Proceedings of 14th – 15th November, 2002, International Conference on Protection of

Structures against Hazards, Singapore

Post Disaster Mitigation- Relief to Human Sufferings

Adnan Qadir1, Muhammad Masood Rafi2, Farnaz Batool3

Abstract
Earthquakes differ from other natural hazards in a number of ways, but more importantly in
their below ground origin and inception on human civilization, degree of warning expected and
extent of damage caused. Recently, another indigenous element of the same character is entered
in the lives of mega cities like Karachi. This is a man-made disaster caused by terrorists’
attacks. Both of these threats can have sudden occurrence and consequences on habitation.
Effective major incident planning, based on most likely and severe disaster, is needed to ensure
that major incidents do not turn into disasters. This should be flexible enough to effectively look
after each of the two types of hazards. This paper describes part of an ongoing study of the
effectiveness of ambulance networks and major hospitals. An adaptive Multi-Casualty Incident
Plan, for these initial responders of a disaster, is underway and it is hoped that it will help
enable them to play an effective role in disaster mitigation.

Introduction
Natural disasters have threatened mankind since history started 1. They have always been the
worst enemies man has confronted with in this universe. These include hurricanes, floods,
tornados, typhoons, famine, fires, landslides and earthquakes. But of all these hazards, only
earthquakes are such an enemy whose onset on human development originates below ground
surface and man is always taken aback by their unwarned and unnoticed arrival. This unique
characteristic of earthquakes made them the most lethal and deadliest natural enemy. The most
terrible consequence of earthquakes is the massive loss of human life, which they are able to
cause. The first task of earthquake protection is, therefore, the reduction of loss of human life.
Unfortunately, in most countries an earthquake is only one hazard of many that might have to be
planned for in a disaster preparedness plan2. The fact is further elucidated by the recent entrance
of an indigenous element of the same character in the lives of mega cities like Karachi. This is a
man-made disaster caused by terrorists’ attacks. Both these threats can have sudden occurrence
and consequences on habitation. Effective major incident planning will ensure that major
incidents do not turn into disasters4. The possible impact of these hazards can, therefore, be
reduced through efforts towards preparedness, mitigation and post-event humanitarian action and
the methods of response, the agencies involved, the information flows and other parts of the
emergency response will have distinct similarities for both these types of hazards 3,2. On the other
hand, poor emergency response or a follow on disaster can double, treble or multiply ten-fold the
death toll of an incident and the situation can rapidly become chaotic, with many uncoordinated
activities and poor communication between relieve providing groups2. In the emergency
response a very large number of agencies, organizations and individuals may become involve.
This demands an urgent and efficient organization of manpower and resources, prioritization of
1
Associate Professor, Department of Civil Engineering, NED University of Engineering and Technology Karachi.
2
Assistant Professor, Department of Civil Engineering, NED University of Engineering and Technology Karachi.
3
Lecturer, Department of Civil Engineering, NED University of Engineering and Technology Karachi.
 Proceedings of 14th – 15th November, 2002, International Conference on Protection of
Structures against Hazards, Singapore

actions with time, and an understanding of the likely consequences of the disaster. The
emergency can be handled effectively and the effects of a disaster can be minimized if a pre-
disaster emergency plan has been drawn up and people trained in what to do2. Emergencies have
wide spread effects and it is vital to integrate the skills and resources of these different agencies,
organizations and individuals into a combined response4. The Department of Civil Engineering at
NED University of Engineering and Technology Karachi, realizing the importance of emergency
planning, has taken up the task to develop a “Multi-Casualty Incident Plan” 6 for various
agencies. The Department, in the first phase, conducted a survey to collect the data of existing
infrastructure and disaster management facilities and planning of our ambulance trusts and
hospitals. This paper describes the matters regarding the preparedness for a disaster of
ambulance trusts and hospitals.

Aims and Objectives

Terrorist attacks are targeted to populated areas. Similarly, an earthquake will too be a disaster
only if it strikes a populated area 2. Only pre-disaster emergency planning can ensure that
disasters can be handled effectively. One of the greatest needs that rescue and medical treatment
teams have is for ways of transporting injured victims to hospital or treatment centres. This need
is immediate, and greatest in the first few hours after the earthquake. With good medical care, a
seriously injured victim can be stabilized at the rescue site, but without early hospitalization and
surgical treatment in a suitably equipped operating theatre, his or her chances of survival are
remote. In many large-scale disasters, a shortage of means of transport for the injured has been a
critical bottleneck in the victim care process2.

In a major incident with immediate casualties the ambulance service will be the first responder
on the scene and will decide where casualties should be taken, provide immediate treatment,
transport, and coordinate communications between other agencies. It provides an essential link
between many agencies, which play a part in post-event humanitarian actions 4. In the context of
emergency response procedures, the task of the ambulance services is usually to evacuate the
wounded or infirm. This includes some of the residents of institutions or reception centres 5. In
the event of an incident involving multiple casualties, better patient care is provided if
ambulance crews conform to a pre-arranged Multi Casualty Incident Plan 6. When a disaster has
had a violent impact, the determination of resources in terms of ambulances (numbers available
and level of service, first-aid equipment, and so on) becomes vital information for assessing
whether the service will be adequate to handle the casualties 5. This study is, therefore, an effort
towards post disaster mitigation and a very much national cause. It is aimed at the evaluation of
the existing state of affairs of awareness and effectiveness of ambulance networks and hospitals
at Karachi in emergency preparedness.

Methodology
Though there are a number of ambulance services working at Karachi but two big and effective
services were included in the Study. These are Edhi Ambulance Service and Saint John’s
Ambulance Service. Both Edhi and St. Johns ambulance services are available 24 hours a day.
Edhi ambulance service has the largest network all over Pakistan comprising of about 600
ambulances. St. Johns also provide their services interprovincially, besides intercity, but because
 Proceedings of 14th – 15th November, 2002, International Conference on Protection of
Structures against Hazards, Singapore

of being comparatively higher in cost Edhi service is more preferred. Edhi Ambulance Service is
a voluntary and charitable service.

Initially seven large hospitals of Karachi, working both in public and private sectors, were
selected for the purpose of this study. But because of the non co-operation of two of these
hospitals, the study was restricted to only five of them. These are Civil Hospital, Jinnah Post
Graduate Medical College Hospital, Liaquat National Hospital, Abbasi Shaheed Hospital and
Agha Khan Hospital. The first two are public sector hospitals. Liaquat National Hospital and
Abbasi Shaheed Hospital are semi private and Agha Khan Hospital is a private hospital. The
hospitals, which refrained co-operation are Zia-ud-din Hospital and PNS Shifa Hospital. The first
is a private while the latter is an armed forces hospital. The unfortunate attitude of these hospitals
is also an indication of the unawareness of the consequences of the lack of such evaluation of
their preparedness. This also proves that aligning local and national efforts into the adoption of a
preparedness and protection strategy may be no easy task7. The survey was conducted using five
different questionnaires. These include:
Form A: Executive Personnel of Hospitals and Ambulance Trusts Survey Form – this is related
to daily operation of ambulances
Form B: Ambulance Services/ Trusts Officials Survey Form – this questionnaire is aimed for
information regarding the level of service and operation of Trust.
Form C: Ambulance Drivers Survey Form – this form provides details of problems faced by
ambulance drivers in their daily operations.
Form D: Casualty Attendant Survey Form – this form is intended to collect the information
regarding casualty facilities and medical supplies.
Form E: Patients/ Sufferers Survey Form – this form is planned to take the feed back of the
users of these ambulance services.

A) Executive Personnel of Hospitals and Ambulance Trusts Survey Form

The survey has been divided into various sections. The details of these sections are as under:

a) Ambulance Strength
Table 1. shows a break down of ambulances maintained by the hospitals and ambulance services
covered in the survey.

Table 1. Break down of ambulances strength

HOSPITAL / AMBULANCES AMBULANCES REMARKS

AMBULANCE TRUST IN ORDER OUT OF ORDER
CIVIL 3 7
JPMC 11 1
ABBASI SHAHEED 2 1 Out of order for 2 years
LIAQUAT NATIONAL 5 - For internal use only
AGHA KHAN 2 - For internal use only
ST. JOHNS 6 -
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Structures against Hazards, Singapore

EDHI 100 -
TOTAL 129 8

Total number of ambulances in the city can vary from the numbers given in Table 1. This is
because of the fact that there are some other ambulance services working in Karachi at a small
scale. These include Alamgir Welfare Trust, Al-Mustafa Welfare Trust etc. Unfortunately, they
are neither organized nor working with any welfare or missionary sprit. Rather, these are being
run on commercial basis and the information provided by these did not confirm the findings
about them. The survey team witnessed the drivers bargaining with the attendants for the shifting
of patients, outside the gate of Civil Hospital. Moreover, these were also accused for their
involvement in the terrorist activities in the recent past in Karachi. Keeping these in view, these
services were not included in the survey.

The ambulances possessed by hospitals are used for the shifting of patients to other hospitals or
at homes. It is, therefore, difficult to assess their effectiveness during a disaster.

b) Ambulance Charges
Table 2. shows charges of ambulances of hospitals and ambulance services. It is obvious from
the table that both Civil Hospital and JPMC are providing these services free of cost.

Table 2. Charges of Ambulances

HOSPITAL / AMBULANCE TRUST CHARGES (Rs)

ABBASI SHAHEED 50 L. S
AGHA KHAN 400 L. S
CIVIL Nil
JPMC Nil
LIAQUAT NATIONAL 137-250
ST. JOHNS Vehicles using diesel 10/km
Vehicles using petrol 12/km
EDHI 50 L. S

c) First Aid
Although all ambulances usually transport a single patient at a time, they have a capacity of two
stretchers to transport two patients. A large number of ambulances of Edhi Trust are Suzuki
Bolan type (Plate 1).

Plate 1: Suzuki Bolan Type Ambulance

 Proceedings of 14th – 15th November, 2002, International Conference on Protection of
Structures against Hazards, Singapore

However, they have got 20 Hyundai ambulances with air conditioning facility and 25 Hiace
ambulances. Both types are more comfortable than the former. Table 3. shows the equipment and
first aid facilities provided in an ambulance.

Table 3. Equipments provided with Ambulances

HOSPITAL / Oxygen Cylinder Fire Extinguisher First Aid Kit

AMBULANCE TRUST
ABBASI SHAHEED   
AGHA KHAN   
CIVIL   
JPMC   
LIAQUAT NATIONAL   
ST. JOHNS   
EDHI 40% vehicles  

It is clear from the table that except St. Johns no other ambulances carry a first aid kit. This is
because of the fact that no paramedical staff is sent with these ambulances and the drivers too are
not trained to provide any first aid to the patients. Though only 40% of the ambulances of Edhi
Trust are equipped with an oxygen cylinder, the numbers can be increased in an emergency
situation. Also they have got a limited number of fully equipped ambulances as well, which can
be called up in case of a critically injured person. Similarly, in order to transfer a patient outside
the city premises only a fully equipped ambulance is used.

d) Number of Drivers
Table 4. shows a break down of number of drivers hired by these hospitals and ambulance
services.

Table 4. Break down of drivers of ambulances

HOSPITAL / No of Drivers
AMBULANCE TRUST Total* On Duty Per Shift Stand By
ABBASI SHAHEED 11 2 5
AGHA KHAN 4 1 3
CIVIL 20 3 4
JPMC 23 10 5
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LIAQUAT NATIONAL 8 3 5
ST. JOHNS 6 4 2
EDHI 150 100 50
* the column gives the total number of drivers hired by the hospitals/ trusts

e) Disaster Drills
It is desirable that the disaster plan be exercised on an annual basis6. The Survey revealed that
only Agha Khan Hospital has got a disaster plan and they carry out drills together with Edhi
Trust. No other hospital has any plan and they obviously then do not carry out any disaster drill.

f) Training of Paramedical Staff

Training and exercising are essential elements to become suitably prepared to deal with a major
incident1. Non-medical or volunteer para-medical personnel can also contribute greatly to
emergency medical care. If they are trained in the first aid, they can relieve the pressure on the
professional staff by treating the large volume of moderate injuries 2. Saint Johns Trust provide
first aid training to the drivers. Edhi Trust is also planning to start a training programme soon for
the paramedical staff.

B) Ambulance Services/ Trusts Officials Survey Form

The information gathered regarding various aspects of operations of these services, their sources
of funds etc. are as follows.

a) Edhi Welfare Trust

There are almost 200 calls received for ambulances everyday. So, because of a network of 100
ambulances, each ambulance usually takes 2 trips daily. The incident is usually reported to the
Trust within 15 minutes of its happening. The funds are generated through private donors, which
consists of both individuals and philanthropist organizations. A large number of these individuals
belong to middle class. Unfortunately, the number of donor organizations is decreasing every
year.

b) Saint Johns Trust

Each ambulance takes almost 5 trips on a single day. The service is run through the fares of
ambulances, as there is no funding agency for the Trust. The officials and other staff are
volunteers except drivers. They have got the most well-equipped and comfortable ambulances.
First aid training is provided to the drivers and there are 3 doctors attached with the trust.

C) Ambulance Drivers Survey Form

The survey was aimed to get information regarding the problems faced by the drivers during
operation. The Form consisted of a number of questions and the details of these are given below:

a) Public Reaction
The public reaction towards ambulances is most of the time very much unsympathetic and
patients have to suffer on various occasions when the ambulance is not given the Right of Way.
 Proceedings of 14th – 15th November, 2002, International Conference on Protection of
Structures against Hazards, Singapore

This apathy is partially because of the misuse of these ambulances when they are in private use
of officials for family shopping. This has created a very bad impact on general public.

b) Serviceability of Roads
The drivers of Edhi Trust are, especially very much unsatisfied with the conditions of roads as
they are covering most of the city.

c) Inaccessible Places
The places, which are difficult for ambulances, according to the drivers, are as follows:
Lines area, Usmanabad, Kharadar, Ranchoor Line, Liaquatabad, Papoosh Nagar, Site area,
Qasimabad, Landhi, Ghareebabad, Samdani Coloney, Yousuf Goth, Golimar, Patal Para. This is
because of the congestion in these areas due to either encroachments or illegal and unplanned
construction.
D) Casualty Attendant Survey Form
There is not much information collected regarding this survey, as most of the casualty attendants
declared the information confidential. The details provided voluntarily are as under:

a) Capacity of Casualty Ward

All the hospitals surveyed have some reserve quota of beds and medical supplies for an
emergency. A summary of these is shown in Table 5.

Table 5. No. of beds and medical supplies available for emergency

Hospital No. of Beds and medical supplies Available For Emergency

ABBASI SHAHEED 30
AGHA KHAN 50
CIVIL 50 + 50*
JPMC 35
LIAQUAT NATIONAL 35 + 65*
Total 200 + 115*
* additional no. of patients that can be treated in case of emergency.

According to Edhi Welfare Trust they too have a provision for 25,000 casualties, which can be
provided food, clothing, tents and medicines.

b) Availability of Electricity
All these hospitals have their own electric generators to supply electricity in emergency to
I.C.U.’s, casualty wards and Operation Theaters.

E) Patients/ Sufferers Survey Form

There is very little information gathered in this regard as well as most of the hospitals were
reluctant allowing their patients to be interviewed. The patients too were not very co-operative in
answering various questions regarding the medical facilities being provided to them. The only
information provided by them was the in time arrival of an ambulance in case of an emergency.
 Proceedings of 14th – 15th November, 2002, International Conference on Protection of
Structures against Hazards, Singapore

Conclusion and Recommendations

1. Only Agha Khan Hospital has got an emergency plan and it, therefore, becomes obvious
that there is a lack of awareness of proper training and preparedness for a disaster on the part
of hospitals.
2. The non-cooperation of some hospitals is also because of the unconsciousness of the
importance of emergency management.
3. The effectiveness of hospital ambulances is difficult to ascertain as these are used only to
transfer the patients to homes or other hospitals.
4. As far as ambulance services are concerned, they are performing their duties quite efficiently.
However, it appears that they lack in infrastructure facilities regarding proper training of their
staff and equipments needed.
5. The need, therefore, is to provide requisite training to para-medical staff in order to reduce
the pressures on the medical professionals in case of a disaster.
6. There is a need for trauma centres in public sectors to provide medical facilities to common
citizens in case of a disaster.

References
1. Askew, A. J., Miller, J. B., Rodda, J. C., 1993: “Countering Natural Disasters- a Global
View” Proceeding of the Conference held in London, 13-15 October 1993 on Natural
Disasters: Protecting Vulnerable Communities, England, 1993: pp. 130-139
2. Coburn, A., Spence, R., 1992: “Earthquake Protection” , John Willey & Sons Ltd,
England, 1992: pp. 1-77
3. Cannon, T., 1993: “A Hazard Need Not a Disaster make: Vulnerability and the Causes of
‘Natural’ Disasters” Proceeding of the Conference held in London, 13-15 October 1993
on Natural Disasters: Protecting Vulnerable Communities, England, 1993: pp. 92-105
4. http://www.open.gov.uk/doh/epcu/epcu/index.htm, pp. 1-23
5. http://www.ocipep.gc.ca/publicinfo/NDMS/index_e.html
6. Tasmanian Ambulance Service, 2001: “Multi-Casualty Incident Plan”, Tasmania, 2001:
pp. 1-30
7. Oakley, D, J., 1993: “A National Disaster Preparedness Service” Proceeding of the
Conference held in London, 13-15 October 1993 on Natural Disasters: Protecting
Vulnerable Communities, England, 1993: pp. 270-281