One rehab professional contributes to disaster relief in Pakistan

By Rob Senior

Since the turn of the century, most all parts of the world have been brought to their knees by disaster, whether natural or manmade. From the terrorist attacks in New York City, Washington, D.C., London and throughout the Middle East, to the Southeastern Asian tsunami, and back to the United States and the hurricane-ravaged Gulf Coast, nary an area has been spared the wrath of these calamities.

However, the worst of times has a way of bringing out the best in people, as perhaps best shown through the Ground Zero cleanup effort after 9/11. Thousands of volunteers descended upon New York City for a job that was sure to take months, even years. Their volunteer spirit has carried onto other affected regions, whether through physical efforts or monetary donations.

Many physical therapists and other rehab professionals have been a part of this effort, some by offering their professional abilities. One such volunteer is Judy Coho, BSPA, director of rehab at Good Samaritan Hospital of Maryland. Following a devastating earthquake in Pakistan on Oct. 8, Coho and two colleagues ventured to Southeast Asia to the physical rehabilitation needs and capabilities. This is her story.

The Idea

Good Samaritan Hospital of Maryland, Inc, has a collaborative program with Johns Hopkins University's (JHU) Department of Physical Medicine and Rehabilitation. Prior to the earthquake Dr. Neil Halsey of JHU School of Public health, was involved in an ongoing dialogue with the Pakistan Institute of Medical Sciences (PIMS)to help develop a Master in Public Health program with the university. Following the acute phase of earthquake recovery, Dr. Halsey was contacted by the Joint Executive Directorof PIMS to request some help with assessment rehabilitation needs of the survivors. A week or two later, Coho received a call in the strangest of places.

"It was the day before Thanksgiving, so there I was in my local grocery store," she laughed. "Dr. Jeffrey Palmer, chairman of the JHU PM&R department, asked if I'd be interested in going to Pakistan."

Coho couldn't say yes fast enough. Two weeks later, she was boarding a plane along with Dr. Charles Knoll, a JHU physiatrist, and Mark Hopkins, PT, CPO. The delegation was headed by Dr. Knoll, who provided medical insight; Hopkins, who provided expertise in the areas of physical therapy, prosthetics and orthotics, and Coho to provide administrative and operational consultation.

Relief Effort

More than 69,000 were injured in the earthquake. Thousands suffered orthopedic injuries, more than 500 were recovering from amputations and more than 400 survived spinal cord injuries. The team was prepared assess current rehabilitation capabilities and future needs. "They had no idea how they were going to start rehabilitating the massive number of survivors," revealed Coho. Yet it was very clear that PIMS wanted to provide appropriate rehabilitation services that would enable the survivors to return to their communities.

PIMS is located in the capital city of Islamabad, but the injured and homeless (estimated around 2 to 3 million) were spread throughout several cities and mountainous regions Pakistan and the Kashmir region.

The quake had occurred around 9 a.m. on a Saturday morning, with the epicenter in the small town of Balakot. Saturday is a work/school day in Pakistan, so most of the men were in the cities at work or in the fields. Therefore, the majority of those who were injured or killed were women and children who were in their homes or schools.

Upon arriving in Islamabad, the contingent was greeted by another earthquake the first night. But it was no small aftershock—the quake measured 6.4 on the Richter Scale.

"I was so tired, I thought I was hallucinating," Coho remembered. "But when we woke up the next morning, we were warned that if many others had been injured, we might've been pressed into emergency triage. Fortunately, that wasn't necessary."

Undaunted, the group pressed on throughout the region, spending their week touring the Islamabad region. It didn't take long for them to realize that rehabilitation in the area was underdeveloped.

"PIMS is a 1,000-bed hospital including the Children's Hospital," said Coho, "but in the height of the evacuation efforts there were at least 4,000 patients there."

Moreover, in Pakistan, family members take care of patients while they're hospitalized–cooking meals, helping with daily activities, even going outside to buy medicines to bring back into the hospital. This meant several thousand more individuals on site–the result of which was the entire hospital's campus being transformed into a tent community.

Staffing was another issue—Coho said that PIMS had only four PTs on staff for every 1,000 patients. Occupational therapy was non-existent in Pakistan. Therefore, a lot of work was done by technicians, who performed very basic, passive PT.

PIMS was helped substantially by the World Health Organization, which built a 100-bed pre-fab spinal cord rehabilitation unit on the campus of the National Institute of Health, a 30 bed acute community hospital outside Islamabad. Another 100 bed pre-fab rehab unit was under construction at the National Institute of Handicapped.

Next, the group headed to the Melody Center, which demonstrated the people's spirit to Coho.

"That place [the Melody Center] was amazing," she remembered. "It was located in an old, burned-out movie theater and held 53 female spinal cord injury survivors from ages 13 to 54. We met a team of physical therapists and spinal cord injury survivors from Thailand and Handicap International who were providing education and support."

Coho found it interesting that the group from Thailand at the Melody Center was comprised mainly of men. In Pakistani culture, women and men do not typically interact on such a level. "It was interesting to see the camaraderie that developed between them," she reported.

Coho's group also encountered another two person rehabilitation contingent, this one from the Australian Red Cross who were conducting a similar needs assessment. Representatives from Handicap International had donated 500 wheelchairs to be used by the survivors located throughout the area.

Orthotics

The Fauji Foundation Hospital is a military governmental complex located in Rawalpindi specializing in manufacturing artificial limbs and orthotics, Coho and her colleagues encountered representatives of the Internation Committee of the Red Cross (ICRC).

"It was incredible to watch their process," she said, regarding the facility processing of wooden prosthetics. "I watched a willow tree transformed before my eyes into a very functional prosthetic."

The turnaround time for a traditional prosthetic is about three to four weeks. The ICRC is working with the Foundation to introduce a new manufacturing system that can shorten production time to three to seven days..

The group at this time also visited the Armed Forces Institute of Rehabilitation Medicine (AFIRM). The institute was designed for military members and their families, but after the earthquake was pressed into service along with all other functional facilities.

After visiting the facilities, one question remained—how would these people maintain a minimum standard of health? In Pakistani culture, people prefer to see a community healer before even considering a trip to the doctor. Preventive health care in the rural regions is essentially non-existent.

The Mountains

For Coho and her group, there was only one place left to visit–the mountainous regions of the northern Pakistan, the foot hills to the Himalayas and the center of the earthquake's destruction. When they finally got to visit, it was the only time they were left alone the entire trip—and it was eventful. Due to a miscommunication, their group was taken to the relief staging area airstrip. After numerous conversations with Pakistani and American representatives, it was determined that they should have been flown to the medical helipad in Muzzafrabad. The Pakistani Air Force agreed to fly them into town after accompaning them on a tent drop.

"They were on a relief mission," said Coho, "so we loaded up the helicopter and accompanied the Pakistan Air Force to a village high in the mountains providing shelter to those left homeless. After the drop they were enroute to Muzzafrabad when all of a sudden, we came around a mountain—and the devastation of the city was unreal."

Whole mountains collapsed down into the valleys and rivers in an avalanche of stone. Six-story buildings were reduced to mere shells. A later tour of the area showed schools that had collapsed, killing hundreds of children. But even more amazing was the sight of surviving children continuing their lessons on a nearby dirt patch. For Coho, that sight was a lasting image of the trip. "Their resiliency is amazing," she admitted. "With a 90 percent literacy rate, people take their education very seriously."

Plan for the Future

Coho somewhat sheepishly admitted that part of her motivation for touring the mountainous areas was to do a home assessment to determine what measures would have to be taken for the injured to return home. This, of course assumed they would still have homes.

After seeing the depth of devastation, the focus shifted to providing education and help for the overwhelmed physical therapists and technicians. " At AFIRM, we met up with a physician from the University of Wisconsin who was originally from Pakistan," said Coho. "He brought over some physical therapists to provide education to care providers."

Similarly, the Hopkins delegation's two-pronged plan involved taking a team rehab professionals over to Pakistan to provide education for the technicians working in rehab capacities. Another consideration was the sorely lacking psychological help to assist all the health care providers, the survivors and their families cope with the magnitude of the devastation and loss they've encountered.

Phase two would potentially involve bringing the Pakistani therapists back to the United States for further training. But even Coho admits that at this point, it's just an idea.

"People have to understand just what a huge undertaking this is," she explained.

But if anyone can do it, it's the people of Pakistan—no strangers to disaster, their natural ability to adapt has only been strengthened. The way they see it, they don't have time to feel sorry for themselves.

"The most impressive thing was how everyone over there has a purpose," said Coho. "Even if it's just cleaning the streets, everybody has a role. No one is sitting around idly."

Rob Senior is on staff at ADVANCE and can be reached at rsenior@merion.com