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Reportage The untold stories of the Sichuan earthquake



  The untold stories of the Sichuan earthquake
  Emily Y Y Chan took part in the relief effort after the Sichuan earthquake in May. She reports
  on the short-term needs of those affected and the medical and public-health challenges that
  will be faced by the Chinese population as rehabilitation and reconstruction continues.

On May 12, 2008, an earthquake that         are organised from CDCs across the                unspoken emptiness was in the air
measured 8·0 on the Richter scale,          nation to battle in the front line                since most citizens had temporarily
hit the Chinese province of Sichuan.        against epidemic outbreaks.”                      moved to rural areas to avoid any
Tremors were felt as far away as              As someone involved in disaster relief          potential collapse of the massive urban
Beijing and even Hong Kong. Soon            in Asia for the past decade, I was asked          structures within the city.
the media were reporting hundreds           to join the Médecins Sans Frontières                 Although the Chinese Government
and thousands of lives lost. Particularly   team that was offering assistance. The             was generally receptive to offers of
dreadful was the loss of life of the        experience provided an opportunity                outside support and help, in practice, it
pupils attending afternoon lessons in       to assess not only the short-term                 was cautious about civilian-based relief
the 7000 schools which collapsed. As        needs of those affected, but also the              efforts from outside mainland borders
of the end of June, 2008, the official        medical and public-health challenges              because of concerns about the overall
mortality figures had reached 70 000,        that will face the Chinese population             efficiency of operations. Even within
but millions of others have been and        in the post-earthquake rehabilitation             the country, dozens of relief teams
continue to be affected both indirectly      and reconstruction effort.                         from other provinces were not given
and directly by the earthquake’s impact.                                                      official facilitation to reach the relief
  The main difference between the            The first days                                     sites. No civilian airtravel was granted
response to the Sichuan earthquake          We arrived at Chengdu by nightfall on             into the disaster area. Meanwhile,
and the 1976 Tangshan earthquake—           day 3 after the disaster carrying drugs           although roads were monitored by
the quake with the highest mortality        donated by colleagues and plastic bags            the People’s Liberation Army, this did
in the 20th century1—has been in            overflowing with donated snacks and                not stop many people trying to rush
China’s progressive openness2 towards       water bottles from flightcrew and                  to the destruction zone to offer their
information and media access. Recent        passengers. Chengdu, the provincial               help. The British consul in Chongqing
economic development has also               capital of Sichuan and a few hours drive          later told me he found himself doing
enhanced the country’s capacity to          away from the earthquake epicentre                most of his search for wounded
respond effectively to major natural         of Wenchuan, was where most of the                British citizens in a series of hitch-
disasters.                                  45 000 medical relief volunteers from             hiked lifts. However, the government
  Within hours of the earthquake, local     outside the province first assembled               granted our civilian medical team,
Communicable Disease Centres (CDCs)         to obtain access to the affected sites.3,4         largely composed of Chinese nationals
had become involved in disaster             Although high-rise buildings in the               from Hong Kong who had relevant
relief, and the national network,           city did not seem to be damaged, an               earthquake-relief experience, immed-
built up as a response to SARS, was
used to bring in public-health help
from other regions. In an email sent
to the director at Chinese University
of Hong Kong a few days after the
disaster, the director of the CDC in
Chongqing wrote, “I was sent to the
epicenter in Yingxiu Town, Wenchuan
County as an expert to direct activities
of epidemics prevention after earth-
quake. The epidemics prevention
group from our center is the first one
to arrive in the epicenter zone. We
conduct water surveillance, medical
                                                                                                                                          Jonathan Watts

aid and environmental protection (eg,
sprinkling disinfectant) activities in
the earthquake areas…many groups            A collapsed section of the elevated expressway near Yingxiu Town, Wenchuan County Vol 372 August 2, 2008                                                                                                                   359

                                             iate facilitation with travel permits,       no immediate surgical needs but            official total mortality had not yet
                                             endorsement letters for participation        who had potentially life-threatening       been released, the media had tended
                                             in relief efforts, and the flexibility to      medical conditions (eg, unstable           to focus their reports on mortality
                                             choose the site where we might best          arrthymias or hypertension) did not        among young people in the collapsed
                                             support the medical-relief effort.            always receive best management             schools. However, the greatest
                                             We travelled from Chengdu by road            despite the availability of drugs and      morbidity will probably be among
                                             and, in contrast to other Asian relief       resources. As a consequence, a patient     those over 60 years who lived in
                                             settings, highway travel was well            entering trauma surgery might have         low-density houses which collapsed.
                                             managed by troops, with no traffic             no pre-operative assessment and poor       Despite military triage before patients
                                             or security problems. En route, huge         management of underlying unstable          were airlifted, which gave priority to
                                             road-side propaganda billboards and          chronic medical conditions.                those with the highest chance of sur-
                                             banners were prominently displayed                                                      vival, the median age of our patients
                                             as encouragement to victims and              Treating elderly patients                  was 79 years. Similar age patterns
                                             relief teams alike.                          That evening, we arrived at Guanghan       were observed in other government
                                               During our first day in the disaster        San Shiu Triage Referral Hospital—one      and civilian relief sites, with 40%
                                             zone (day 4 after the earthquake), we        of the six airlift triage sites that had   of patients older than 60 years.5 Al-
                                             visited several relief medical facilities,   been receiving patients evacuated          though no major outbreak of tetanus
                                             and our rapid assessment of health and       by helicopter from the areas which         has been reported in Sichuan, this is
                                             medical needs revealed no apparent           experienced the greatest devastation:      inevitably a risk, and our survey 6 found
                                             lack of medical supplies. However, the       Wehchuan, Ching Ping, Mengzhu,             that 78% of the population older
                                             effectiveness of the medical response         Beichuan, and ShiFang. The site was        than 60 years were not vaccinated.
                                             seemed to be impaired by suboptimum          originally a modern maternal and child       Elderly people in rural Sichuan will
                                             organisation of the medical facilities,      health centre and had been turned          be heavily dependent on the post-
                                             mismatch of clinical specialties, and        into a triage site 2 days after the        disaster reconstruction programme,
                                             a general lack of skill mix in the field-     earthquake. Its workforce consisted        which will have major implications
                                             relief teams. In some sites, although        of both local and out-of-province          for their future. In addition to the chal-
                                             the patient to doctor ratio was 1:3,         volunteer doctors, none with previous      lenge of rebuilding their socioeconomic
                                             80% were orthopaedic surgeons                experience in disaster response or         support systems, they face not only
                                             and too few anaesthesiologists were          preparedness training. Overwhelmed         the typical needs after an earthquake
                                             available to assist operations or            and working with limited resources,        related to orthopedic trauma, but
                                             manage pain control. Many sites had          the existing team quickly incorporated     also the continuing needs for clinical
                                             no generalist physicians to manage           us into the medical-relief operations.     management of complex chronic con-
                                             underlying common chronic medical            We soon found ourselves at the front       ditions. However, past experience in
                                             conditions5 and no mental-health             line of care, receiving patients and       Japan, the Pakistan earthquake, and
                                             specialists to deal with post-disaster       assessing their injuries and general       Hurricane Katrina7-9 suggests that
                                             psychological needs during the first          medical conditions.                        chronic medical needs post disaster are
                                             week. The lack of multidisciplinary             Providing adequate medical treat-       often inadequately managed and can
                                             teams or a more holistic approach            ment for our patients was challenging      result in increased rates of complica-
                                             meant that some survivors who had            since many were seriously injured,         tions and indirect morbidity after a
                                                                                          having been trapped in the rubble          disaster. The issues about payment for
                                                                                          for at least 48 h, anxious about           such conditions within a health system
                                                                                          their families, and in mental shock.       recently reorganised to provide some,
                                                                                          Unlike affected populations in other        but not all, medical health-care costs
                                                                                          large-scale disasters in Asia such         can potentially increase the stress and
                                                                                          as the 2004 Indian Ocean tsunami           anxiety of survivors as they struggle to
                                                                                          and 2005 Pakistan earthquake,              rebuild their lives. Additional medical
                                                                                          many patients were older, reflecting        costs will pose a substantial finan-
                                                                                          the socioeconomic environment in           cial burden for people caring for their
                                                                                          rural China, where many people of          families, if not for themselves.
                                                                                          working age have migrated to urban
                                                                                          settings for better job opportunities,     Mental-health needs
Getty Images

                                                                                          leaving behind a population in which       Not only will chronic diseases pose a
                                                                                          older people, women, and children          burden, but the mental-health needs
               Many earthquake survivors were elderly people                              are over- represented. Although the        of patients, which were apparent in

               360                                                                                                            Vol 372 August 2, 2008

the immediate aftermath of the quake,       patients to hastily erected hospital
will also need long-term treatment          field tents, each one with different
and support.                                manufacturers’ instructions.
   Typically, patients first arrived with       Such experiences highlight the
an excessive eagerness to tell us how       mental and physical stress that
they survived through the ordeal            health relief personnel were under. In
but as they settled after a few hours,      addition to their heavy clinical duties
their emotional state was obvious,          under suboptimum conditions and
ranging from abnormal positivity            resources, teams had no preparedness
towards their rehabilitation after the      training, little rest, and were working
earthquake to uncontrollable crying,        under ad-hoc arrangements. Dis-agree-
and even attempted suicide. The lack        ments about protocols for clinical

                                                                                                                                                                    Emily Chan
of experience and training in mental-       management, quality of care, and
health needs perhaps limited patient        level of expertise inevitably emerged,
care and sensitivity in this phase of the   adding to the pressures. However, the     Patients are transferred out of the Sichuan Province by simple trucks
emergency response. The imbalance of        team shared a common goal: helping
the doctor:patient relationship in rural    survivors. And everyone held great        additional care over and above the
China, where doctors are credited with      respect for our site coordinators, who    disaster response. Their rehabilitation
powerful professional status, perhaps       tried their best to support our work      will pose particular challenges—not
contributed to a lack of sensitivity to     in difficult circumstances. The team        least how their care will be paid for.
patients’ psychological needs, but the      spirit helped alleviate the discomforts      Survivors expressed their concerns
health-care staff themselves also had        of our shared makeshift home, where       about medical costs and the associated
their own needs. Chronically fatigued       regardless of rank or gender, we slept    treatments. To quote a 49-year-old
and emotionally disturbed by the            in the open air on the streets, next      man with multiple rib and hip frac-
traumas they had witnessed, our role        to the tents where our patients were      tures who was sent to Guangzhou to
as more experienced disaster-relief         crammed together. When it rained we       receive surgical intervention: “I don’t
workers included providing support to       created makeshift shelters using thin     know how we will get back to Sichuan.
members of our local medical team.          plastic sheets, which kept us partially   Things were so expensive in Guang-
   Although the mandate at the              dry but offered little protection from     zhou and we have nothing left.
triage site was to stabilise patients       the cold when the ambient tempera-        Everything is buried under the rubble.
after their aeromedical transfer and        ture fell to below 10ºC. The sound of     We have no resources to survive in
to quickly redirect them out to other       falling cement, the movements of          the city and to pay for the treatment.”
hospitals at the city or provincial         aftershocks, and patients moaning         Almost 10% of the most severely
level, by May 17, the third day of the      made an unlikely lullaby.                 injured patients were sent out of
triage centre’s operation, the hospital        Our work at the triage site came to    province for treatment and it was not
was overflowing with patients. Trans-        an end on day 14 after the disaster       clear how they might pay for their
fer to the well equipped secondary          as the government decided to close        daily living maintenance, rehabilita-
hospitals designated for major opera-       down all triage sites and send all        tion after surgery, or return expenses
tions was just not possible since these     patients either to tertiary hospitals     to Sichuan after a potentially long stay
tended to be multistorey buildings,         in Chengdu or Chongqing or out of         for treatment despite the ongoing
and their use was prohibited because        the province for severe cases.            generosity and public support from
of fear of structural instability. Our                                                richer parts of China.
work was also further complicated           Post-emergency medical issues                Migrant workers among these in-
by the frequency and magnitude of           Reflecting on the experience several       ternal displaced people could also face
aftershocks. We could only work on          lessons emerge. The rapid and effective    lack of entitlement to free medical
the ground floor of our three-storey         response by the government should         services after the disaster. In the
building after an aftershock measuring      be commended, but the region’s            immediate aftermath, the govern-
6·3 on the Ritcher scale occurred.          preparedness was insignificant, even       ment provided free access to services,
Indeed, at midnight on day 5, the           though Sichuan is known to be at          irrespective of place of origin or status.
government, worried about further           risk of earthquakes and had a major       Yet migrant workers, who make up
aftershocks, issued an evacuation           quake with human mortality in 1981.10     15% of the population in the affected
order to move all patients outside the      The patterns of morbidity revealed a      area, tend to be from the lowest
building onto the street. Within 2 h we     large burden on older people, whose       socioeconomic strata11 and could face
had transferred 100 seriously injured       chronic long-term conditions required     uncertainty about entitlement to Vol 372 August 2, 2008                                                                                                                      361

                                                                                                      prey upon lost children and orphans      I gratefully acknowledge the support and time given
                                                                                                      in hospitals. Concerns for “orphaned”    by Professor Sian Griffiiths during the writing
                                                                                                                                               process. The views expressed in this article are those
                                                                                                      older people should run in parallel.     of the author, and do not necessarily reflect the
                                                                                                      Social service and primary health-       policies of any organisation. I declare that I have no
                                                                                                      care facilities with an understanding    conflict of interest.

                                                                                                      of geriatric services will be needed     Emily Y Y Chan
                                                                                                      to bridge the service gaps and pre-
                                                                                                      vent complications which could arise     Assistant Professor, School of Public Health, Chinese
                                                                                                      from a lack of medical treatment and     University of Hong Kong, Prince of Wales Hospital,
                                                                                                      care for their often multiple chronic    Shatin, NT, Hong Kong, SAR, China.
                                                                                                      diseases.                                1     OFDA/CRED. Emergency Events Database.
                                                                                                                                                     Top 10 Countries affected by Earthquake
Jonathan Watts

                                                                                                                                                     1901–2008. Brussels, Belgium: Centre for
                                                                                                      Conclusion                                     Research on the Epidemiology of Disaster.
                                                                                                                                                     Université catholique de Louvain. http://www.
                                                                                                      Most media and the international      (accessed June 25, 2008).
                 Survivors evacuate through the rubble of Yingxiu on their way out of the epicentre   community have witnessed and com-        2     Watts J. China’s health challenges after the
                                                                                                      mented positively on how China has             earthquake. Lancet 2007; 371: 1825–26.
                                                 health services once the immediate                   responded to the Sichuan earthquake,     3     Xinhua News Agency. Sichuan Province Official
                                                                                                                                                     News Updates of Wenchuan Earthquake. Xinhua
                                                 emergency relief is over.                            the most severe natural disaster of            News Agency (Beijing), May 21, 2008. http://
                                                    In addition to physical needs,                    the 21st century to date. The long-  
                                                 mental health after the disaster will                term health issues that China will             8222294.htm (accessed July 24, 2008).
                                                 need to support not only survivors                   need to address include sensitivity      4     Xinhua News Agency. Beijing, Jiangxi, Hunan,
                                                 but also those involved in the relief                to the demographic profile and its              Inner Mongolia, Anhui, Shanghai, Li Ning,
                                                                                                                                                     Hei Nong Jiang, and Shengzhen organize post
                                                 process, including health-care workers               implications for affordable treat-              quake emergency groups and relief teams to
                                                 themselves. And, as the acute phase                  ment, rehabilitation, and long-term            response to resources and rehabilitation
                                                                                                                                                     needs. Xinhua News Agency (Beijing), May 21,
                                                 of disaster relief comes to an end, the              care at both ends of the age spectrum          2008.
                                                 challenge of long-term policy and                    including concerns about mental      
                                                                                                                                                     05/21/content_8222881.htm (accessed
                                                 planning for rehabilitation services                 health.                                        July 24, 2008).
                                                 for populations with long-term dis-                    The successful avoidance of epi-       5     Anon. Nutrition and health status report on
                                                 abilities becomes an additional need.                demics of infectious disease and               Sichuan province. Chongqing, Sichuan: Sichuan
                                                                                                                                                     Province Centre of Disease Control, 2006.
                                                 Earthquakes are known to cause                       provision of basics for public health    6     Chan EYY, Yiu HWO, Chow AJ. Report on
                                                 comparatively high mortality but low                 such as clean water and food were              medical intervention at San Shui Temporary
                                                                                                                                                     Triage Referral Hospital (SSTTRH) at Guanghan,
                                                 morbidity.12 Injury patterns reported13              commendable, and the efforts of                 2008 Sichuan Earthquake. Brussels, Belgium:
                                                 in Sichuan seem to be similar to other               volunteers and local organisations             Médecins Sans Frontières, 2008.
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                                                 left with permanent disabilities might               rescue and response was managed                rates for various illnesses. Public Health 2000;
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                                                 as well as having psychological                      lack of emergency preparedness and       8     Miller AC, Arquilla B. Chronic disease and
                                                                                                                                                     natural hazards: impact of disasters on
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                                                 Chok Wan Chan, the president of the                  challenges of a natural disaster in            Prehosp and Disaster Med 2008; 23: 185–194.
                                                 International Pediatric Association                  a high-risk geographic area should       9     Jhung MA, Shehab N, Rohr-Allegrini C, et al.
                                                                                                                                                     Chronic disease and disasters medication
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                                                 child survivors in the affected area. On              policy development.                            Am J Prev Med 2007; 33: 207–10.
                                                                                                                                               10    OFDA/CRED. International Disaster Database.
                                                 his return he commented: “Children                     Finally, as in other major disasters         Earthquakes in China 1901–2008. Brussles,
                                                 are housed in temporary tents where                  and human-security crises, the trau-           Belgium: Centre for Research on the
                                                 daytime temperatures can reach up                    matic events will inevitably fade into         Epidemiology of Disasters. Université
                                                                                                                                                     catholique de Louvain.
                                                 to 40ºC. Although their health condi-                the background and be forgotten                (accessed June 25, 2008).
                                                 tions are stable, most of them are very              by the media as other world events       11    Hu LX. Analysis of Sichuan migrant population.
                                                                                                                                                     Migration Pattern 2006; 71: 15–17 (in Chinese).
                                                 frightened and many [are] left with                  unfold.14 The most difficult challenge
                                                                                                                                               12     Alexander D. The health effects of earthquakes
                                                 disabilities. In addition to their mental            in 2008 will be for the public to              in mid-1990s. Disasters 1996; 20: 231–47.
                                                 health, the wellbeing, rehabilitation                celebrate the Beijing Olympics while     13    Ma CH, He XY, Cui YK, Lei ML, Yang GY,
                                                                                                                                                     Zhao DQ. Experience of medical support for
                                                 and protection of these orphaned                     remembering the plight of those                the injured and patients in the 5x12
                                                 children needs to be highlighted.”                   survivors who face long-term con-              earthquake of Wenchuan. Zhongguo Wei Zhong
                                                 Indeed, the media reports a police                   sequences and must rebuild their lives         Bing Ji Jiu Yi Xue 2008; 20: 375–76 (in Chinese).
                                                                                                                                               14    The Times. Earthquake in China: the
                                                 crack down on infant traffickers who                   and communities.                               aftershocks. The Times (London), May 17, 2008.

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