is pushing for a Master training session to be held in Bagh and opened to all district providers to then provide the opportunity to bring the training into Haveli.

•  Anna has also been closely liaising with the district level officials to assist in building networks and relations between the local staff Ministry of Population and Welfare and the Ministry of Health to improve access to family planning and STI services.

•  AAI supported the second phase of the Polio campaign by proving cold chain capabilities.

3. COMMUNITY HEALTH

3.1 Clean The World Program

•  Mellissa Tylee working in schools throughout Pakistan donated her holiday time to visit Kahuta. During her brief visit, she coordinated and implemented a “clean up Kahuta” program in line with the international Clean Up the World programmes. The AAI team spent 2 days visiting 4 of the largest local area schools working with the school children to clean their school grounds. AAI also requested from the local military metal drums to be delivered to the schools to be used as incinerators for rubbish. In a few days time AAI revisited the schools to check on the maintenance. We were more than pleased to see that each of the schools have continued to keep their areas rubbish free.

•  AAI 's school hygiene education program has completed sessions now at 21 schools covering 2458 children (Refer to Attachment 2, School Hygiene Program Database). This program has been an outstanding success and will be wrapped up in the next week. AAI would like to thank Bill and Neena Rohs, Denise Elzinga and Azhar–Ul-Islam for designing and implementing this fantastic program. The feedback from not only the schools, but from the local community has been remarkable. All members involved with seeing this program to fruition should feel a true sense of accomplishment in combating public health issues within the community at the most basic levels through reaching out to the Haveli children.

•  AAI has continued to distribute a full cricket set to each of the schools that participated in the program.

•  AAI has given 10 water tanks to the local schools which have had no access to running water. AAI hopes that this will improve the children in complying with hand washing practises.

3.2 PUR Water Distribution Pilot Program – Ahkori

•  AAI in a joint venture with UNICEF is trialling a pilot water purification distribution program. After natural disasters, contaminated water often presents a major problem. Two major sources of contamination are microbial pathogens and suspended matter.

•  PUR is a water treatment program, used to remove harmful pathogenic micro-organisms (bacteria, protozoan parasites, viruses), and suspended matter (solids and organic matter) from water.

•  The local community of Ahkori was selected for the trial by AAI. Ahkori has a population of 200 people. A small community allows for effective product delivery, management, and further data collection for an accurate measure of the trial.

•  AAI has co-ordinated on behalf of UNICEF, the distribution of 2100 PUR water sachets and 41 water buckets, reaching 224 people amongst 41 households in the community of Ahkori. These supplies are intended to last one month from distribution.

3.2.1 PUR Product Delivery and Education

•  AAI staff invoked the assistance of Akhori community leaders to facilitate a day where PUR water training could be carried out to each household leader.

•  Training was run by a local AAI staff member Mr Baber.

•  The training was well received by members of the community. AAI feels confident that the PUR water technique for use of the product was grasped by the household leaders in attendance. AAI staff will observe the usage and effectiveness of PUR water in the community of Ahkori on a weekly basis and report all findings to UNICEF.

4. Morbidity and Mortality

•  AAI analysed data on the Priority Diseases Identified for Haveli Tehsil Facilities.

Click here to see results.

Notes:

Notes:

Sasha Poll
Medical Director, AAI, Pakistan

4 March 2006

AAI ACTIVITIES PER PROGRAM AREA:

1. REVITALIZATION OF PRIMARY HEALTH CARE FACILITIES

AAI facilitated the delivery of blankets to 26 Haveli Sub district clinics. Local authorities prioritized the clinic needs providing AAI with the distribution plan allocating each clinic anywhere from five to forty blankets.

AAI distributed and constructed the last of the initial allotment of winterized tents from IOM /WHO to the very appreciative Bhata Kot clinic.

AAI is currently working with the Sub District authorities in making plans for the distribution of 38 more tents to clinics that are accessible for the first time since winter.

AAI teams continue to distribute the health promotion materials mentioned in previous reports to all levels of health care workers now including key community members.

Health education materials have recently been developed covering Basic first aid; accidental amputation, snake bite, wound care, choking, chest pain, bee stings and other related topics. In response to the start of spring, our educational materials will begin to focus on addressing tropical infections and diseases. Leishmaniasis Dengue fever and Malaria materials are currently being disseminated.

AAI team members are beginning to implement measures to assess the nutritional status of Haveli children. AAI is partnering up with 12 dispensaries and lady health workers to collect the height and weight of all children. The analysis of such data will likely show where support is needed.

AAI medical director has made an appeal to the UN special operations unit to reopen the road to Behdi. Behdi is a highly populated area of Haveli that has been completely shut off since the start of winter. After hearing about AAI training sessions, the lady health visitor from Behdi made an extraordinary journey to Kahuta in order to participate. In response to her dedication to better serve her community AAI is honoured to help increase access to and from this region.

In a continuing effort to support the lady health workers, AAI is assessing the 126 health houses from which the lady health workers provide their services. AAI intends to prioritize the needs and provide assistance where possible. Some health houses will need provisions for safe water, such as pots for water boiling, while other houses have been completely destroyed and would greatly benefit from CGI or tents.

2. TRAINING PROGRAM

AAI has now successfully completed 2 training programs

1. Surveillance and Reporting of WHO Notifiable Diseases

The training team is currently pushing toward handing over the training program (needs assessment, design and implementation) to the master trainers and local authorities. AAI will continue to be a resource, providing educational materials, as well as general support and supervision where necessary.

AAI clinical nurse specialist and training program coordinator Anna Dyer met with a local nutritionist this week in Rawalpindi . Anna has coordinated a special 3 day nutrition training that will be presented by a local Pakistani specialist to the health care professionals of Haveli on March 14, 15 and 16.

AAI plans to support the second phase of polio vaccinations starting Monday 6 th March 2006 .

3. COMMUNITY HEALTH

Food Distribution Program

School Hygiene and Health Promotion Program

AAI 's school hygiene and health promotion program has completed sessions at 13 schools covering 1841 children. This program has been an outstanding success. In response, AAI has expanded the program now targeting all of the schools in Haveli sub district.

The children from surrounding schools have started delivering beautifully decorated waste bins to the AAI office. In recognition of their dedication to clean up Kahuta, AAI has begun distributing the waste bins through Kahuta town bizarre.

AAI continues to distribute a full cricket set to each of the schools that participates in the program.

As a result of the efforts and interests of schools in cleaning their environment AAI lunched a pilot program of Clean Up the World this week. The pilot was tested at a school at the Gramma School , Rawalpindi which proved to be very successful and gained significant media coverage in local news. Many thanks to Nasreen Iqbal, School Director, and Melissa Tynne, Australian School volunteer for their fabulous efforts in making this such a successful program. This program will now be implemented throughout the schools in Kahuta next week and again in September for the Clean up the World Day.

This week AAI ordered 10 water tanks for distribution to local schools. The tanks will be a part of hygiene stands to be constructed at schools in need of running water for hand washing stations.

4. MORBIDITY AND MORTALITY

AAI analysed data on the Priority Diseases Identified for Haveli Tehsil Facilities during this reporting period.

Click here...

Notes:

Sasha Poll, Medical Director, Pakistan
and,
Frank Tyler, Director of Operations

19 February 2006

AAI ACTIVITIES PER MIDQUATER REVIEW
1 December – 19 Feb
REVITALIZATION

AAI remains committed to mitigating the double burden of inequity and poor access to quality health care and aims to improve the level of health for the 122,000 people of Haveli Tehsil. Using a multi-faceted approach AAI engages the community in health activities encouraging sustainable solutions.

Revitalization of the Primary Health Care services

Assessment and Monitoring of Primary and secondary Health Care Facilities:

•  A total 13 health facilities and the THQ hospital have been assessed.

•  12 health facilities and the THQ hospital have been supported by AAI .

•  12 health facilities have been provided with direct bedside supervision, training in clinical practise, and support to the health care providers.

•  100% of the population have had access to curative PHC service in the clinic catchment areas supported by AAI . These clinics have remained open throughout this quarter and stocked with medical supplies. Clinic catchment areas range from four thousand to 22000 people with monthly clinic visits averaging between 250 to 600 per clinic.

•  An estimated 75% of population have had access to secondary level health care service through THQ Hospital , MST, and Cuban field hospital.

Meeting Priority Needs

•  AAI distributed 9 winterized tents to BHU's, RHC's and the THQ hospital.

•  The AAI health team is currently assisting the distribution of a further 41 donated winterized tents. The tents will be delivered according to priority as designated by the DHO and WHO.

•  Chlorine tablets and hygiene education has been provided to 12 PHC facilities and THQ hospital. Catchment area of 122,000 people.

•  AAI have maintained the distribution to 12 heath facilities of essential drugs

•  100% of BHUs and RHCs are providing and having in stock Amoxicillin and Cotrimoxazol

•  AAI assisted with the distribution of governmental supplies of essential medication to the First Aid Post in Chireekot.

•  AAIs previously procured medical supplies were distributed to 12 PHC facilities, THQ and MST hospitals.

•  During the worst phase of the winter AAI facilitated the distribution of 250 blankets donated by WHO and UNICEF to various primary health facilities throughout the area.

•  Over 200 hygiene kits where distributed to the BHU Gugdar. Kits were further distributed by the Lady Health Workers (LHW) assessing pregnant women and families of newborn babies.

•  AAI implemented the family hygiene program in Haveli Tehsil in accordance with the MoU signed with UNICEF. AAI have attended phase I of training and are awaiting phase II to begin training of the Lady Health Supervisors (LHS) and distribution of hygiene kits.

•  In partnership with the WFP, AAI is currently implementing a school supplementary feeding program. This will consist of caloric biscuits and dates to be provided to the children on a daily basis in effort to compliment daily nutritional intake.

•  Expanded Program of Immunisation (EPI) Services were provide directly by AAI to:

•  11 EPI centres are partially functional

•  186 children vaccinated during AAI supported Polio campaign

Strengthening Local Health Systems & Building Capacity

•  14 training sessions have been held in disease surveillance, outbreak control and reporting of WHO notifiable diseases. Of the 154 targeted health care providers, 135 have attended the training to date with a total participants now projected at over 200. These training sessions have included healthcare providers not currently supported by AAI . The participants represent every level of health care provider from LHWs to doctors and DHO officials.

•  AAI conducted the identification, training and use of local DHO master trainers to facilitate AAI training programs; these trainers included the Assistant District Health Officer (ADHO), medical technician, 3 LHVs, Vaccine inspector, and 2 LHWs.

•  AAI completed the design, translation, and distribution of community and primary health provider information documents concentrating on the needs as identified by morbidity mortality reports and assessment of the health care facilities. Distribution of these materials to date includes: 12 PHC facilities, 127 LHWs, 1 midwife, 46 Dispensers, 5 Female Dispensers, 5 nurses, 6 LHVs, 6 LHWS, 4 Doctors, 1 ADHO, and 3 Medical Technicians. The materials have been shared with UNICEF and the WHO to utilize and further distribute.

•  The school hygiene program concentrating on personal hygiene and waste management has now reached 3 school and 465 children.

Disease Surveillance and Early Warning System

Establishment of Disease Early Warning System and Timely and appropriate response to outbreaks with pre-positioned supplies & drugs

•  Enhance Disease Surveillance activities

•  Support of Sentinel Surveillance Reporting Sites: Initially 4 sentinel sites were identified by the DHO and requested to provide weekly reports at the District level. Of the 4 sites, none of the dispensers received formal training in accordance with WHO protocol. To this date AAI have now trained the 12 dispensers serving AAI supported clinics and 18 dispensers from other clinics in Haveli Tehsil. All AAI supported clinics are currently reporting directly to DHO level on a weekly basis. Previously 1 site has also been reporting to AAI while we expect all 12 clinics to report this week and for the upcoming future. AAI would like to extend a grateful thankyou to Dr. Quadoos, Mr Kasim for their support and assistance.

•  AAI is progressing at the Tehsil level with the process of data collection, management, analysis, and response. Provider staff have been trained in case definition, thresholds, and referral from 12 PHC facilities and THQ hospital.

•  AAI provided support of a Disease Early Warning System , Outbreak Task Force and Alert System through assisted with training at the WHO and analysed data with the health care providers.

Refer to Attachment 6 for Current THQ WHO reporting

DISEASE SURVEILLANCE/EDUCATION & TRAINING

•  AAI Surveillance and Reporting of WHO Notifiable Diseases training has added more clinics and clinicians to the growing roster of participants. Assessment of knowledge by pre-test and post-test questions are included in the following Attachments. Assessment of further training needs remain ongoing.

•  Please refer to the following for complete details:

3. COMMUNITY ASSISTANCE

AAI saves the day with assistance to a Pakistan Jingly Truck!!!!

•  On a routine drive with the medical education training team to THQ, AAIs long term driver, Mr Ahassan found himself at an impasse with a Jingly truck in one of Kahutas' tiny roads. The Jingly was deep in mud created from the recent rains. Before long the traffic back logged and the crowd gathered to watch an unsuccessful unrest of the heavy beast.

•  Mr Ahassan attempted to unwind the vehicle winch to no avail. Regardless, he attached a half metre tow rope to the front of the truck leaving no room for error in co-ordinating the movements of each vehicle. With delicate care and much grunting and heaving the Jingly was freeded and the road was cleared. We were so excited we forgot to take a photo of our number 1 driver. Thanks Mr Ahassan.

AAI delivers a WHO donated winterised tent to the Dispensary of Naga Nari… 

•  The oncoming spring and melting of snow has finally provided AAI with an opportunity to assist the people of Naga Nari in the aftermath of the earthquakes. While the road to Naga Nari has been cleared, new land slides from the recent rains have left in places only the smallest of margins on the mountain side road to pass. This made for some hair raising driving to say the least. Soon after leaving the bitumen the sleet fell heavily and the muddied track deteriorated, however the help and assistance of the local residents AAI made for a safe journey to the clinic.

•  Upon meeting the Health Dispenser and other village seniors, AAI discussed a suitable site and plan to return early next week to assist in pitching of the tent. We are looking forward our return of this beautiful village.

•  We would like to offer our sincerest thanks to the WHO for their donation to the Naga Nari dispensary.

•  AAI receives new team member: With bounding energy, a mind for logistic support, and the eagerness to jump right in we are pleased to welcome Michael Mchale to Kahuta. Michael has already made his mark on the community being instrumental in the distribution of winterized tents, blankets, and cricket sets not to mention schmoozing daily with the community elders and local authorities.

Sasha Poll
Medical Director

4. EMERGENCY SHELTER PROGRAM 

AAI successfully completed the IRAS shelter program on, 11 Feb 2006 . The IRAS shelter program has consisted of supplying and distributing approximately 1300 emergency shelters to homeless families. 450 IRAS shelter kits were distributed to individual families during this week through the assistance of the Pakistan Military. This distribution was the final phase of AAI 's emergency shelter program which has concentrated on filling the gaps for families whom have missed out on previous rounds of emergency shelter distribution. AAI would like to thank Captains' Cheema and Imran for identifying needy families and arranging the distribution and monitoring of the emergency shelter kits. Furthermore, with the assistance of Captain Imran's men from the 21 st Sind Regiment of the Pakistan Military, AAI masons built ten IRAS's for vulnerable families all consisting of female headed households.

As the weather in Kashmir is greatly improving and most needy families have received some type of emergency shelter AAI have decided to finish the IRAS emergency shelter program. The program has been a great success and AAI would like to thank the IRAS designers, Mr Umar Iqbal Khan and Mr Hammad Husain , who provided the first round of operational support to ensure that AAI could get IRAS's out to homeless families living at high altitude before the onset of the Kashmir winter. AAI would also like to thank all members of the Pakistan Military that assisted and supported the program. Lastly we would like to thank the AAI family which consisted of many volunteers (Jim Thynne, Gordon Willcock, David Wegman, John Weil, and Jim Judge) all from Australia contributing there own time and money to come out and help get shelters to homeless families in Kashmir.

Frank Tyler
Director of Operations

A. AAI SUPPORTED HEALTH FACILITIES

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7 February 2006

AAI ACTIVITIES PER PROGRAM AREA:

1. REVITALIZATION OF PRIMARY HEALTH CARE FACILITIES
AAI health teams have visited the following health facilities in Haveli Tehsil providing direct bedside supervision, teaching in clinical practice, and direct support to health care providers:

Access to certain health facilities remains limited secondary to weather and road conditions.

AAI team members are also investigating breastfeeding and weaning-food practices from all mothers who present to health facilities.

For a summary of findings, click on Appendix 1, Summary of Clinic Visits .

In addition, AAI teams are educating health care providers at facilities in the following topics : hypertension, diabetes, universal precautions, hypothermia, scabies, diagnosis and treatment of paediatric ARI, and sterile technique for injection.

Through the generous donation of chlorine tablets by Colonel Habib , Pakistan Military Hospital , Bagh, AAI team members have promoting safe water usage and hygiene education to all health facilities visited, including THQ Hospital Kahuta.

AAI team members were poised to assist and facilitate the WHO/UNICEF/DHO Polio Campaign beginning 24 th January. However, as Haveli Tehsil was not included in this polio round per WHO, AAI staff continued normal daily operations instead of polio immunization monitoring and supervision.

AAI supported and monitored the Polio Campaign in Haveli on February 3 rd , 4 th , and 6 th . AAI thanks Mr. Aslam, Asst Superintendent Vaccination, and Mr. Farooq Mir, Vaccine Inspector in Charge, greatly for their cooperation in these activities.

AAI has signed an MOU with UNICEF to implement a family hygiene program in Haveli Tehsil and already received the first donation of family hygiene kits. AAI will send a team member to attend the UNICEF meeting regarding hygiene promotion in early February. This AAI team member will then implement hygiene education in the field utilizing Lady Health Worker Supervisors and Lady Health Workers. At the completion of hygiene training done at health facilities, community members will then receive one UNICEF hygiene kit per family. AAI thanks Mr. Julian Parker for his assistance and cooperation in this program.

AAI will facilitate the distribution of blankets donated by WHO and UNICEF to ADHO, Haveli Tehsil. These blankets will be given to various primary health facilities throughout the area.

2. DISEASE SURVEILLANCE/EDUCATION & TRAINING

AAI successfully training programs in Surveillance and Reporting of WHO Notifiable Diseases. The beneficiaries were many levels of DHO health care staff. Assessments of knowledge were made by pre-test and post-test questions. Assessments of further training needs were completed by final evaluations. Overall, these training sessions have been met by overwhelming approval and desire for more.

Please refer to the following for complete details:

3. COMMUNITY HEALTH

AAI has created community education materials on hypothermia, frostbite, and scabies, diabetes, hypertension, and universal precautions. These are being distributed through the Shelter and Health Programs, through DHO facilities, and through DHO health facility staff. In addition, these materials have been shared with WHO and UNICEF to utilize and further distribute.

AAI has implemented a school hygiene education program , targeting the following schools in the Kahuta area: government girls' school (1), government boys' school (1), government girls' college (1), government boys' college (1), and private co-ed primary schools (4). This program includes didactic curriculum as well a contest in the creation of artistic posters to be used as further teaching tools.

Neena Rohs , MD MSTPH
Country Medical Director

4. EMERGENCY SHELTER PROGRAM

AAI successfully completed the IRAS shelter program this week, 7 Feb 2006 . The IRAS shelter program has consisted of supplying and distributing approximately thirteen hundred emergency shelters to homeless families. 450 IRAS shelter kits were distributed to individual families during this week through the assistance of the Pakistan Military. This distribution was the final phase of AAI 's emergency shelter program which has concentrated on filling the gaps for families whom have missed out on previous rounds of emergency shelter distribution. AAI would like to thank Captains' Cheema and Imran for identifying needy families and arranging the distribution and monitoring of the emergency shelter kits. Furthermore, with the assistance of Captain Imran's men from the 21 st Sind Regiment of the Pakistan Military, AAI masons built ten IRAS's for vulnerable families all consisting of female headed households.

As the weather in Kashmir is greatly improving and most needy families have received some type of emergency shelter AAI have decided to finish the IRAS emergency shelter program. The program has been a great success and AAI would like to thank the IRAS designers, Mr Umar Iqbal Khan and Mr Hammad Husain , who are the IRAS designers and provided the first round of operational support to ensure that AAI could get IRAS's out to homeless families living at high altitude before the onset of the Kashmir winter. AAI would also like to thank all members of the Pakistan Military that assisted and supported the program. Lastly we would like to thank the AAI family which consisted of many volunteers (Jim Thynne, Gordon Willcock, David Wegman, John Weil, and Jim Judge) all from Australia contributing their own time and money to come out and help get shelters to homeless families in Kashmir.

Frank Tyler
Director of Operations

A. AAI SUPPORTED HEALTH FACILITIES

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31 January 2006

Mavericks who punch well above their weight.

The AAI shelter team continues to build and distribute shelters in the Bagh District of Kashmir at a rapid rate. Two days ago a further 200 shelters were moved from Islamabad to Bagh and immediately distributed to various surrounding villages. Dave Wegman and Marc Preston, with assistance of the soldiers from the 21 st Battalion, The Sind Regiment constructed an IRAS shelter in 4 hours to demonstrate the efficacy of the IRAS emergency shelter system.

In addition to building these shelters the team has been monitoring and supporting villages where shelter kits have already distributed. The team have been more than pleased at the manner in which the IRAS system has been used either in itself or modified by the resourceful villagers.

AAI has also arranged for the delivery of a further 600 shelter kits within the next 2 weeks and will continue

In addition to shelter tasks the team also arranged for the transportation and distribution of 1000 hygiene kits to villagers in the Kahuta region where the medical team is continuing to implement its community initiatives program to train and support 12 Basic Health Units in the District. In addition, Dr Neena Rohs is developing further programs to augment this project including water sanitation and small camp hygiene assessments.

The 4 volunteer nurses from Dynacare in the US have found their feet in an environment far different from their native Chicago and have provided indispensable expertise to our medical capabilities. Medical stalwarts Sasha Poll and Anna Dyer continue to provide the backbone of the team and are at home in one of the more remoter parts of Kashmir close to the Line of Control.

The team have continued to receive accolades and have been described as “Mavericks who punch well above their weight”

8-22 January 2006

AAI ACTIVITIES PER PROGRAM AREA:

1. REVITALIZATION OF PRIMARY HEALTH CARE FACILITIES

•  AAI facilitated the delivery of government stock of essential medications to the First Aid Post at Chireekot.

•  In direct collaboration with the DHO in Bagh, AAI facilitated the transport and delivery of over 200 hygiene kits to the BHU Gugdar. These kits will be distributed by Lady Health Workers to pregnant women and families of newborn babies.

•  AAI distributed and constructed winterized tents from IOM/WHO to the following health facilities in Haveli Tehsil: Chireekot.

•  While AAI attempted the delivery of another winterized tent to Naga Nari, due to snow and road conditions, this was unsuccessful. Naga Nari will most likely remain unreachable until the spring season prevails.

•  AAI also attempted delivery of a winterized tent to Bhatakot, however due to snow and road condition, this was unsuccessful.

•  AAI will re-attempt delivery of both remaining winterized tents for the above facilities when weather conditions improve in the coming weeks.

•  AAI medical teams have visited the following health facilities in Haveli Tehsil providing direct bedside supervision, teaching in clinical practice, and direct support to health care providers:

•  Access to certain health facilities has been limited secondary to weather and road conditions.

•  AAI teams have developed educational materials in areas identified by needs assessments of health care facilities. These include: hypertension, diabetes, universal precautions, and sterile technique for injection. AAI are distributing these materials to all health facilities visited and to all levels of health care worker.

•  AAI team members are currently investigating breastfeeding and weaning-food practices from all mothers who present to health facilities.

•  AAI medical teams distributed all currently available AAI inventories of medical supplies to the health facilities listed above, in addition to THQ Kahuta and MST hospital facilities. While the current supplies are limited, AAI hopes to provide whatever medications possible during these winter months.

2. DISEASE SURVEILLANCE/EDUCATION & TRAINING

•  AAI successfully held a training program in Surveillance and Reporting of WHO Notifiable Diseases. Sixteen participants were trained, including THQ Kahuta Doctor, THQ Kahuta Lady Health Visitors, THQ Kahuta Lady Dispensers, THQ Kahuta Nurses, and Lady Health Visitors from Gugdar and Soli.

•  AAI analysed data on the Priority Diseases Identified for Haveli Tehsil Facilities in December 2005. Click here.

•  AAI has been collecting WHO surveillance data from the THQ Hospital in Kahuta, with many thanks to Dr. Majeed. No significant outbreak has been reported. ARI, diarrhea, and scabies still account for majority of notifiable cases treated at this facility.

•  Click here to see Appendix 1: WHO Surveillance data from THQ Hospital , Kahuta, Nov/Dec 2005.

3. COMMUNITY HEALTH

•  AAI has partnered with the Cuban Hospital to distribute Community Health education materials through health facilities as well as schools. Topics include personal hygiene, sanitation, pregnant women, safe water, and EPI vaccinations.

•  AAI has completed the design, translation, and distribution of community education materials on hypothermia, scabies, and frostbite. These will be distributed through the Shelter and Health Programs, through DHO facilities, through DHO health facility staff as well as given to the WHO and UNICEF to share with other agencies.

•  AAI has been distributing community and primary health provider information on Acute Respiratory Infection and Winter- and weather-related conditions. AAI thanks both WHO and Colonel Habib, Pakistan Military Hospital Bagh, very much for the provision of these excellent educational materials.

•  AAI has developed and will begin implementation of a school hygiene education program, targeting the following schools in the Kahuta area: government girls' school (1), government boys' school (1), government girls' college (1), government boys' college (1), and private co-ed primary schools (4). This program will include didactic teaching as well a contest in the creation of artistic posters to be used as further teaching tools.

Neena Rohs , MD MSTPH
Country Medical Director

4. SHELTER PROGRAM

Previous IRAS Situation

In total there have been 411 IRAS Shelter kits distributed in the following locations:

•  Kahuta
•  Lower Bella
•  Lasdana Road
•  Malot
•  Topi
•  Dhare

As of 4 th January 2006, Bagh District underwent a major weather change, with 5-6 ft of snow falling in high areas over night. Bagh town itself experienced 1-2 ft of snow. As a result, all roads out of Bagh were closed, and distribution of all shelter material temporarily ceased.

This rapid and dramatic weather change caused some initial delays in the distribution of shelter kits to our target areas. These delays have presented the AAI shelter team with several issues:

• AAI's limited ability to transport IRAS kits from Islamabad to Bagh.
• AAI's limited ability to distribute IRAS kits from Bagh town to height affected villages (above the snowline).
• As a result of the snow, there was a sudden increase in IRAS demands from other Union Councils (UC's) within Bagh District.

Current IRAS Situation

This reporting period (10 Jan – 16 Jan 06) has been significantly affected by the Eid celebrations in Pakistan . Most of the key stakeholders in the IRAS program have taken their leave from work or have traveled home to stay with family. This has included:

•  logistic staff in Islamabad
•  local staff in Bagh,
•  UN staff in Bagh,
•  Pakistani Military staff in Bagh
•  logistic staff in Bagh

All shops and services were shut for at least 3 days from 11 Jan 06 until 13 Jan 06. AAI staff continued to maintain contact with as many stakeholders as were available over this period.

Anecdotally, the Eid period also affected attendance at medical centres and distribution points. Interestingly the high demand for medical attention and pharmaceuticals dropped to almost nothing during the Eid period. Since the conclusion of Eid, the attendance and demand for pharmaceuticals has risen to pre-Eid levels again.

There have also been a number of local issues that affect the capacity of all NGOs in the region to deliver on specific shelter program outcomes. These are:

•  Village representatives are approaching NGOs and stating that they have not received shelter assistance from any organizations. On further investigation and comparison to the data currently maintained by IOM, ESC (Emergency Shelter Committee) Coordinating Organisation, it has been discovered that a number of these villages are attempting to “double dip” with different NGOs. These have not been isolated incidents and it appears that this trend is on the rise.

•  Recipients of shelter kits are stockpiling the material in preparation for the Spring thaw. It appears that these individuals are living with relatives in less affected areas during the winter.

•  Recipients of shelter kits are delaying construction of emergency shelters in anticipation of a second round of distribution. It has been stated that they feel if they construct a shelter, then they may not be eligible for a further round of distribution.

•  Some areas see the provision of some shelter kits as for permanent use as opposed to the intent of providing recipients with emergency shelter kits. As such, they feel that this may affect their entitlement to Government compensation.

•  The Pakistani Military are unable to affect a change in this mindset. and have also expressed their frustration at the attitudes they are beginning to face in the region.

•  There has been a paradigm shift in attitude from one of acceptance of relief material to one of demand. Even at the most basic level AAI staff are witnessing this in our campsite. We frequently are faced by people asking for shelter goods and clothing despite the fact that we have none for local distribution.

•  This has led the ESC (Emergency Shelter Committee) as well as AAI staff to the conclusion that there is a trend of feigned dependence. This has manifested itself in the attitude of demand and helplessness that is being displayed for the reasons listed above. It has been stated that the only way in which it is possible to effectively ensure construction of emergency shelter will be to finalise the distribution process and withdraw these programs from the region.

Due to all of these factors, full implementation of AAI's shelter program has become extremely difficult. There are some affected areas where IRAS is being constructed as originally intended; however, the majority of cases exemplify attitudes as stated above. 

Immediate future of the IRAS Program

AAI staff have had the opportunity to consolidate our information and to plan for the next phase of operations in the district.

Our members are now attending the villages where IRAS has been received, and inspecting already constructed shelters as well as those currently under construction. They also liaise directly with the Pakistani Military to assist their members with the distribution, recording and monitoring processes.

Discussions with the Pakistani Military have identified an immediate need to provide shelter to two major regions around Bagh:

AAI have completed initial training in these areas. This has included the construction of demonstration shelters as well as teaching the Pakistani Military in the construction process.

In both Topi and Dhare, AAI has distributed 100 shelter kits. As of this report these 200 kits have been distributed to those most in need of emergency shelter. AAI discussions with the Pakistani Military have led to the immediate planned distribution of 500 to the Topi area and a further 200 to the Dhare area.

AAI staff will be attending both of these areas and ensuring that our construction standards remain high. They will ensure that the distribution information is being recorded correctly, and that those families most in need receive shelter kits as a priority.

To assist in the recording process, AAI staff will be conducting an inspection program over the next two weeks. With a focus on each area, AAI aims to obtain documentary and photographic confirmation of our distribution and construction information.

Distribution Plan

Whilst difficult, the distribution of IRAS to both Topi and Dhare will be accomplished rapidly, weather permitting.

An initial 200 shelters will be delivered directly to the base camp of the Topi Military. They will be splitting this between two affected sites in the vicinity of Topi.

An additional 300 shelters, which are designated for the same area will be delivered directly to the town of Bagh . This will be handed over to 27 SIND , local Pakistani Military, who have been highly motivated in the distribution and construction process within their areas of responsibility.

After this, an additional 200 will be brought to the district. AAI discussions with the Pakistani Military in the coming weeks will focus on the most efficient means of transporting the material to those in need.

It is anticipated that the distribution and construction of the IRAS shelters will be almost complete by the end of January 2006.

As stated earlier, the weather presents an impediment to this process. This has been factored into our planning process. Even with significant delays caused by snow and ice, AAI will be well placed to have the shelters distributed and under construction during the month of January.

Summary

AAI are currently conducting training, distribution, construction and monitoring of IRAS throughout the Bagh District. We have finalised the distribution plan for the remaining IRAS material.

This enables the AAI Shelter Team to focus on the ongoing monitoring of IRAS construction throughout the area.

James Judge
Emergency Shelter Program Coordinator

A. AAI SUPPORTED HEALTH FACILITIES

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7th January 2006

GENERAL OBSERVATIONS

Beginning 5 January 2006 , AAI welcomes two new team members: Jim Judge, Shelter Program Coordinator, and Anna Dyer, Nurse Educator.

AAI Shelter Program shifted primary location of operations from Forward Kahuta to Bagh as of 26 December. The Medical Program will remain based in Forward Kahuta.

Snow and rain came New Year's Day to Kahuta bringing fiercely cold weather and harsh conditions. Roads in and out of Kahuta remained closed for 5 days due to slides and snow. Although there were many fears of landslides, there were no major events reported. Cases of ARI are expected to rise due to the climate change, and general inaccessibility may cause further morbidity due to lack of access to higher levels of care.

The AJK Government was due to complete distributions of flour to communities near Hallan Shamali on Wednesday, 4 January 2006 .

The Pakistani Military base has been able to undertake air operations. AAI received visits from Major Shakeel and his Commanding Officers from Bagh.

The Cuban Hospital stationed near the THQ Hospital suffered tent collapse and grounds' damage due to snow and rainfall. With various Kahuta community leaders, AAI is assisting their move to a safer, more secure structure.

AAI ACTIVITIES PER PROGRAM AREA:

1. REVITALIZATION OF PRIMARY HEALTH CARE FACILITIES =

Since Dec 26 th , AAI health teams completed visits to the following health facility locations with AAI's Area of Operations (AO):

• Tungari
• Palangi
• Degwar
• Gugdar
• Hallan Shamali
• Badhal Sharif
• Soli
• Kalamula

While AAI awaits the receipt of a full 6-month supply of medications for each facility, team members distribute limited medications currently available in inventory.

The need for pediatric medications has been particularly high.

AAI plans to continue distribution in the coming week as well.

AAI distributed and constructed winterized tents from IOM/WHO to three health facilities in Haveli Tehsil: Tungari, Badhal Sharif, and THQ Hospital .

Note that a 2 nd winterized tent constructed by another agency at THQ Hospital did not withstand the recent snowfall. AAI will attempt to facilitate reconstruction of this tent with new materials as available.

AAI had intended to distribute and construct three more winterized tents from IOM at Chireekot, Naga Nari, and Batakot. However, due to winter conditions and heavy snowfall in these locations, this plan will need to be revised after further discussion with IOM, WHO, and DHO.

2. DISEASE SURVEILLANCE/EDUCATION & TRAINING

AAI has added an Addendum to the original MOU as signed by AAI, ADHO, and THA (Tehsil Health Authority). This Addendum correctly states the 12 health facilities as supported by AAI.

In collaboration with DHO, AAI analysed data from the National Programme for Family Planning and Primary Health Care.

The following data have been reported from Haveli Tehsil by LHW's for November 2005:

• 118 Live births recorded
• Of 99 newborns weighed, 8 (8%) low birthweight babies born
• Of 2405 children >3 yrs weighed, 346 (14%) children noted to have low weight for age
• 2 stillbirths
• 5 early new natal deaths (defined as within 1 week of life)
• 0 child deaths
• 0 maternal deaths
• 192 cases of TB diagnosed
• 40 deaths overall

AAI analysed data on the Priority Diseases Identified for Haveli Tehsil Facilities in November 2005. Click here to see Figure 1.

The main diseases reported reflect findings elsewhere in Bagh district, with ARI, scabies, and diarrhoea being major concerns.

For further disease information, please refer to Appendix 1: Figure 2, Disease Category per age group, for Haveli Tehsil data reported to the DHO, November 2005. Click here...

AAI has been collecting WHO surveillance data from the THQ Hospital in Kahuta, with many thanks to Dr. Majeed. No significant outbreak has been reported. ARI, diarrhea, and scabies remained major causes of morbidity of cases treated at this facility.

Please refer to Appendix 2: WHO Surveillance data from THQ Hospital , Kahuta, Nov/Dec 2005. Click here...

AAI team members attended the WHO Training session on Outbreak Control in Complex Emergencies on 28 December 2005 . This training was designed for all members of investigative and response teams in the three subdistricts of Bagh.

AAI's Health Program has made disease surveillance and reporting the first priority for the six-month training and education program. The targets of these trainings will include

• Nurses from THQ Hospital
• Head dispensers from each health facility
• Lady Health Visitors (LHV's)
• Lady Health Worker Supervisors
• Lady Health Workers (LHW's)

AAI aims to support the training and education of all of these LHW's as the primary link to the health of community members. Each LHW is assigned 120 families, or 800-2000 individuals.

AAI has been working closely with the Head of THQ Hospital, ADHO Dr. Quddus, and DHO Dr. Latif to develop and implement data collection, disease surveillance, and primary health care training and education programs.

• As part of primary health training, AAI plans to support education for vaccinators within Haveli Tehsil and the 11 identified EPI centers, as feasible: THQ Hospital , Hallan Shamali, Soli, Khursidabad, Tungari, Gugdar, Degwar, Changal, Bhedi, Cherikot, and Sirsian.

3. COMMUNITY HEALTH

AAI has completed the design of community education materials on hypothermia in Urdu. These will be distributed through the Shelter and Health Programs, as well as given to the WHO and UNICEF to share with other agencies, and are appropriate for community members of many levels of education.

AAI is partnering with the Cuban Hospital to distribute Community Health education materials through health facilities as well as schools. Topics focus on personal hygiene, sanitation, pregnant women, safe water, and EPI vaccinations.

AAI plans a hygiene education program in Kahuta-area schools through art classes, thus promoting creativity and local dissemination of knowledge to combat the high rates of diarrheal diseases reported.

SHELTER PROGRAM

AAI has distributed and constructed 189 IRAS (Improvised, Rapid, All-weather Shelter) units to date in Haveli Tehsil and Bagh district areas.

Please refer to Appendix 3: IRAS Register. Click here...

AAI will continue to distribute IRAS shelter units, and monitor the construction of 200 more shelters in the Bagh district area.

AAI has been operating in the Bagh district with the cooperation of 27 th Sindh Pakistani Army unit, assisting in construction and distribution of shelter units. In addition, Major Shakeel and 21 AK Regiment continue to be of great support to AAI in the Kahuta region.

Weather-permitting, AAI plans to complete the IRAS construction and distribution program by the end of January.

AAI SUPPORTED HEALTH FACILITIES Click here...

17th December 2005

AAI's STRATEGIC PROGRAM DESCRIPTION:

AAI's charter is to provide humanitarian relief in some of the most remote and isolated regions of the world.

AAI, responded within 10 days of the earthquake by bringing in medical and logistic teams. AAI immediately began performing search and recovery operations in the most remote areas of Azad Jammu Kashmir province. Highly skilled in providing emergency medical care in resource-poor settings, AAI successfully delivered definitive care as well as evacuations given limited supplies and equipment to over 2000 patients in their initial 6 week response.

In line with the humanitarian phases of international relief (emergency, rehabilitation and recovery, and development), AAI have developed a program design that facilitates efficient and effective capacity building and sustainability of the local health care system. Using this methodology allows for comprehensive short and long term program planning, straightforward transitions between phases, and overall effective management strategies.

The overall focus remains consistent with AAI 's operational mandate—to focus on capacity building and support of the local health care infrastructures at both the primary and, where appropriate, secondary levels. Through primary health, public health, and community health programs, AAI aims to not only match but also to surpass existing access to health care and standards of care found prior to the recent events.

ORGANISATIONAL STRUCTURE ON THE GROUND IN PAKISTAN

Kahuta/Bagh Field Site

Bill Rohs – Site Manager

Dr. Neena Rohs – Medical Director

Sasha Poll – Medical Coordinator

Owen Wolahan

Tuesday 6 th December saw the existing field team shift from Lasdana mountain base to an improvised office/accommodation building AAI are leasing in Forward Kahuta, 50 kilometres east from Bagh, in preparation for the winter ahead. AAI are currently in a transitional phase in which we say goodbye to several volunteers who have been instrumental in exhibiting both expertise and commitment to AAI 's philosophy. The core team above will now focus on the long term sustainability of the health program and full implementation of the Improvised All-weather Shelter (IRAS) project in the Bagh District region.

OBSERVATIONS POST EARTHQUAKE IN AND AROUND KAHUTA

The weather has improved this week thereby increasing access to all clinics within the Haveli sub-district, Kashmir in which AAI are supporting. With the reprieve in weather, AAI , WHO and local organisations have increased supplies of vital medications to major distribution points, allowing regional dispensaries to restock before the winter finally closes in. Also associated with the warmer weather, the incidence of acute respiratory illness has stabilised for the week. Shelter provision continues to be pivotal to the wellbeing of the community and many families throughout Kashmir remain without suitable winter accommodation, increasing the likelihood of pneumonia and hypothermia in the weeks to come.

AAI are witness to unfortunate stories from around the area: a tent fire on the hill above Kahuta on Saturday night, 10 th Dec claimed the life of one child; the mother and two other children are in hospital in Rawalpindi . This may become more prevalent as locals desperately try to keep warm and may be oblivious to the hazards of living in tents.

The Cubans Government have set up a tent field hospital adjacent to the damaged THQ (Tehsil Headquarters - equivalent to a sub district hospital). This field hospital will consist of a surgical theatre with xray and ultrasound facilities. This is expected to be fully operational to inpatients late next week while they are currently providing assistance to outpatients at a macro level, including making house calls. This will be very beneficial to the many patients receiving preliminary treatment who require follow-up and are unable to return to the hospital. AAI look forward to developing a collaborative relationship with the Cuban Field Hospital within AAI 's designated area of operations.

AAI ACTIVITIES PER PROGRAM AREA TO DATE:

1. PRIMARY HEALTH CARE/DIRECT PROVISION OF SERVICES

•  AAI's Emergency Medical Response Team (EMRT) entered Pakistan on 16 Oct. with more medical, logistic, and shelter personnel rapidly following.

•  AAI medical teams also volunteered time and expertise in the PIMS hospital emergency department in Islamabad in the emergency receiving area.

•  In the initial 6-week period, AAI's medical teams definitively treated over 2000 patients in remote village settings.

•  AAI teams evacuated over 100 patients to appropriate higher levels of care as necessary.

•  Concomitantly during search and recovery work, AAI teams conducted village and health facility assessments in all locations accessed.

•  As winter approached, AAI developed and distributed community education materials regarding hypothermia and frostbite.

•  Types of injuries/conditions treated:

•  long-bone fractures (both simple and compound)

•  lumbar and pelvic fractures

•  spinal cord injuries

•  closed head injuries

•  crush injuries to the thorax, pelvis and extremities

•  secondary infections/abscesses related to untreated or maltreated lacerations

•  acute motor vehicle trauma

•  acute upper respiratory infections

•  acute diarrhea

•  hygiene-related skin diseases, such as scabies

The following appendices provide WHO surveillance reporting data for AAI activities in the first phase of response:

•  Appendix 1 : 22-28 Oct

•  Appendix 2 : 29 Oct-4 Nov

•  Appendix 3 : 6-11 Nov

•  Appendix 4 : 12-18 Nov

•  Appendix 5 : 21-26 Nov

Proposed activities:

AAI 's area of operations (AO) continues to be the Haveli Tehsil within Bagh district of AJK province.

AAI has already begun the process of transition to a longer-term rebuilding and development phases of operations. After conducting full assessments of health facilities within the AO and in accordance with AAI 's Emergency to Recovery Continuum program model, AAI is moving toward mentoring, training, educating, and supplying phases.

2. SHELTER PROGRAM

The IRAS is a transitional shelter which can last between one to five years depending on how well owners protect the structure by using plastic sheeting or mud render. Therefore the cost of the design will go to providing a permanent outbuilding for animals or as a store in the future when communities move into their permanent structures.

The unit cost inclusive is approx $280. The major cost is the CGI sheets which have increased in value by up to 50% due to the supply demand. Some other organisations solutions require double the amount of CGI sheet than is being proposed by the IRAS design. Therefore many other shelter kits are more expensive than the IRAS. There are also no tools or equipment that has to be provided to construct the IRAS, also reducing the costs of design.

Since the building of the first IRAS in Bagh, a number of groups have expressed interest in the design and have asked AAI to assist them with the construction and distribution in their own AO's. One of AAI 's main goals is to promote the IRAS design so that other organisations doing emergency shelter will consider using the IRAS system which will save on resources and cost, which most other designs are unable to compete with.

Locally designed, by a group of architects and engineers who wanted to assist with the relief effort, they feverously began researching and testing temporary shelters that could quickly and cheaply be built for immediate distribution to the homeless in Northern Pakistan. What they have developed is the IRAS that meets all requirements of not only suitable emergency shelter but that of integration of emergency shelter into longer life structures.

The designers looked at the basic guidelines of temporary shelter and established that shelters should be, quick and easy to build by community members, be safe against extreme weather and further earthquakes that are common in this region, be inexpensive (costing about the same price as a non-winterised tent), easily transported to remote mountainous villages by foot, constructed of locally and culturally familiar materials and methods of construction, and built requiring no special tools or equipment.

The materials used include empty cement bags, filled with soil on site to construct the walls. These replace brick and stone. Barded wire is used as a binder instead of cement and gives the structure a monolithic design and contributes to earthquake resistance. The roof is made of only 5 sheets of CGI sheets requiring no internal supports due to the barrel vault roof design.

3. PUBLIC HEALTH/COMMUNITY HEALTH PROGRAM

In direct collaboration with the District Health Office, AAI serves to revitalize and improve the existing health care infrastructure for 11 health care facilities, reporting over 2100 patient visits per month total. AAI aims not only to restore the levels of health care delivery to pre-disaster standards, but also to improve and raise the standards of care for these poverty-stricken village populations. Through comprehensive public health and community health programs, AAI plans extensive education and training in keeping with Pakistan Ministry of Health standards. These programs focus on maternal health, child health, nutrition, hygiene, and diagnosis and treatment of the area's most prevalent preventable illnesses.

A. AAI SUPPORTED HEALTH FACILITIES Click here...

16th December 2005

The existing field team shift from Lasdana to a house we are leasing in Forward Kahuta, 38kms southeast of Bagh (as the crow flies) and approximately 6kms from the Line of Control.

PERSONNEL

The last two weeks has seen significant movement in the personnel department. Tuesday also saw the arrival of the Site Manager, John Weils and Community Liaison Officer, Corie Waddell to the already talented team operating in the field (Forward Kahuta Office).

We said goodbye to Dr Bryan Chaffee on Saturday 10 th December followed closely by Dr Jamin Mulvey on Monday the 12 th December. Both were instrumental in providing expertise and commitment to the cause. They provided the much needed data/statistics in relation to each of the clinics so that Sasha Poll and Dr Neena Rohs can continue developing and now implementing their medical program. See Dr Jamin's medical update below.

We were joined in the field by Dr Neena Rohs and Owen Wolahan, our Information Officer, on Wednesday 14 th Dec and look forward to Bill Rohs, Site Manager, joining the field team today. Bill's arrival is the last of the permanent crew who will spend the next 6 months implementing the numerous initiatives started by the immediate response team.

Wednesday 21 st December will see four team members return home. Gordon, David and Corie will complete their volunteering tenure with the hope of assisting in some capacity, with AAI, in the future.

SITUATION UPDATE

COMMUNITY LIAISON:

Corie Waddell

After a recent misunderstanding with the military based in Bagh, about the route taken from Islamabad to Kahuta on Tuesday 6 th December, we relied on the relationship building and expertise of the existing team with the locally based military here in Forward Kahuta.

In an attempt to cut traveling time between Islamabad and Kahuta, we took the road east of Islamabad to Rawalkot via Mandi. This section is closed to foreigners due to security concerns. It became increasingly apparent for the need for AAI, and all NGO's, to work with the military police effectively as their main priority is to protect all foreigners working/volunteering in this region.

As a result, we need to check in with the military on a daily basis to inform them of our movements so they can assess whether or not we require an escort or provide us with important information. The Shelter Boys have built firm relationships with the military, in order to promote the IRAS Design as the ideal shelter program to see the local community through the coming winter. They are currently gathering information on the families in most need in the immediate area. See below for a more detailed update on the IRAS program.

The urgency of getting these shelters built is increasing daily as we are expecting more snow in some of the higher regions within the week. The past week here in Kahuta has already exhibited a shift to the lower end of the thermometer. Despite some sunny days, the nights are cold.

Yesterday saw our first altercation with ice while leaving the village of Mirchkot . Albeit small, it was a good indication of what is to come and a timely reminder to ensure all vehicles are fitted out with the necessary equipment to combat icy conditions on the roads.

While the transition phases are winding up with many volunteers having to return home, transferring all the knowledge including contacts and statistics is in full swing. The office in Kahuta will be receiving some much needed equipment and supplies in the form of desks, couches, heaters and IT equipment as well as alternative means of communications as currently we only have satellite services. We are also investigating the possibility of setting up an office in Bagh to facilitate the need to attend meetings and liaise with partners more efficiently. Currently, it takes three hours, one way, to commute from Forward Kahuta and Bagh meaning we are often driving at night and with the weather deteriorating, this will become extremely difficult if not at times, impossible.

We are starting to hear some unfortunate stories from around the area. A tent fire on the hill above Kahuta on Saturday night claimed the life of one child while the mother and two other children are in hospital in Rawalpindi with serious burns. This may become more prevalent as locals desperately try to keep warm and may be oblivious to the hazards of living in tents.

Other news is that the Cubans are in town. They have set up a tent hospital adjacent to the crumbled THQ (Tehsil Headquarters-which is equivalent to a sub district hospital). This tent hospital will consist of a surgical theatre and xray and ultrasound facilities. It is expected they will be fully operational to inpatients late next week and are currently providing assistance to outpatients at a very macro level. This will be incredibly beneficial to the many cases whereby patients who received pre-liminary treatment, were asked to return in a week or two but did not, only to return at a later date with additional ailments as a result of not following instructions or contracting new infections.

Adding Spanish to the flavour of languages and/or accents currently in Forward Kahuta, they are said to have two English speaking team members of a total of 70 staff. After some impromptu discussions with them yesterday, there are at least five members who can have varying degrees of English comprehension which should make communication with them relatively easy once key contacts are established.

We look forward to developing a very strong relationship with the Cuban Tent Hospital as they will relieve some of the pressure we are receiving to actually treat people and enable us to re-direct our efforts back into our training program for long term sustainability. We will continue to stock each clinic with the necessary supplies however, having a point of contact for referrals and medivac assistance/support is fantastic for us.

Much of my week has been spent accompanying both the doctors and the shelter boys on route to some of the villages for assessments. An eye-opening experience personally and affirmation to the extraordinary team working hard to meet both the immediate need for shelters and emphasis on the long term sustainability of our medical program in an attempt to decrease the current level of dependency on NGO's.

A recent interview conducted for Incommunicado with 19 year old Thir (Ta-er) Riz from the village of Nakr , just above Palangi, brought understanding of the devastation of the earthquake to a new level. Hearing a personal account of what it was like during the actual earthquake was intense and hearing about the recurring nightmares many of the villagers are experiencing is heartbreaking. Thir watched a wall of his classroom fall on four of his friends. Only one of them survived. A short exerpt of the interview is below:

Crying earthquake is coming, to his father, and horribles, dead body, dead body, very horribles…

Our roof is very telling. I have 3 friends. I stand near the wall. I am standing at this point, friends are standing over at wall, I say come here, come here but they do not come, wall falls on his friends. wall falls on me. Please somebody give me help.

Thursday also saw us evacuate a 12 year old girl from Mirchkot with suspected hepatitis. Sasha and I came across this little girl (Tasleem Nakir) after our visit to the dispensary in Mirchkot on Tuesday. On arrival yesterday, she was walking and had taken both fluid and solids since our last visit. While still very fragile, her condition had improved. We took her directly to the Cuban Hospital with the intent to get some blood tests and confirm our initial diagnosis as well as admit her. They were unable to admit her as their inpatient service was not ready. We tried the THQ but that too proved fruitless. We then relied on contacts made with Major Anjum at MST (Mobile Surgical Team) who, while predominantly a surgical hospital, set us up with their medical consultant, who graciously accepted to see her. Her prognosis was better than expected, she received some new treatment and we were able to take her home again. Should time permit, we will endeavor to visit her again in a week or two and see if she has improved. If not, then the Cuban Hospital will be operational and be able to run the lab tests we were initially hoping to do yesterday.

Some other projects in the pipeline include collating GPS coordinates, primarily of the medical clinics, in order to produce a detailed map of the region (cluster) AAI is covering. The objective is to illustrate some key detail that will enable the medical team to plan their visits to the clinics from both a time and locality point of view. We will also attempt to provide as much geographical detail as possible to provide safe and/or alternative routes should the snow prevent access on familiar roads. This information will be additional to the data collected and maps produced during the immediate response phase.

I plan to continue assisting the medical team and the IRAS's if applicable in the form of training documentation and modules to support the training they will be providing to the dispensar's. It will involve translating simple instruction sheets into Urdu. Whether it can be done in time to provide assistance to the shelter program is unclear as yet but it will be considered a priority on my return to try and turn it around as soon as possible.

MEDICAL UPDATE:

Dr Jamin Mulvey

The weather has improved this week meaning access to all our clinics within the Haveli sub-district, Kashmir . With the reprieve in weather, AAI, WHO and local organisations have increased supplies of vital medications to major distribution points, allow regional dispensaries to restock before the winter finally closes in. Also associated with the warmer weather, the incidence of acute respiratory illness has stablised for the week, although this too is certain to change. In some ways, this period of warmer weather is the calm before the storm. Shelter provision continues to be pivotal to the wellbeing of the community and many families throughout Kashmir remain without suitable winter accommodation, increasing the likelihood of pneumonia and hypothermia in the weeks to come.

We have visited all clinics this week, reviewing their patient presentations, medical stores and advising them of our education program to be initiated in the coming weeks. As always, medications were accepted with much gratitude, particularly paediatric paracetomol, paediatric antibiotics and scabies treatment, all of which are constantly in low supply within the Kashmir region. Earthquake-related injuries have mostly been diagnosed and treated, and most illnesses are back to pre-quake levels. The AAI team this week saw a variety of patients, including numerous lacerations and one elderly diabetic male with a dense hemiparesis (stroke) requiring urgent referral and treatment. The AAI health program continues to give much needed support to the local people and improving medical care.

I have had the opportunity to work closely with the Military Hospital in Kahuta, analysing data from the initial earthquake and the use of ketamine in emergency field surgery for 150 patients. Major Anjum (anaesthetist) and myself are closely reviewing this information, with the aim to publish results in the near future. This week I will be working with the understaffed surgical team at the Military hospital, assisting in major cases. This collaboration strengthens AAI's commitment to the Kashmir region and improves our relationship with the military hospital and local health providers.

Sasha Poll, our most recent addition and Medical Coordinator, is closely liaising with the local District Health Officer both in our region, in Bagh, and in Islamabad . Here for up to six months, Sasha is developing and instituting an Education program for the local medics and lady health workers. As medicines and disease treatment has changed somewhat, and many workers have not had further education for up to 25 years, this training and education program aims to improve health care provision and allow for sustainability after AAI leaves the Kashmir region. The aim of this program has been discussed with local health staff and authorities and they are eager to participate. The curriculum is currently being discussed with the Pakistani Government District Health Office.

With the Department of Foreign International Development (DFID) funding being approved this week, our medical program stepped up a notch and is full steam ahead. AAI continues to fully assess, support and work with the local health care providers in difficult circumstances, leaving its mark of world standard health care in Kashmir .

IRAS PROGRAM:

A very slow week in terms of the construction of IRAS's in and around the Bagh area. Initial complications with securing funding for the equipment then lead to hold-ups at the border for items such as CGI sheeting for the roof of the IRAS. However, a great deal of work has been spent developing mutually beneficial working relationships with the military in Kahuta to identify the areas and families most in need. We now have a list of around 25 families to add to our register in the Forward Kahuta region and we will endeavor to focus on building these IRAS as soon as possible. As of Friday 16 th December, we completed our first IRAS in partnership with the military in the tiny village of Kalsan , above Forward Kahuta. Gordon was instrumental in making this happen with assistance from contacts he made through the military, primarily with Major Shakeel. Knowing how to play cricket is a distinct advantage. John is currently coordinating the construction of IRAS's in the area known as 27 Sindh, just west of Bagh and David is currently working in Rawalkot/Bakaram with the same intent. We look forward to an update in both these regions next week.

These areas have been identified as key areas for some time, however, the distribution of materials has been the main challenge, monitoring the distribution extremely difficult and maintaining timeframes virtually impossible. We are in discussion with partners such as the UN (logistics), IOM and the military on a regular basis to shift these materials where they are most needed.

The longer the distribution issue exists, the more difficult it will become to implement the IRAS initiative as we are currently going through a transition whereby our enthusiastic shelter boys will be leaving us in the next week. Our priority now is to train and/or instruct as many masons, military personnel and locals on how to construct the IRAS so we can step back and take on a more supervisory and/or guidance role.

This issue has also made negotiations with our partners a little tedious at times and we have learnt not to promise anything. However, the shelter boys have continued to reassure their relevant contacts of our commitment to the IRAS program and the completion of the IRAS at Kalsan has come at a very opportune time.

As of today, there is movement in the wings and delivery of supplies is imminent.

Morale or motivation amongst the locals in engaging in the construction of their IRAS is not as prominent an issue as previously. Of the few IRAS we have constructed in the last week, the locals have been very keen to assist and are extremely appreciative of our assistance. It will be important to continue exhibiting the necessary influencing skills to continue momentum. This will become easier as they begin to understand the benefits of the IRAS design and how it will see them through the impending winter.

It is incredibly rewarding to see an IRAS completed with acknowledgement of the recipient and their family. This alone will make phase two of this initiative a very exciting one to watch unfold.

10th December 2005

The weather has improved this week meaning access to all our clinics within the Haveli sub-district, Kashmir . With the reprieve in weather, AAI, WHO and local organisations have increased supplies of vital medications to major distribution points, allow regional dispensaries to restock before the winter finally closes in. Also associated with the warmer weather, the incidence of acute respiratory illness has stablised for the week, although this too is certain to change. In some ways, this period of warmer weather is the calm before the storm. Shelter provision continues to be pivotal to the wellbeing of the community and many families throughout Kashmir remain without suitable winter accommodation, increasing the likelihood of pneumonia and hypothermia in the weeks to come.

We have visited all clinics this week, reviewing their patient presentations, medical stores and advising them of our education program to be initiated in the coming weeks. As always, medications were accepted with much gratitude, particularly paediatric paracetamol, paediatric antibiotics and scabies treatment, all of which are constantly in low supply within the Kashmir region. Earthquake-related injuries have mostly been diagnosed and treated, and most illnesses are back to pre-quake levels. The AAI team this week saw a variety of patients, including numerous lacerations and one elderly diabetic male with a dense hemiparesis (stroke) requiring urgent referral and treatment. The AAI health program continues to give much needed support to the local people and improving medical care.

I have had the opportunity to work closely with the Military Hospital in Kahuta, analysing data from the initial earthquake and the use of ketamine in emergency field surgery for 150 patients. Major Anjum (anaesthetist) and myself are closely reviewing this information, with the aim to publish results in the near future. This week I will be working with the understaffed surgical team at the Military hospital, assisting in major cases. This collaboration strengthens AAI's commitment to the Kashmir region and improves our relationship with the military hospital and local health providers.

Sasha Poll, our most recent addition and Medical Coordinator, is closely liaising with the local District Health Officer both in our region, in Bagh, and in Islamabad . Here for up to six months, Sasha is developing and instituting an Education program for the local medics and lady health workers. As medicines and disease treatment has changed somewhat, and many workers have not had further education for up to 25 years, this training and education program aims to improve health care provision and allow for sustainability after AAI leaves the Kashmir region. The aim of this program has been discussed with local health staff and authorities and they are eager to participate. The curriculum is currently being discussed with the Pakistani Government District Health Office.

With the Department of Foreign International Development (DFID) funding being approved this week, our medical program stepped up a notch and is full steam ahead. AAI continues to fully assess, support and work with the local health care providers in difficult circumstances, leaving its mark of world standard health care in Kashmir .

Dr Jamin Mulvey
Medical Officer

7th December 2005

The full force of winter threatens the people of earthquake ruined Bagh District of Kashmir , with temperatures plummeting nightly to below freezing at altitudes higher than 6000ft. Heavy snowfalls at the beginning of this week created a holt in transportation and distribution of medical supplies, shelter, food and clothing to eastern Bagh due to the closure of a major arterial road through the 8,600ft mountain pass at Lasdana. The limited operations by NGO's and military due to the sudden winter change have focused relief to the still much needed areas in the lower valleys.

Emergency shelter provision is still of utmost priority for all parties involved in the relief effort for Kashmir . A large number of families are still without adequate shelter, and there is serious concern for those at higher elevations above the snowline. Winterised tents, corrugated galvanised iron (CGI) sheeted A-frames, and pre-fabricated fibreglass shelters have been provided by some NGO's, however it remains unclear whether these materials and designs will withstand the extreme conditions of wind, temperature, snow and ice.

A new concern for the emergency shelter program by most NGO's is the delay in forwarding supplies of CGI sheets. 70,000 sheets of CGI sheets are currently sitting on the docks of Karachi and have been awaiting distribution for two weeks to Kashmir. It has been suggested that the delay is due to materials being manufactured in India. Departments of the United Nations are discussing options for its expedient forward supply, including the direct involvement of the Pakistani President.

Of real concern, the further delay of material to families still living in make-shift accommodation, may force whole families and communities from their villages into Internally Displaced Persons (IDP) camps. The UN is currently discussing a contingency plan should this disaster eventuate.

The health situation is still on high alert. Weekly surveillance programs of health centres closely monitor any changes in health profile. A total of 23, 032 consultation were reported to the World Health Organisation for analysis. Infestations have increased approximately 700% from last year, likely due to overcrowding and poor hygiene/sanitation. Acute respiratory infections are steadily increasing with the decreasing temperatures with approximately 1000 cases reported. Localised outbreaks of watery diarrhoea are a constant concern with 126 cases reported for the previous week and bloody diarrhoea incidence has tripled from the previous week. Fortunately, after the initial rise in acute flaccid paralysis attributable to tetanus after the earthquake, no further cases have been identified in the last few weeks. Rapid identification of these health concerns allows for quick assessment, treatment and containment. A fierce attack by a wild bear on three Kashmiri's required urgent evacuation and surgical intervention. These patients remain in a critical but stable condition.

AAI RESPONCE

The shelter program by AAI, using the IRAS design, was in full swing this week. A large distribution early this week, coinciding with the heavy falls in snow, provided much needed shelter to many families in the Bagh District. With the help of village elders, families at greatest risk were identified, including widowed female headed households, orphaned children and families with injured persons. Village males were trained in the construction of the IRAS. Our shelter team, lead by Jim Thynne and myself hiked 3 hours in steep terrain and failing light to monitor progress of construction in the village of Lohar . The success of our shelter program was demonstrated this week by the ease of distribution of materials, willingness of locals to learn construction methods, and ease of construction to provide a warm, secure, wind- and water-proof shelter. Compared to other designs which cannot keep out the elements, the IRAS appears to be superior and well suited to the harsh conditions that Kashmir will shortly experience. With the recent arrival of three fit, Australian volunteers for the shelter program, and more IRAS arriving this week, our shelter program continues to excel. Even more importantly, our CGI is manufactured locally, bypassing the current gridlock at Karachi and supporting local industry.

The medical program this week has been hampered by the snow, limiting access to the remote regions of eastern Bagh district and Haveli sub-district. The arrival of Dr. Bryan Chaffee, an Emergency Physician from the United States , has greatly increased our presence in the community; however the snow dictated our movements. The eagerness of the AAI medical response team could not overcome the extreme risk of travelling the steep mountain pass by road, covered with ice and snow for 5 days. Our efforts however have been focused in assisting the urgently busy AAI shelter team, and our presence was appreciated by all. The roads have now cleared with 72hrs of warm weather and sun, and our program will steam ahead at full speed. Sasha Poll since arriving in country and more importantly into the field has been instrumental in guiding AAI in our efforts to assist the earthquake-ravaged medical clinics, supply urgently needed medicines, and continue training of medical staff in the Haveli sub-district with the goal to improve their health program and allow for sustainability into the future.

CONCLUSION

AAI continues to pave the way with the relief work in the Haveli and Bagh sub-districts in Kashmir. Our efforts, although hampered by the snow, have also reinforced the urgency to prepare the region for the impending winter. With average snowfall reported at 25ft at higher elevations, it is imperative that shelters are provided as urgently as possible. Closely entwined in the shelter program, the health program continues this week. Although no major disease outbreaks have been reported as yet, if shelter is not provided, it seems inevitable that health will acutely deteriorate, with increasing pneumonia and hypothermia.

AAI continues to work closely with the UN/WHO and Islamic Relief to provide for the people of Kashmir in these uncertain times.

Prepared by:
Dr Jamin Mulvey
Chief Medical Officer
Australian Aid International

1st December 2005

AAI RESPONCE

Winter has arrived. The international community is loosing in the race against time coming in as a slow second to Mother Nature as the harsh weather begins to settle in. Area access roads are blocked. Icy and treacherous conditions have made already difficult journeys an extreme challenge. At present, AAI's camp is virtually inaccessible. Weather conditions have begun to drastically hamper relief efforts in remote and isolated communities.

Shelter material remains insufficient to meet the needs of the affected populations of the area. AAI with local partnership has successfully implemented the IRAS emergency shelter program. In consultation and with tremendous support from our local partners AAI is forging the path in shelter design and construction. Initially, AAI has made 1000 homes available. Daily, AAI's Director of Operations, Frank Tyler, meets with business executives in an effort to collaborate locally for materials and funding which will allow AAI to continue mobilizing and building suitable shelters. Along with providing essential living conditions, AAI notably is providing the most basic preventative health approach. Shelter, when adequate to combat extreme conditions will serve as the first line of defence and most appropriate mechanism to prevent respiratory illness and other cold weather related health threats.

Reports of death and despair begin to flood into the AAI office as three more shelter experts begin to ready for their fated drop into the harsh conditions of the Himalayas . Effectively the race against time is in the hands of AAI's shelter team of 4 men. Without shelter the morbidity and mortality rates will skyrocket.

AAI continues to provide hands on basic health care in emergent situations while moving into a more mentoring role with local medical personnel. AAI doctors and nurses are vigorously moving toward training and enhancing systems with the local dispensers at Hallen Shamalli, Soli, Pallangi, Gugdar, Tangari, Buhdal, Bhata-Kot and Mirch-Kot in an effort to give back a sense of autonomy and effectively leave a sustainable system founded on the legacy of knowledge.

SITUATION

The Ministry of Health and partnered organizations met yesterday in an effort to prioritize the international aid communities approach to this unprecedented disaster and aftermath. The priorities at this time include but are not limited to; establishing shelter, disease surveillance, re-establishing primary health care facilities, and identifying female health care providers. With an alarming 80% of health facilities destroyed or damaged beyond use the tasks at hand provide a real challenge.

Another area of concern, expected to worsen with the onset of wet weather, is communicable disease. The Chief of Public Health recently reported that Crimean Congo Hemorrhagic Fever has killed one doctor in Karachi . Blood samples have been urgently dispatched and the medical community remains on high alert. An alarming increase of cases of acute water diarrhoea was detected in one of the spontaneous camp settlements in Muzaffarabad and is now believed to be contained. With the weather drastically worsening and aid becoming more difficult in remote regions many of the fears regarding outbreak and deadly respiratory illnesses have turned from fears to reality.

CONCLUSION

With temperatures plummeting to -15° Celsius in the highest settlements coupled with the recent snow fall, the tasks at hand have become increasingly urgent.

AAI continues to work with members of the local population, government and military to provide medical and shelter assistance to the affected population living in the conflict zone situated along the militarised Line of Control. AAI continues to be the only NGO in the extreme zones. The team has been briefed and is thoroughly prepared to meet this challenge and prevail.

Prepared by:
Sasha Poll
Medical Coordinator
Australian Aid International

An historic opening of the Kashmir border, which separates Pakistan from India, has been scaled back from five to two crossing points. "Only two relief points were opened on November 7 along the Line of Control", Indian army spokesman Vijay Batra said.

India and Pakistan last week agreed to open five points along the LoC in the aftermath of the October 8 earthquake. India gave no reason for the decision not to open three of the posts, but sources explained that both areas are highly mined.

The openings at the LoC after nearly 60 years have been widely hailed as a major advance in relations between India and Pakistan. An Indian government official made it clear there would be no long queues of survivors or relatives waiting to cross over to meet relatives. Access would be strictly limited to relief operations.

In Indian Kashmir, 1,300 people were killed and more than 150,000 made homeless by the earthquake. Official Pakistani Government figures continuing to rise, with the death toll now reaching 73,276 and the number of injured in excess of 69,000.

Temperatures continue to drop in the Haveli Tehsil where AAI teams continue to operate within a short distance of the Line of Control. Temperatures vary between –2 and 15 degrees. Scattered showers and light snow have been observed in areas above 10,000 feet. 

AAI RESPONCE
One month after the October 8 earthquake left almost 3 million homeless in the Kashmir region, AAI race against the weather and terrain to reach the injured, ill and those who are most vulnerable in the remote mountainous communities. Our efforts are slowed by poor weather, long and a damaged roads, as well as the terrain, which is mountainous and difficult to access.

Bhata- Kot
An AAI medical team has completed an assessment of Bhata-Kot, which is about 50 minutes drive north of Gugdar. Due to the treacherous road conditions no relief has been delivered to the village by the Pakistani Government or other sources. The closest relief had been received at Gugdar, which received building supplies, but no medical assistance.

Bhata-Kot has a damaged but useable dispensary, which services approximately 5000 people. According to the local population, their greatest needs are housing materials and medical care. The AAI medical team issued the local dispenser a Basic Emergency Health Kit and a supplementary supply of parenteral antibiotics and medications. AAI will continue to work closely with the dispenser over the winter months.

Mirch-Kot
A villager from Mirch-Kot attended the AAI base camp at Lasdana late on Monday night requesting assistance for two women who needed to be evacuated. A medical team drove into the valley and hiked the remainder of the way to the patients. One woman received medical treatment in her make-shift-home and the other was stabilised and transported to MST near Kahuta.

The Mirch-Kot dispensary was destroyed by the earthquake and will not be repaired before snow begins to fall in that area. On Wednesday, another team delivered a Basic Emergency Health Kit, a supplementary supply of parenteral antibiotics and medications, and a tent to serve as a temporary dispensary, until a more permanent structure can be built.

Bedhi
A follow up visit to Bedhi and further liaison with the local dispenser and military personnel confirmed that the army medical teams will be withdrawing from the area before it begins to snow. The military will leave two medics to assist the dispenser, who has now moved into a local school building. The dispenser will work closely with a military doctor over the next few weeks to treat as many patients as possible before the cold winter months. As there are currently no female medical providers in the area AAI will establish a much-needed female clinic in the area within the next 72 hours.

Khurshidabd (Kella)
The village and surrounding area of Khurshidabd has had no doctor since the earthquake. A full time dispenser is employed and operates from the town hospital. The hospital is in good physical condition, however due to lack of staff, patients who require in-patient facilities are transported to Kahuta Hospital, approximately two hours drive west of Khurshidabd. The hospital has a sporadic electrical supply and has not had running water since October 8. Most people had received regular vaccinations up until October, but the hospital now has no supply of medicines or vaccinations and is in need of resupply. A Basic Emergency Health Kit was given to the dispenser by an AAI team.

There is no major visible structural damage to the buildings, however locals expressed concern at the structural integrity of their homes since the earthquake and requested assistance with acquiring tents.

Hella
The town of Hella has a solid freestanding three-room building that is used as a first aid station, which services approximately 6000 people from the surrounding area. The building was not damaged by the recent earthquake and has sporadic electricity. Water is now available from a local spring. No medical supplies have been received at the first aid station since September and as a result, patients are now only receiving limited medical treatment. A Basic Emergency Health Kit was given to the Health Technician by AAI to assist with daily operations.

The Health Technician, who has 16 years experience as a health service provider, sees between 700 and 900 patients each month. The first aid station is a free service, which does not provide an in-patient facility. Vaccines are administered by the dispenser in Kella.

Kahuta
An AAI team established contact with the civilian and military authorities in Kahuta and dialogue was initiated to coordinate future activities. AAI discussed with the area commander, Brigadier Abid, future vaccine programs, our plans with the District Health Officer, relationships with local dispensers and AAI logistical issues. The possibility of a new base of operations in Kahuta was also discussed, as many of the roads in the Haveli Tehsil will be unusable during the winter months. Staff from AAI will meet with the Pakistani military again next week.

CONCLUSION
Exchanges with other local military commanders, MoH officials, NGOs and UN agencies will continue to ensure that the targeted and effective response by AAI is maintained as we quickly approach the coldest months of the year.

As AAI medical teams are still recovering injured patients from earthquake affected areas and evacuating them to higher levels of care, we are now beginning to work with the local dispensers and establishing good working relationships with them. We have commenced a program of reviewing the dispenser's skills, level of training and experience. Where needed, we are providing on-the-job training to the dispensers, vaccinators and Lady Health Visitors, while assisting medical providers with treatment to members of the local community and maintaining their medical supplies to a reasonable level.

30th October 2005

Three weeks after the earthquake, it is estimated that half the deaths and injuries caused by the October 8 earthquake are children. With a steady stream of injured people continuing to be located by our medical teams, the United Nations increased its plea for aid from $313 million to $550 million. The timing for receipt of pledges from donor nations has not been confirmed, but Kofi Annan, the Secretary-General of the United Nations pleaded with the international community on Wednesday for more support to prevent a “second wave of deaths”. NATO has now operated 27 relief flights to Pakistan with 454 tons of assistance. An additional 210,000 winterised tents and 2 millions blankets are still required though.

The United Nations Office of Coordination for Humanitarian Affairs (OCHA) has estimated that there is a three-week window of opportunity to deliver assistance to mountainous areas before first snowfall. OCHA further assessed that as much as 30% of the area affected has not been reached, which could translate into at least 200,000 people not getting the assistance they need. Access via primary roads has improved in the last couple of days. An influx of helicopter assets has also assisted the logistical process of moving personnel into remote locations and extracting injured patients. AAI has extracted 7 patients in the last 48 hours, and they have been referred on for further medical treatment in Bagh and Islamabad .

The number of homeless caused by the October 8 earthquake is estimated to be between 2.7 and 3.2 million. Landslides continue to be a threat to road travellers and aftershocks continue; the AAI team based at Lasdana has been woken three out of the last seven nights from tremors.

AAI teams have reported an increase in the amount of Scabies and Acute Respiratory Tract Infections. These are now becoming major public health problems due to lack of hygiene, cold weather and inappropriate shelter. Infection of wounds and untreated fractures are the most frequent issues our medics and doctors are coming across as they continue fighting to save limbs and lives.

The World Health Organisation (WHO) has recorded 111 cases of tetanus, including 19 deaths in several locations and 14 cases of measles in Balakot and Batagram.

In Indian-administered Kashmir , less than ten kilometres from where AAI medical teams are operating, the estimated death toll stands at approximately 1,400 dead, 5,000 injured and 140,000 homeless.

AAI RESPONCE
On Thursday an AAI medical team attended the village of Bedhi , which has a surrounding population of 12,000 people. Bedhi is a three-hour drive from the Lasdana base camp along rugged roads that have been damaged by the recent quakes. 25% of the patients treated were children, many with respiratory problems, who were treated with Albuterol inhalers, Prednisone and Zithromax. Nearly 40 patients were seen, with six surgical procedures performed. AAI later met with Syeh Bukhari, the Sunni Muslim leader in Azad Kashmir, who gave his support to the Australian relief group.

On Friday the same medical team established two medical clinics at Halla Shimali, each with a doctor and medic and again later in the day at Soli, with a total of 58 patients seen and eight surgical procedures conducted. One eight year old male and a 12 year old female were suffering from scabies.

An evaluation and evacuation run was conducted on Saturday by an AAI medical team. Two patients were re-evaluated and transported to Bagh, with a 65 year old male, who was suffering from a femur fracture, flown to Islamabad for surgery.

Another medical team was the first to respond to an emergency road traffic accident. A 14 year old male was found dead, with a nine year old male suffering from a concussion and bruising to the head, treated with fluid resuscitation due to his lowered conscious state and referred for further tests for suspected neurological injuries. A ten year old male had a severely dislocated elbow and was given pain relief before the dislocation was reduced. The driver of the vehicle, an 18 year old male received a 2cm laceration to the centre of his head, which was bleeding profusely. His wound was cleaned and compressed. All patients were conveyed by AAI to the MST Military Hospital .

The medical team then treated a seven year old male from Pallagni, who had a suspected bone infection who was also referred to the MST Military Hospital for further observation.

The AAI logistic support team is currently sourcing suitable cold weather tents from various countries, to provide shelter to villages in the vicinity of Lasdana, to help prevent deaths during the oncoming winter.

In collaboration with the WHO, AAI will in the next 48 hours commence a measles, tetanus and polio vaccination program in the Haveli Tehsil, 27km east of Bagh

CONCLUSION
On Thursday, President General Pervez Musharraf directed an all out effort, providing relief to the areas still not accessed after the earthquake ravaged areas of NWFP and Azad Kashmir.

The President showed grave concern that some people in remote areas have not yet received relief goods and may still be in need of medical assistance, and asked all concerned to reach out to the people stranded in the inaccessible mountainous regions.

AAI recognises that the window to reach earthquake survivors in the remote mountains and high valleys of quake-hit Pakistan is fast closing with the onset of cold weather. AAI teams continue to work in the Haveli and Bagh Tehsils providing essential medical services to people in need.

26th October 2005

Relief efforts for survivors of the 7.6 magnitude earthquake that levelled towns and villages in Pakistan on 8 October, 2005 continue to rely heavily on helicopters to reach isolated communities in the region. The death toll has now reached 53,000, with 75,000 injured and an estimated 2.8 million people homeless.

As President General Pervez Musharraf reaffirmed Pakistan 's commitment to finding a resolution to the long-standing Kashmir dispute, AAI teams continue to work in the disputed region.

The UN has warned that relief efforts have about three weeks to deliver enough aid to quake survivors in the mountainous areas of Azad Kashmir, before the first snowfalls, but torrential rains and very low temperatures are expected within the next few days.

AAI RESPONCE
The AAI team trekked two hours and descended over 2500 feet to reach injured villages at the remote village of Mirch Kot , home to 50 people yesterday. There, AAI treated nine patients, all suffering from various conditions. One of the patients, a 42 year old female, has endured a serous femur fracture since the October 8 earthquake. AAI stabilised the patient and coordinated the evacuation of this patient with support from the Pakistani Military. The team then moved to Pallangi and treated another eight patients, including three other serious orthopaedic injuries.

Today AAI liaised with other NGO's in Bagh. They included MSF, Humanity First and Save the Children. AAI will be working closely with Humanity First to refer other seriously injured patients to their facility in Bagh.

Whilst travelling to Bagh, a AAI medical team treated another serious femur fracture. This patient, a 56 year old male, was found on the side of the road accompanied by relatives. A 26 year old women suffering from a fractured sacrum was also treated by the team and transported to medical facilities in Bagh. During our time in the Lasdana area, 22% of our patients have had major traumatic neurological, orthopaedic or soft tissue trauma injuries.

As new cases of tetanus, measles are reported immunisation continues in Bagh. Skin diseases caused by lack of hygiene, cold weather and inappropriate shelter continue to be seen in remote villages in the area of Lasdana and Haji Pir. Treatment continues for cases of impetigo and scabies as they are found.

In the last 24 hours AAI medical teams have treated 22 patients who needed urgent medical attention.

AAI has been asked by the Pakistani Military to locate and coordinate suitable landing zones for Pakistani relief operations.

CONCLUSION
With the health infrastructure shattered in Azad Kashmir, AAI medical teams continue to provide life saving treatment, as aftershocks continue in the affected areas. Predictions of bad weather are cause for concern, as it will have a devastating impact on relief efforts, with the chances of accessing remote areas practically impossible. AAI continues to work hard to save as many lives as possible before the harsh Kashmir winter arrives.

HEATH UPDATES

13th December 2005

AAI, Australian Aid International, responded within 10 days of the earthquake by bringing in medical and logistic teams. AAI immediately began performing search and recovery operations in the most remote areas of Azad Jammu Kashmir province. Highly skilled in providing emergency medical care in resource-poor settings, AAI team members successfully delivered definitive care as well as evacuations given limited supplies and equipment. At times trekking over 2 hours in rough terrain to reach injured patients, AAI treated over 2000 patients in their initial 6 week response.

In addition, AAI has been a frontrunner in fighting the race against winter and educating village populations in hypothermia prevention. Through a unique local partnership, AAI has been successfully implementing the distribution and building of Improved Rapid All-weather Shelter (IRAS Program). To date, AAI has built over 100 shelters including a facility for the UN. AAI are also currently building a IRAS hospital for Rawal Kot, and assiting with building a 100 IRAS unit camp in Bala kot for Peace Malaysia . AAI plans to continue implementation of IRAS through December in order to minimize further sequelae and deaths resulting from hypothermia and intensely cold weather. AAI has also provided community education to remote village populations in prevention and home treatment of cold-weather-induced injuries and mild hypothermia.

AAI has already begun the process of transition to a longer-term rebuilding and development phases of operations. The beneficiaries of AAI operations will continue to be the most remote areas of AJK province, with a cachement area of over 140,000. In direct conjunction with the Department of Health, AAI serves to revitalize and improve the existing health care infrastructure for 11 health care facilities, reporting over 2100 patient visits per month total. AAI aims not only to restore the levels of health care delivery to pre-disaster standards, but also to improve and raise the standards of care for these poverty-stricken village populations. Through comprehensive public health and community health programs, AAI plans extensive education and training in keeping with Pakistan Department of Health standards. These programs focus on maternal health, child health, nutrition, hygiene, and diagnosis and treatment of the area's most prevalent preventable illnesses.

Neena Jain MD
Medical Director, Pakistan