Gujarat Earthquake Relief Mission - World Health …apps.searo.who.int/pds_docs/B0591.pdf ·...

WORLD HEALTH ORGANIZATIONGandhinagar, Gujarat (India)

World Health Organization May 2002

Gujarat Earthquake Relief MissionThird Report of WHO Activities following the Earthquake

(1 August 2001 - 31 January 2002)

SEA/EHA/A1

Backdrop 1

Health Sector Coordination 4

Operation Health, Kachchh 15

Malaria Outbreak in Kachchh District- a Case Study 15

District Disease Surveillance Task Force 18

Public Health Laboratory at Bhuj 19

Strengthening of Water Quality Surveillance for Kachchh District 24

Water Quality 25

Capacity Building through Training and Awareness Programmes 27

Water and Sanitation Sector Review Workshop, 29

Ahmedabad, 13 October 2001

Inter-State Meeting on “Gujarat Earthquake: Health Sector 31

Perspectives”, Ahmedabad, 6-9 November 2001

Expansion of WHO Activities in other Earthquake-affected 39

Districts of Gujarat

Report of WHO Activities, 1 August 2001 - 31 January 2002

Gujarat Earthquake Relief Mission

Contents

Page

Backdrop

The devastating earthquake that hit the Kachchh district of Gujarat on 26 January 2001

affected 37.8 million people. Housing, schools, roads, communication systems and

power lines were all completely destroyed which resulted in a loss of livelihoods as

well as lives. The Government of Gujarat and the national and international community

responded quickly to this disaster with emergency relief services. The emergency phase

lasted until mid-March 2001. Since then, the rehabilitation phase began, keeping in

mind the long-term goal of sustainable development. The United Nations Disaster

Management Team (UNDMT) in India prepared a comprehensive report on the UN

System response. WHO was designated as the focal agency for the health sector

response and a cooperating agency for water, sanitation, food and nutrition. From the

beginning, WHO was instrumental in acting as a link between the Government and

NGOs, and coordinating activities to minimize overlap and maximize available

resources. WHO played a vital role in protecting and promoting the health of the people

through improving the quality of water supply and establishing a disease surveillance

system.

The first quarterly report from 26 January - 30 April 2001, and the second report

covering the period 26 January - 31 July 2001 were brought out earlier. This is the third

report in the series for the period 1 August 2001 - 31 January 2002.

1



2



The main areas of activity of WHO in the last six months were:

(1) To support the re-establishment and rehabilitation of health services in the

earthquake-affected areas with special attention to primary health care;

(2) To provide technical advice to the Government, UN agencies, bilateral agencies

and NGOs on priority public health issues in the aftermath of an earthquake;

(3) To collaborate in the health sector coordination;

(4) To support the Government in establishing disease surveillance in the

earthquake-affected areas, including an early warning system and capacity

building for rapid response to epidemics;

(5) To provide technical support for emergency repairs of water distribution system, water treatment and temporary distribution, sanitation and solid waste disposal, food safety, vector and zoonoses control; and

(6) To expand all WHO activities in other earthquake-affected districts.

3



Team Leader

Disease Surveillance Coordinator

Water and Sanitation Specialist

Surveillance Officers (NUNVs)

Administrative Assistant

Logistics Assistant

Information Technology Assistant

Data Entry Operator

Drivers

1

1

1

6

1

1

1

1

7

WHO Team in Bhuj (October 2001)

Designation Number

• Technical advice and coordination in the health response to the emergency situation, disease surveillance, water and sanitation to the Government of Gujarat and other UN agencies.

• Working closely with international and local NGOs to support their activities and assist with coordination within the health sector.

Health Sector Coordination

WHO was requested by the United Nations Disaster Assessment and Coordination

(UNDAC) Team to support public health and health sector coordination in Gujarat

through restoration of public health services as soon as possible following the

earthquake, and to maintain its presence in the state to help ensure that public health

care was given adequate attention in the period of time after immediate relief and

before complete restoration of the health services. WHO is the lead agency to support

health sector coordination and cooperation amongst international agencies.

• Good coordination between WHO, Government, UN agencies, national and international NGOs.

• Thirteen meetings of Health Sector Coordination Group held during the

period of six months.

• Sub-sector group meetings held regularly every fortnight.

• Weekly coordination meetings at Taluka level in four most affected talukas,

viz. Anjar, Bhachau, Bhuj and Rapar.

The first health sector coordination meeting was held on 5 February 2001 in the field

headquarters of the International Federation of the Red Cross and Red Crescent

Societies Field Hospital at Lallan College. Till 30 April 2001, ten health sector

coordination meetings had been held, while during the period of six months from 1

May to 31 October 2001, a total of 13 meetings took place.

During the second and third quarters, as the need for intensive coordination decreased,

the meetings were taking place fortnightly instead of weekly. The district government

health officials regularly attended the meetings. Attendance at the meetings decreased

towards the end of the third quarter as many agencies finished their work and left the

area.

4



Meeting Days in Bhuj

May

June

July

August

September

October

November

December

2

2

2

3

2

2

1

1

10, 24

7, 21

5, 19

2, 16, 30

13, 27

11, 25

29

20

Month Number Dates

WHO is responsible for the health sector meeting minutes and the e-mail system was

used effectively to communicate them to government officials in the state headquarters,

all the agencies attending the meetings and even to those organizations whose

representatives were unable to attend the meetings.

During the third quarter, with the initiative of the Collector and District Development

Officer of Kachchh, an executive committee was established. The responsibility of

NGO coordination was assigned to UNDP, while the responsibility of health sector

coordination continued to remain with WHO.

Meetings at Planet Bollywood, International Federation of

Red Cross and Red Crescent Societies (IFRC), Bhuj

Health Sector Meetings on Thursday

Psychosocial support

Reproductive and child health

Rehabilitation and prosthesis

Health promotion

General health sector

Time

9.00 A.M.

11.00 A.M.

2.00 P.M.

4.00 P.M.

6.00 P.M.

5



The health sub-sector groups of psychosocial support, reproductive and child health,

rehabilitation and prosthesis and health promotion have maintained their schedule of

regular fortnightly meetings throughout the six months.

The sub-groups of hospitals and infrastructure restoration were dissolved. The nutrition

group was separated and the responsibility for coordination was taken by WFP.

Abhiyan

Action Aid

American Red Cross

FICCI - CARE

CESVI (World Aid from Italy)

Catholic Relief Services (CRS)

Government of Gujarat (GoG)

Handicap International

Health Services, Bhuj

Hospital for Mental Health, Bhuj

International Federation of Red Cross and Red Crescent Societies (IFRC)

Kutch Vikas Trust (KVT)

Life Line Express

Merlin

Oxfam, India

Oxfam, UK

Save the Children Fund (SCF), UK

Self-Employed Women's Association (SEWA)

UNDP

UNICEF, Gujarat

Voluntary Health Association of India (VHAI)

WHO, Bhuj

Organizations attending the meetings:

6



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8



Communicable Disease Surveillance and Response

Highlights

• Sustained active involvement of private sector due to regular meetings,

transparency in data and consistent feedback.

• Weekly epidemiological summary with data analysis and use of

Geographical Information System (GIS), also available on the WHO

website.

• Training of medical officers and paramedical staff for disease surveillance

and diseases of public health importance. (Provided technical inputs on

biochemical warfare, also).

• Epidemic preparedness and adequate response ensured at the district and

sub-district level.

• Coordinated response to malaria outbreak - mobilization of medicine,

fogging and spraying machines, and manpower (Operation Health,

Kachchh).

• Regular situation review meetings with the health department officials and

district administrators.

• Development of a platform for crucial review during malaria outbreak

through field coordination meetings by WHO.

• Provision of equipments and necessary support to establish the Public

Health Laboratory at Bhuj.

9



Immediately after the earthquake, experienced surveillance medical officers already

working under the National Polio Surveillance Programme of WHO (NPSP) in the state

and neighbouring areas were mobilized to the worst earthquake-affected district of

Kachchh. With technical guidance and direction from the NPSP coordinator of the West

Zone, these surveillance officers established an immediate disease surveillance system.

Mobile medical teams (approximately 450) mobilized from all over the state were the

main reporting units. Very soon PHCs/ CHCs and hospitals became functional in tents

and also started reporting.

A surveillance format was agreed upon with the government in the local language, with

the assistance of NPSP state surveillance officer located at the state HQ. It was a daily

syndromic reporting system and aggregate data were analyzed at the sub-district and

district levels. With the same sources and methods for data collection functional all

over the district of Kachchh, a regular weekly epidemiological summary (disease

surveillance report) was released/published in the health sector coordination meeting.

This practice continued in the second and third quarter, which was very well

appreciated by all including the senior government officials.

In the second quarter, a new multi-disease standard surveillance format was prepared in

consultation with the government counterparts, with inputs from international NGOs.

This was a mixed approach in many contexts. It was a disease-specific and a syndromic

approach, combining both institutional and field surveillance. It collected aggregate

secondary data and primary case-based data in certain identified diseases of public

health importance. It involved the fixed and mobile medical institutions of both the

state and central governments. It also collected data from short-listed private

practitioners and all NGO/Trust hospitals of the district. In addition, international

NGOs camped in the field for medical services were also included in the reporting

network. This new weekly surveillance system was expanded to include all the state

government institutions of the district, i.e. all ten talukas of district Kachchh.

10



WHO standard case definitions were accepted in consultation with the Government of

Gujarat and treatment protocol advocated. The WHO surveillance unit conducted an

exhaustive training programme of all medical officers of reporting units and private

practitioners. The topics included were:

Concepts, principles and methods of epidemiology;

Disease surveillance - reporting and analysis;

Outbreak investigation and epidemic preparedness;

Acute respiratory tract infections;

Diarrhoeal diseases;

Malaria;

Dengue fever; and

Biochemical warfare.

Senior district and state level government officials from the health department, experts

from the Regional Family Welfare Centre of the Government of India, Ahmedabad, and

independent renowned consultants participated as resource persons in this training

programme. This WHO initiative was very well converted into a Continuous Medical

Education programme by good coordination between WHO, government and

international NGOs. Many NGOs made use of the WHO established training platform

for various training programmes on health and nutrition, mental health, prosthesis and

rehabilitation.

v

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11



Training Category

PHC medical officers

MOs - State dispensary

MOs - Mobile team

MOs - Community Health Centre

MOs - Civil / Referral hospitals

Sub-district public health professionals

Paramedics / ICDS workers

No.

36

40

124

16

8

22

160

These training programmes were very interactive, with group work and exercises. All

the participants took very active interest in them. Through this, medical officers

(government and private) were sensitized for epidemic preparedness and trained in

reporting, investigation procedures and rapid response.

National United Nations Volunteer (NUNV) doctors with the government counterparts

met and convinced the identified private practitioners for the regular reporting. They

assisted in collection, compilation and analysis of these weekly reports. They

continuously nurtured the system by providing the regular feedback, training and

245

57

MLVs

Private practitioners

12



Training course for Medical Officers of Rapar Taluka PHCs at Rapar in Kachchh district

Presentation by WHO staff of Malaria case study at Bhuj

technical material, chlorine tablets, ORS, IV solutions, chloroquine and primaquine

tablets, and chloroscopes. The state government or international NGOs working in the

aftermath of the earthquake provided all these medical supply items and equipments

with WHO coordination efforts.

In India, private practitioners of a district reported for the first time, throughout the last

nine months, in the aftermath of the earthquake. National UNV doctors provided all

necessary reporting formats and trained them in the various procedures. Regular

technical meetings in the evening using the platform of Indian Medical Association

were organized. WHO ensured the participation of senior government officials in this

meeting to provide feedback to the private reporting units. The 'Action' component of

the surveillance was given proper emphasis in these meetings. Private practitioners

extended full support and cooperation to the health department and very much

appreciated WHO's efforts to bring the two together. In addition to reporting of diseases

of epidemic potential, private practitioners also assisted the government in

immunization campaigns, cleanliness drives, health education and hygiene promotion.

Their role in controlling the malaria epidemic was very important and appreciated by

the government health department. They helped in radical treatment, drug resistance

and G6PD deficiency studies, public acceptance of insecticide spraying and fogging,

and malaria talks on TV and Radio. WHO ensured proper and timely feedback to all

these private reporting units and ensured complete transparency in the data and

reporting.

After regular reporting from all over the district, baseline data for certain common

syndromes and diseases were worked out. Non-availability of the previous year's data

and uncertain/unknown denominator made it very difficult, but in consultation with the

state level health officials, the figures used in the last pulse polio immunization

campaign (January 2001) were considered as authentic population figures.

13



An early warning system was established, based on weekly data comparison against

this baseline data for the ARI, fever and diarrhoeal diseases. A regular system of

weekly situation review meeting with the district officials was established. WHO

surveillance officers provided detailed information where action was necessary to

prevent/control the rising trend of a particular illness or syndrome.

Hepatitis E in Rapar, food poisoning in Mandvi and Bhuj, cholera in Gandhidham,

outbreak of fever in Abdasa and Nakhatrana, and malaria in Rapar and Anjar, are few

examples of the use of early warning system. In all cases, proper and timely

information to the district authorities and prompt action significantly reduced further

morbidity and mortality.

Once the disease surveillance system became fully established, its integration with the

polio Acute Flaccid Paralysis (AFP) surveillance, TB control programme, and malaria

control programme was worked out in consultation with the concerned officials. Each

and every case of AFP got reported immediately and the concerned SMO/NPSP was

informed of it.

Syndrome / Disease

Bloody diarrhoea

Watery diarrhoea

Gastroenteritis

ARI

URTI

LRTI

Fever

Malaria

A*

0.48

4.63

0.13

13.33

11.03

2.30

4.02

0.21

B**

0.16

1.35

0.05

4.43

3.61

0.82

1.74

0.11

* Weekly incidence rate per 1 000 children below five years of age in Kachchh District

** Weekly incidence rate per 1 000 persons (all age groups combined) in Kachchh District

14



With the guidance of ISM/WHO/SEARO, an efficient Geographical Information

System (GIS) was established. Every week, WHO and GoG jointly released

geographical maps in relation to disease distribution (ARI, diarrhoea, and malaria) as a

component of weekly epidemiological summary, which became very well known to all

including the district administrators. For medical officers and others, it became an

important tool for decision and action.

With the help of WHO/HQ, Health Mapper, customized software was also introduced.

An exposure-cum-orientation programme was conducted at Bhuj (district HQ) and

Gandhinagar (state HQ) for the officials of concerned departments.

This was a Government of Gujarat initiative. It mainly looked after the epidemic

preparedness and diseases of public health importance. Practically, it was a mirror

image of WHO's disease surveillance mechanism, but with more field staff to

implement various surveillance activities. Under this initiative, the Government of

Gujarat deputed a public health expert, Taluka liaison officers and Epidemiologist-cum-

Sanitary Supervisor in all four worst affected Talukas and approximately 400 malaria

link volunteers. The operation facilitated smooth transition of WHO surveillance

system (in the emergency) to the government-owned surveillance mechanism. WHO

surveillance officers worked in close cooperation with the government officers for

outbreak investigation, reporting, and analysis.

In mid-July 2001, the disease surveillance system started giving early warning signals

for the impending outbreak of malaria. The analysis also correlated the cyclical

epidemiological pattern of the malaria outbreaks in the district, particularly in relation

to the rainfall. The district and state officials were alerted and the whole system was

charged to tackle the problem well in time. Operation Health, Kachchh officials were

Operation Health, Kachchh

Malaria Outbreak in Kachchh District - a Case Study

15



immediately identified as the focal points at the district and sub-district HQ. WHO

conducted a rapid training programme of all medical officers and private practitioners

regarding epidemiology of malaria, epidemic preparedness, parasitology and biological

control, standard treatment including radical treatment, drug resistance (in certain areas

of the district) and Early Diagnosis and Prompt Treatment (EDPT).

The weekly surveillance system continued to pinpoint efficiently the problem areas.

Government medical officers reported confirmed malaria cases on daily basis over

telephone. The weekly reports became a very crucial tool to monitor the epidemic

situation. Weekly Taluka field coordination meetings became the platform for malaria

situation review. Health field staff, integrated child development service (ICDS)

workers and malaria link volunteers (MLVs) working under the Operation Health,

Kachchh did effective field surveillance and ensured radical treatment (RT) to all

positive patients.

National UNV doctors (WHO surveillance officers) collected positive blood

smears/slides from the private practitioners. Trained laboratory technicians of the

district malaria control programme verified and cross checked these slides. Field

workers provided radical treatment to all positive patients.

The problem started actually due to migrant labourers coming from malaria endemic

districts of the state, for the reconstruction work in the earthquake-affected areas. Their

screening and fever radical treatment (FRT) and mass radical treatment (MRT)

programmes were implemented, with the help of construction contractors and district

administrators.

WHO played a very vital role in coordinating the response to this malaria outbreak.

Private practitioners were provided with chloroquine and primaquine tablets and were

requested to follow National Malaria Eradication Programme (NMEP) treatment

guidelines, to ensure complete treatment and avoid drug resistance. The District

Malaria Programme of the Government of Gujarat asked for WHO assistance to

16



17



Weekly Incidence of Malaria in Kachchh

Post-Disaster Week

compensate for the shortage of insecticide spraying and fogging machines. WHO,

understanding the urgency, itself procured and provided five portable thermal fogging

machines immediately. WHO convinced IFRC and Oxfam for the same, and they

provided many spraying and fogging machines.

National UNV doctors functioned as the backbone of the outbreak investigation and

rapid response teams.

During August 2001, an outbreak of fever was investigated in Kurbai village. Serum

samples were collected for dengue virus, which ultimately tested positive. But due to

timely and proper control measures, a simultaneous outbreak of dengue fever could be

prevented.

To tackle the malaria situation during the months of September-October 2001, extra

personnel from other parts of the state were called in. Special teams attached to the

respective PHCs (under direct supervision and direction of PHC medical officer)

looked after each positive case, particularly amongst the camps of migrant labourers.

At the request of the Health Secretary, WHO also coordinated a health education

campaign regarding control of malaria. Regular data input and analysis continuously

evaluated this campaign. All international agencies including Oxfam, Merlin, CARE,

IFRC, and other partners in the field contributed for this programme with the technical

guidance provided by WHO and necessary support by the Government of Gujarat.

The malaria control programme had several gaps in the form of shortage of manpower,

insecticides and fogging machines. WHO surveillance officers addressed these

problems very well in respective Taluka coordination meetings. In Rapar, even

intersectoral coordination mechanism was developed for malaria control. Every week,

the disease surveillance unit provided detailed linelist of slide positive (P. falciparum

and P. vivax) cases to urban malaria control personnel and followed-up to ensure that

radical treatment is given to all. WHO, in consultation with the National Anti-Malaria

Programme, also advocated prophylactic treatment of malaria for the pregnant women

in the district.

With the overall well coordinated response generated by the efficient surveillance

system, malaria incidence showed a downward trend. The number of new cases

decreased rapidly by November 2001.

In view of sustainability of the surveillance mechanism, a task force needs to be

established to ensure efficient and sensitive data collection process, epidemic

preparedness and timely response. The Chief District Health Officer (CDHO), Chief

District Medical Officer (CDMO) and other senior district health officials, renowned

private practitioners, representatives of Indian Medical Association (IMA) and Indian

Academy of Paediatrics (IAP) would constitute this task force. District Development

Officer and Collector would also play a vital role in this task force. The surveillance

officer of WHO would provide the technical expertise. The necessary steps are being

taken in this direction.

WHO has now established its Kachchh District Disease Surveillance Unit (DSU) in the

campus of the District Development Officer's Office. It serves as a common platform

for senior government officials for technical guidance, updates and liaison. One can say

that practically all health sector activities in response to the earthquake are centred in

this WHO office.

District Disease Surveillance Task Force

18



Public Health Laboratory at Bhuj

To support the disease surveillance system established in the aftermath of the

earthquake in Kachchh district, WHO established a very well equipped public health

laboratory in a pre-fabricated structure at Bhuj. WHO provided the structure,

equipments, reagents and other supplies and technical guidance. The Government of

Gujarat agreed to provide the manpower to look after day-to-day functioning of the

laboratory. Due to this initiative of WHO, confirmatory diagnosis of diseases of public

health importance would become possible at Bhuj. The medical college laboratories and

the private sector laboratories were also involved in the surveillance activities.

WHO-Gujarat's Water and Sanitation (WATSAN) division and Disease Surveillance

division worked in close cooperation with the water and health department of the state

government, which resulted in very effective coordination between these two linked

departments.

Epidemiological data has also been used for evaluating interventions in health

education and hygiene promotion, sustainable water quality control. For example, the

Disease Surveillance Unit staff have conducted regular checking of free residual

chlorine in drinking water in the field, maintained records and provided feedback to the

concerned authorities.

A very effective liaison and coordination resulted in - No Epidemics even after such a

devastating earthquake. This was very well appreciated by the health and water

department which requested WHO to expand/replicate the Kachchh district model in

other earthquake-affected districts.

GIS (Geographic Information System) developed by WHO was a very effective

decision-making tool.

19



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21



Highlights

• Continued WHO support to the Government and local authorities in

improving water and environmental sanitation services to achieve

sustainable level.

• Expansion of activities to seven more earthquake-affected districts.

• Appointment of one more national UNV (WATSAN Engineer).

• Emphasis on monitoring of quality of water supply.

• Monitoring of rural chlorination on daily basis and regular review.

• Awareness and health promotion drive through public fairs and religious

platforms.

• Supply of chlorine solution to 200 villages and four towns.

• Upgrading water-testing facilities for earthquake-affected districts

other than Kachchh.

• Training activities in water quality and sanitation facilities in

coordination with government departments and local NGOs.

• Strengthening water quality surveillance for the Kachchh District.

• MOU with German Federal Agency for Technical Relief (THW) for

chlorination of rural water supply.

Technical Support for Water and Sanitation Services

22



The water supply and sanitation facilities were very badly damaged due to the

earthquake. Considering the promotion of health as the main objective, WHO

continued to extend support to the Government and local authorities in improving water

and environmental services to the sustainable level. The water and sanitation experts

worked closely with the Gujarat Water Supply and Sewerage Board (GWSSB).

Coordination at district and taluka levels is well established. In addition to the sanitary

engineer provided to undertake an assessment of the damage to the water supply and

sanitation systems in the affected area, two more public health engineers joined the

team as UN volunteers to strengthen the field activities.

Since December 2001, WHO has expanded its water and sanitation activities to seven

more districts in addition to Kachchh. The WHO office for state activities has been

shifted to Gandhinagar, the state capital, to have close linkage and coordination with

government machinery. During the course of time, two more national UNVs have been

recruited to cope with the increased work. One UNV each looks after Kachchh-

Saurashtra and central-north Gujarat region.

WHO's main support included the following:

Strengthening of water quality surveillance for Kachchh district;

Monitoring of water quality through testing chlorination;

Upgrading water-testing facilities for earthquake-affected districts other

than Kachchh;

Capacity building through training and awareness programmes;

Coordination with Government, NGOs and other actors in the sector;

Technical advice and counselling; and

Health promotion through various activities.

v

v

v

v

v

v

v

23



Strengthening of Water Quality Surveillance for Kachchh District

The State Government through the Gujarat Water Supply and Sewerage Board

(GWSSB) has been making commendable efforts to supply water to the affected

villages. UNICEF has been supplementing their efforts by providing hardware support.

However, water quality surveillance and monitoring was one area which was

adequately attended by WHO.

Considering the health significance attached to the quality of water, it was felt essential

to provide support to the District Water Laboratory of GWSSB at Bhuj. A project worth

US$ 93 000 has been taken up for providing following support to strengthen the water

quality surveillance and monitoring activities in the Kachchh district:

a. Manpower to carry out surveillance and water testing;

b. Mobile water testing laboratories mounted on utility vehicles;

c. Field-testing kits;

d. Chemicals, glassware and miscellaneous items;

e. Training of staff; and

f. Strengthening and furnishing of laboratory building.

Under the project, checking of drinking water samples from all villages on regular basis

by scientific staff, who will be provided vehicles to move in the field is envisaged. The

findings of the visit and analysis will be reported to the concerned authorities for

remedial action. The project is also expected to improve data bank and information

dissemination.

24



Water Quality

The quality of drinking water is essential to the health of communities. Hence, WHO

has accorded priority attention to the monitoring of water quality in the earthquake-

affected Kachchh district. Chloroscopes were distributed to the government and local

agencies during the first quarter.

Chlorination is considered to be the most essential operation in water treatment to

prevent any morbidity related to drinking water, more so, in an earthquake-affected

area. WHO, therefore, established a network for monitoring of chlorination in the four

worst affected Talukas (sub-districts) of the district, through the support of the health

department, Gujarat Water Supply and Sewerage Board (GWSSB) and German Federal

Agency for Technical Relief (THW).

THW provided about 50 chlorination plants for villages, which were being managed

through the Gram Panchayats. WHO entered into an agreement with THW to monitor

the working of the plants. THW has withdrawn from the field since September 2001,

and WHO is looking after the performance and providing technical guidance in trouble-

shooting. As a result, chlorination in rural areas has appreciably improved and is

regularly reviewed in the weekly health coordination meetings. This has helped to a

great extent in preventing any water-borne disease so far.

WHO had provided 1 250 chloroscopes to field staff for measurement of residual

chlorine and also imparted necessary demonstrations and training. The health staff in

the field is regularly checking the residual chlorine in villages and reporting the

performance in weekly coordination meetings held at the Taluka level. On an average,

more than 85% samples show presence of chlorine. The representative of GWSSB

present in the meeting takes note of the shortfalls and reports compliances in the next

meeting. WHO surveillance officers persuade follow-up action during the following

week.

25



Good understanding and working relations prevail between the Water and Health

Departments due to advocacy by WHO. The quality surveillance mechanism has been

appreciated by the State Government and it has requested for its replication in other

earthquake-affected districts. WHO has considered this request under its future

expansion plan that has become operational since December 2001.

Severe effects of the earthquake were reported in Kachchh district where WHO has

been paying maximum attention. However, other districts suffered moderate to heavy

damages, which included water services also. The districts other than Kachchh affeced

by the earthquake were mainly Rajkot, Jamnagar, Surendranagar, Ahmedabad,

Banaskantha, Mahesana and Patan. The district laboratories for these districts are

located at Rajkot, Gandhinagar and Palanpur. At the request of GWSSB, WHO also

provided laboratory equipment for testing of water samples at these district

laboratories. Chlorination practices on the lines of Kachchh district are planned to be

taken up in other earthquake-affected districts also.

26



Online chlorine check by staff of district water laboratory at Bhuj

Demonstration of chlorine measurement in water supply by WHO staff

Capacity Building through Training and Awareness Programmes

It was essential to develop the manpower that would take up the new challenges posed

by the situation. In these circumstances, WHO took up an extensive programme to

provide training to the professional staff and create awareness among the user

communities.

WHO took up training programmes for pump operators, linemen, water supply

supervisors, health workers, PHC and sub-centre staff, village head and Panchayat

members, conservancy staff of municipalities and representatives of NGOs. There are

several Government agencies and NGOs working in the water and sanitation sector.

Each agency has got its own mandate of work. To avoid duplication of work and to

share the information, a sub-group on WATSAN activities was formed which meets

regularly (initially weekly, then fortnightly and now monthly) to review and take

follow-up action. WHO has been playing an active role in organizing such meetings

and taking follow-up action. WHO also maintains regular contacts with other NGOs

and UN agencies for concerted efforts.

27



Health message through religious platform at Anjar in Kachchh district

Review mission of Dr Dennis Warner, WHO Short-term Consultant, who visited Bhuj

in the month of June 2001. In his extensive report, the work of WATSAN sector is

appraised.

28



Chlorination Status in Kachchh District from August to December 2001

Source: WHO Water and Sanitation, Gujarat

Water and Sanitation Sector Review Workshop,

Ahmedabad, 13 October 2001

As recommended by Dr Dennis Warner, WHO Short-term Consultant, in his review

mission report of July 2001, a one-day workshop was organized at Ahmedabad on 13

October 2001. The objectives of the workshop were:

(1) To review the activities of the WATSAN sector in Kachchh, and

(2) To invite suggestions for planning future activities.

The workshop was inaugurated by Hon'ble Mr Narottambhai Patel, Minister for Water

Supply, Government of Gujarat, and was presided over by Mr SK Nanda, Secretary

(Health), Government of Gujarat.

More than 50 participants from the Departments of Health and Water of the

Government of Gujarat, NGOs and other UN Agencies participated in the workshop.

The Hon'ble Minister, in his inaugural address, lauded the role of WHO. He appreciated

the joint efforts of WHO, the Department of Health and the Gujarat Water Supply and

Sewerage Board (GWSSB) due to which major outbreaks of water-borne diseases could

be contained. The Hon'ble Minister stressed the need for monitoring the disposal of

domestic wastewater, and protection of the sources of the public water delivery system.

More attention needed to be paid to chlorination of water and the water quality

monitoring network required strengthening. He further said that the WHO activities

should be replicated and expanded to other earthquake-affected parts of the State.

Mr SK Nanda, Secretary (Health), Government of Gujarat, said that a disease

surveillance model linked to the water quality surveillance should be developed and

more technical inputs provided to control the malaria menace. The information,

education and communication (IEC) activities should be strengthened to decrease

water-borne morbidity and mortality. The constraints in the sanitary facilities should be

29



removed through R&D activities, and adequate water supply and sanitation facilities

ensured at all health infrastructures. He suggested that WHO should plan for long-term

assistance to the State.

At the conclusion of the workshop, the following recommendations were made :-

(1) Priority must be accorded to monitoring of drinking water quality.

(2) Community-based approach should be encouraged.

(3) Capacity building exercise should be made an ongoing programme.

(4) WATSAN activities should be expanded to other affected districts and

coordination between health and water supply departments established

as done in Kachchh.

(5) Documentation of data and experience gained should be ensured.

(6) Support should be provided to water quality monitoring in urban areas.

(7) Programmes to provide sanitary protection to the water supply sources

should be undertaken.

(8) WATSAN committees should be motivated.

(1) Help must be extended to urban bodies in the treatment and disposal of

wastewater.

(2) Proper procedures for disposal of biomedical waste should be

established.

(3) Training manuals in Gujarati language should be developed.

(4) Intersectoral coordination must be promoted.

(5) Water and sanitation awareness programmes should be initiated.

A. Drinking Water Supply

B. Environmental Sanitation

30



Inter-state Meeting on “Gujarat Earthquake: Health Sector

Perspectives”, Ahmedabad, 6-9 November 2001

With technical and financial support from WHO, the Government of Gujarat organized

an Inter-state Meeting on “Gujarat Earthquake: Health Sector Perspectives” at

Ahmedabad, from 6-9 November 2001. The purpose of the meeting was to introspect

some of the policy, managerial and operational issues related to emergency response

and preparedness.

50 senior government officials from Delhi, Gujarat, Himachal Pradesh, Manipur,

Punjab and Rajasthan participated in the meeting, besides the Indian Army officials.

From Gujarat, the Health Commissioner, the Health Secretary and senior government

officials took active part in most of the deliberations.

The meeting was inaugurated by Hon’ble Dr Vallabhbhai Kathiria, Minister of State for

Heavy Industries and Public Enterprises, Government of India. Hon’ble Mr Ashok

Bhatt, Minister of Health and Family Welfare, Government of Gujarat, along with Mr

SK Nanda, Health Secretary and Mr Joy Cheenath, Health Commissioner, also attended

the inaugural session. In addition, the Health Minister also participated in the

deliberations of the meeting on a number of occasions.

31



Inaugural session of the Inter-State Meeting on "Gujarat Earthquake: Health Sector Perspectives" held in Ahmedabad, from 6-9 November 2001. The meeting was inaugurated by

Hon'ble Dr Vallabhbhai Kathiria, Union Minister of State for Heavy Industries and Public Enterprises

Various NGOs which were actively engaged in the earthquake-affected areas took part

in the deliberations of the meeting. Amongst the UN agencies, UNICEF and UNFPA,

besides WHO, participated in the meeting.

The Government of Gujarat organized a two-hour session through the state-owned

remote sensing satellite for close interaction with those districts level officials who

could not attend the meeting due to ceiling on the number of participants which was

enforced to make the meeting more effective. In this session, the WHO team consisted

of Dr Abdul Sattar Yoosuf, Director, SDE/WHO/SEARO; Dr Tej Walia, WHO Public

Health Administrator, WHO Representative's Office, New Delhi; Dr Luis Jorge Perez,

EHA/WHO/SEARO; Dr Lin Aung, STP-EHA/WHO/SEARO, and Dr Bipin Verma,

WHO Focal Point for EHA Activities in India. The Government of Gujarat team

consisted of Dr Joy Cheenath, Health Commissioner, and Dr Paresh Dave, Assistant

Director, Health Education Bureau. About 1,500 district level officials participated

through the satellite.

At the conclusion of the meeting, the following observations and recommendations

were made :-

32



It is unanimously resolved that

appreciation should be expressed to

all those who worked to save lives

and minimize the losses to the

community affected in the disaster-

affected areas. This is more crucial

for those who worked in the first 24

hours simply on their human

instincts and in the absence of

adequate resources.

Dedicated work and

appreciation.

1.

S.No. Observations and Expectations Recommendations

Various stories and tales of

battles for survival and outstanding

courage should be recorded and

published by the Government.

Exemplary attempts to help

their fellow brethren and

courage seen in the local

community.

2.


33



A permanent organization for

disaster management is

established by PMO. States

are to prepare State plans.

The disaster management

plan is the immediate need

and it should reflect ground

level realities and applicable

to local situations.

A permanent state level coordination

committee, with various stakeholders

as members, should be an integral

part of the Disaster Management

Authority. Similar units could be

formed at the district, taluka and

village levels. The approach should

be to build a transparent and

efficient system.

The proposed plan by the

Government of India should

immediately be discussed and

adopted with appropriate

modifications.

A disaster management plan should

immediately be prepared and, if

already prepared, should be

modified with current information

and technology.

Coordination had

significant positive impact

on the outcome.

3.

4.

5.

The nodal institutes have to

be safeguarded so that the

key facilities do not get

damaged, crippling the relief

operations.

All nodal centres for health and

medical care and other emergency

and essential civil services should be

assessed for their vulnerability to

disasters. The plans should be

implemented by allocating

appropriate funds to apply

technology for the new constructions

of such centres before clearance for

the work is given.

7.



The first response was

unplanned and rescue

operations in future require

preparedness.

The rescue teams should be

identified, effectively trained and

equipped with self-sufficient

facilities for uninterrupted action.

The need for rapid transportation

of such teams with effective

communication systems should be

guaranteed. This is necessary for

quick transfer of critical cases to

nearest care centres and deploying

other mobile medical units.

6.

34Report of WHO Activities, 1 August 2001 - 31 January 2002

Active participation of local

doctors and social workers is

imperative.

A detailed directory of various

agencies that can assist in disaster

management should be prepared

and made available to all concerned.

8.



Periodic drills for the rescue

activities will be necessary.

All activities aimed at immediate

action in a disaster situation should

be subjected to periodic (once in six

months) drills or mock events. This

will require a manual detailing

the person, task, time-frame and

responsibility for the entire

operation. The manual can be part

of (or a separate identity) a manual

covering guidelines for relief and

rehabilitation issues.

9.


All these agencies should have

coordination so that their

participation at any given point of

time and place is ensured.

Training and awareness are

important in disaster

management.

A state Disaster Management

Institute running multi-faculty

courses and providing refresher

courses recognized by the University

is necessary. Such an institute in a

border state like Gujarat will help

in combating any situation related

to man-made disasters like war. The

institute should have the capacity to

take up operational research on

disaster management.

10.

Simple modules and health education

material for the general public

should be prepared in vernacular

and lessons on disaster management

should be incorporated in school

textbooks and college education.

Till the institute comes up,

appropriate regional centres should

be identified to carry out this

function.




Disease surveillance and

environment management

have potential to prevent

epidemics after disasters.

WHO assistance in training

and monitoring is

commendable.

Disease surveillance by trained

workers has to be a regular activity

of the health sector. Better softwares

and analytical methods and

equipment must be made available

for this crucial activity.

The issues of safe water and sanitary

waste disposal should be tackled

even in normal times.

The surveillance in the rehabilitation

stage should include recording,

managing and follow-up of injured

and handicapped. WHO assistance

should extend to other districts for

betterment of surveillance and

reporting system.

11.

The role of the media in a

disaster is very crucial and

should be utilized in best

possible manner.

A media cell within the health sector

is needed. Some senior academicians

and public health managers should

be trained for media interaction. A

close liaison with media should be

ensured by frequent regular

interaction.

12.




Psychosocial and nutritional

rehabilitation to the affected

population.

Necessary planning for long-term

intervention should be made by the

core groups and reviewed

periodically.

Physical rehabilitation. An organization should be set-up

for all such cases that may require

physical and social rehabilitation.

Training for material

management by using supply

and management (SUMA).

Planning for reconstruction

and redevelopment of the

health facilities is subjected

to new initiatives which have

been quite successful.

It is recommended that the

personnel at CMSO be trained in

supply and management (SUMA).

It is recommended that the

experience be supported,

strengthened and disseminated.

This particularly applies to the

empowerment of the health sector

for taking up the construction

projects.

13.

14.

15.

16.




Coordination experience in

the disaster management has

been quite satisfactory.

This experience needs to be

documeted. The team of experienced

officers should be used effectively

in future so that their skills are best

utilized.

17.

Expansion of WHO Activities in other Earthquake-affected Districts

of Gujarat

The administrative and coordination unit of WHO has been shifted to Gandhinagar, the

state HQ, and it will continue to function as the State liaison office, while the disease

surveillance unit will remain in Bhuj with minimal staffing.

His Excellency the Governor of Gujarat inaugurated the first state level liaison office

of WHO India country office, in the presence of WHO Representative to India, Hon'ble

Health Minister of Gujarat, and senior government officials.

Three surveillance officers (National UNV doctors) now share offices and other

resources with NPSP officers in the field (Rajkot, Mahesana and Gandhinagar), to build

on the existing system and network of different surveillance activities. Currently, five

national UNV doctors and two national UNV engineers (water and sanitation) work in

the field for the integration of disease surveillance and coordinated water quality

surveillance in eight needy districts of north-west Gujarat.

In addition to the existing funds of Gujarat Earthquake Relief Mission, new funding

from the European Commission is assured for integrated disease surveillance activities

in these districts (June 2002 - August 2003), based on lessons learned in Kachchh.

The new WHO office at the state HQ has started functioning as the state liaison office

for WHO India country office. In addition to the integrated disease surveillance and

regular liaison with the state authorities, many more activities are being considered.

39



• Integrated disease surveillance in eight districts of Gujarat;

• Coordinated approach with water quality, sanitation and environmental

health;

• Linkages with health sector disaster preparedness;

• Developing guidelines for surveillance of noncommunicable diseases;

• Developing a public health resource centre at the state HQ;

• A disaster epidemiology training course for government officials;

• Improvement of water and sanitation facilities in the health institutions;

• NGO partnership for pilot, innovative projects in the fields of:

o Indian systems of medicine;

o Blood disorders; and

o Prosthesis and rehabilitation.

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