The United Nations (UN) reports that the massive international relief effort mounted in response to the South Asian earthquake last October has been largely successful, according to the March 9 issue of the New York Times. In the immediate aftermath, expert observers predicted that large numbers of survivors might suffer from disease, lack of food and water, and exposure to a harsh Himalayan winter; but the anticipated second wave of casualties was averted because of well-coordinated humanitarian aid and unexpectedly mild weather. Last month, the UN shifted its focus from emergency relief to a year-long recovery and reconstruction program coordinated with the government of Pakistan and humanitarian organizations.

The epicenter of the 7.6 magnitude earthquake was located in Pakistan's North-West Frontier Province, about 65 miles northeast of the capital, Islamabad. Estimates of the death toll range from roughly 73,000 to more than 87,000, with similar numbers injured and more than 3 million left homeless. Hardest hit was the Pakistan-controlled section of Kashmir, a politically unstable territory claimed by both Pakistan and India. The earthquake, which struck on October 8, 2005, also killed about 1,300 in Indian border communities.

Gerald Martone, MS, RN, director of humanitarian affairs at the International Rescue Committee (IRC), travelled to Pakistan and Kashmir in February as part of a team assessing the aid work of UN agencies.

"Pakistan didn't have a fully functioning public health system to begin with, especially in the very remote areas affected by the quake," Martone said. "Some of the tribal regions along the border with Afghanistan aren't really under control of the central government. People in places like that are especially vulnerable when a disaster occurs."

FIGURE. A girl whose hand was crushed in the earthquake.

FIGURE. This map shows the area affected by the magnitude 7.6 earthquake that struck last October.

FIGURE. Local laborers dig a trench for a sewage pipe to improve sanitation in a camp housing approximately 40,000 displaced people near Islamabad. Not using latrines can be a major problem in camps for displaced people, especially in the rainy season.

FIGURE. One of many spontaneous camps set up by earthquake survivors in the Mansehra district, in Pakistan's mountainous North-West Frontier Province. Many buildings left standing after the quake were so damaged that they're not structurally sound. Camps often sprang up around still-standing homes and buildings that were no longer safe to inhabit.

FIGURE. A child washing her hands is a sign that better hygiene is catching on as a result of basic health education efforts.

FIGURE. A staff member points outs damage to a clinic in Danna, a village built atop a fault line in Kashmir. No roads lead to Danna. Aid workers reached it after hiking a couple of hours over steep, rough terrain. Outside the damaged clinic, tents were set up to accommodate patients who are too afraid to stay inside during aftershocks. The primary earthquake lasted approximately 26 seconds, and others, some quite powerful, continued in the following days and weeks.

FIGURE. A reproductive health team reviews patient records with nursing staff.

But Martone praised the government response to the disaster.

"The Pakistan government and military were extraordinarily competent and, everyone will admit, they outperformed the aid effort," he said. "They don't know that much about relief work and disease, so there was definitely a technical role for the aid agencies to play, but the military's ability to organize was unusually good."

Martone, a veteran of relief operations around the world, noted that the IRC adopted an innovative strategy in helping earthquake survivors in South Asia. Typically, people displaced by a natural disaster gather in camps that either arise spontaneously or are set up by government or relief organizations. But here, the IRC brought help to people in their villages, discouraging migration to the camps.

"Camps are toxic. Many people living in close proximity, without adequate sanitation and shelter, creates an environment where communicable diseases, such as respiratory infections and diarrhea, are easily spread," Martone said. "And the dreary, monotonous routine of camp life is emotionally and psychologically devastating, particularly for children."

Therefore, the IRC set up "child-friendly spaces" where simple educational and recreational activities can be organized to counter the boredom that comes with so much unstructured time.

Such spaces also offer an opportunity to present important health information to villagers. "A lot of people think of aid work as handing out things, which we do, but as in nursing, the most potent public health intervention we do is actually education, teaching people to change their behavior in ways that promote health."

Despite the success of the emergency relief effort, there are challenges ahead. Melting snow this spring and monsoon rains that usually begin in July could potentially cause more landslides. And the combination of unsanitary conditions in camps and excess rain may also spread disease.

FIGURE. Hired by the IRC, a local worker with a generator-driven band saw recycles building materials salvaged from collapsed houses to make temporary dwellings.

FIGURE. Because of a shortage of winterized tents, there was a need for shelters that were small enough to be heated by coal or kerosene but large enough for a family to sleep in. The solution was the "warm room" (shown here before and after construction), a one-room structure with a simple, earthquake-proof design, wrapped in plastic, with a zinc roof.

"The emergency is over but hard work lies ahead," Martone said. "Recovery efforts must not only rebuild structures but engage and involve communities in determining their own future."-James M. Stubenrauch, senior editor

FIGURE. A child displays a drawing in a child-friendly space set up by the IRC in Danna. These spaces are used for group educational and recreational activities, and for community meetings, as shown at right.

FIGURE. A boy stands in front of a new temporary dwelling.