Available online at www.sciencedirect.

com
Available online at www.sciencedirect.com

ScienceDirect
ScienceDirect
Procedia
Available Engineering
online 00 (2017) 000–000
at www.sciencedirect.com
Procedia Engineering 00 (2017) 000–000 www.elsevier.com/locate/procedia
www.elsevier.com/locate/procedia
ScienceDirect
Procedia Engineering 212 (2018) 855–862

7th International Conference on Building Resilience; Using scientific knowledge to inform policy
7th
andInternational Conference
practice in disaster on Building
risk reduction, Resilience;
ICBR2017, 27Using scientific knowledge
– 29 November to inform
2017, Bangkok, policy
Thailand
and practice in disaster risk reduction, ICBR2017, 27 – 29 November 2017, Bangkok, Thailand
Natural disasters and public health in the era of Sustainable
Natural disasters
Development Goals: and public health study
a retrospective in the of
erathe
of October
Sustainable
2015
Development Hindu
Goals:Kush a retrospective study of the
earthquake in Pakistan October 2015
Hindu Kush
a,b,c*
earthquake in Pakistan
d e
Junaid Ahmada,b,c*, Mokbul Morshed Ahmadd, Nafees Ahmade
Junaid Ahmad , Mokbul Morshed Ahmad , Nafees Ahmad
a
Disaster Preparedness, Mitigation and Management (DPMM)
a
b
Disaster
Asian Preparedness,
Institute Mitigation
of Technology and Management
(AIT), Pathumthani, (DPMM)
Bangkok, Thailand
b
Asian Institute
c
HigherofEducation
Technology (AIT), Pathumthani,
Commission Bangkok,
of Pakistan, PakistanThailand
c
d
Regional and Rural Development Planning,Higher SchoolEducation Commission
of Environment, of Pakistan,
Resources Pakistan
and Development, Asian Institute of Technology, Thailand
d
Regional and Rurale Department
Development Planning, School
of Development of Pakistan
Studies, Environment, Resources
Institute and Development,
of Development Economics Asian Institute
(PIDE), of Technology, Thailand
Pakistan
e
Department of Development Studies, Pakistan Institute of Development Economics (PIDE), Pakistan

Abstract
Abstract
Over the last two decades, earthquakes across the world have taken hundreds of thousands of human lives and caused countless
Over the However,
injuries. last two decades,
limited earthquakes
informationacross the world
is available on have
how taken
these hundreds of thousands
natural disasters, suchofashuman lives andimpact
earthquakes, causedhealthcare
countless
injuries. However,
institutions limited information
and communities and how this is available oninhow
is reflected these
global natural
health disasters,
indicators. Wesuchaim as earthquakes,
to assess impact healthcare
how earthquakes impact
institutions
communities’ and communities
public health andand how thisservice
healthcare is reflected in global
providers health
by using selectindicators. We indicators.
global health aim to assess how retrospective
We used earthquakes impact
cohort
communities’
study design, andpublic health and
retrieved ten healthcare service providers
districts’ monthly data. We by using select
determine, global health
uniquely, that theindicators.
geographicWeareausedmost
retrospective
affected bycohort
the
study design,
earthquake and retrieved
in 2015 tenwith
is the area districts’ monthly
the highest data. Weprevalence
tuberculosis determine,rate.
uniquely, that found
The study the geographic
that, in thearea
areamost affected
severely by the
affected by
earthquake in 2015
the earthquake, is the area
the baseline with the
number highest attending
of women tuberculosis
the prevalence rate. The
antenatal clinics study found
in January 2011 that, in the area
was 3,718, and, severely
throughoutaffected by
that year
the earthquake,
to 2016, there isthe baseline
a slow, numberincrease
but steady, of women attending
in the number theofantenatal clinics in
women visiting theJanuary 2011
antenatal was 3,718,
clinics. The sameand,month
throughout that year
of earthquake,
to 2016, of
number there is aimmunized
fully slow, but steady,
childrenincrease in the numberlikely
drops significantly, of women visiting
due to the antenatal
the interruption of clinics.
regular The same
health monthprovided
services of earthquake,
in the
number
aftermath of earthquake. This is the first comparisons of pre and post-earthquake health indicators of two region most andinleast
of fully immunized children drops significantly, likely due to the interruption of regular health services provided the
aftermath
affected byofthe
earthquake.
earthquake.This
Byisanalyzing
the first comparisons of pre
selected health and post-earthquake
indicators before and afterhealth
the indicators
earthquake, of ittwo regionthat
is clear most and least
earthquakes
affectedpublic
impact by thehealth
earthquake. Byvarious
and cause analyzing selected health indicators before and after the earthquake, it is clear that earthquakes
vulnerabilities.
impact public health and cause various vulnerabilities.
© 2017 The Authors. Published by Elsevier Ltd.
© 2018 The Authors. Published by Elsevier Ltd.
© 2017 The Authors.
Peer-review Published by Elsevier Ltd. committee of the 7th International Conference on Building Resilience.
Peer-review under
under responsibility
responsibility of
of the
the scientific
scientific committee of the 7th International Conference on Building Resilience.
Peer-review under responsibility of the scientific committee of the 7th International Conference on Building Resilience.
Keywords: Sustainable Development Goal 3; Disasters; Earthquake; Public Health; Global Health Indicators; Pakistan; Disaster Induced Health
Keywords:
Risks Sustainable Development Goal 3; Disasters; Earthquake; Public Health; Global Health Indicators; Pakistan; Disaster Induced Health
Risks

*
Corresponding author. Tel.: 0066-984-281-829
*
Corresponding
E-mail author. Tel.: 0066-984-281-829
address: Junaid.ahmad@ait.asia
E-mail address: Junaid.ahmad@ait.asia

1877-7058 © 2017 The Authors. Published by Elsevier Ltd.

1877-7058
Peer-review©under
2017responsibility
The Authors. of
Published by Elsevier
the scientific Ltd. of the 7th International Conference on Building Resilience.
committee
Peer-review under responsibility of the scientific committee of the 7th International Conference on Building Resilience.

1877-7058 © 2018 The Authors. Published by Elsevier Ltd.

Peer-review under responsibility of the scientific committee of the 7th International Conference on Building Resilience
10.1016/j.proeng.2018.01.110
856 Junaid Ahmad et al. / Procedia Engineering 212 (2018) 855–862
2 Junaid Ahmad, Mokbul Morshed Ahmad, Nafees Ahmad / Procedia Engineering 00 (2017) 000–000

1. Introduction
According to the Center for Research on the Epidemiology of Disasters (CRED), the number of earthquakes
worldwide has increased roughly four-fold in the past twenty-five years while the number of individuals affected by
earthquakes has increased roughly three-fold over the same period [1]. Earthquakes incur widespread physical,
economic, and social costs as well as damage the environment [2]. As well, loss increases exponentially if earthquakes
are followed by secondary hazards [3]. For health and economic loss, earthquakes are a major issue of concern both
for developing and developed countries. The 2030 agenda for Sustainable Development Goals (SDGs) and the 2015-
2030 Sendai Framework for Disaster Risk Reduction (Sendai Framework) agenda both intend to reduce the number
of lives lost and minimize human suffering from natural disasters across the globe [4]. Nevertheless, without
specifically integrating global public health concerns and disaster risk reduction, there is a high probability that goals
conceived to reduce human loss and suffering cannot be achieved [5]. For effective disaster management on a global
scale, strategies are shifting from a reactive to a proactive approach [6] and this has proven to be quite successful so
far [7]. We propose that the same approach could be implemented for public health so as to focus on prevention rather
than cures and treatment when preparing for natural disasters.
A limited number of these studies, however, are undertaken with natural disasters in mind, and those
conducted in this way mainly focus on the psychological and mental health of individuals following a disaster [8].
Since the field of disaster management is an emerging field, few studies systematically analyze the impacts of
earthquakes on key health indicators [8]. Thus, there is a serious need to study the effects of disaster on health and
identify the most effective ways to prepare and respond to disasters so as to improve health indicators, which is a
process that will hopefully lead to saving more lives overall. Despite the lack of such studies, it is a well-established
fact that the impact of earthquakes increases exponentially if they are accompanied by an outbreak of disease [9].
Whenever an earthquake hits any part of the world, inhabitants of that area are affected regardless of sex, age,
economic standing, or social status [10]; nevertheless, very often, the highest mortality and morbidity rates belong to
some specific group of the population: the poor, women, children, elderly, disabled people, etc. [11]. Additionally,
the devastating impact of two earthquakes of the same magnitude and intensity are very different when they occur in
developing rather than developed countries [11].
It can be argued that this is the first study of its kind since the SDGs, which were created to be achieved
through 2030 and endorsed by 187 countries, and since the adoption of the Sendai Framework agenda. Further, this
study is unique because it will provide insight for all stakeholders so that they may take into account disastrous
events\when planning interventions and strategies to achieve and monitor SDGs. By undertaking and integrating
public health assessments within preparedness plans, both monetary and physical efforts will be spared when
responding to disasters. As well, this study emphasizes the need to study the impact of natural disasters on different
groups within the population in real time [12]. It is exceedingly difficult to study this phenomenon as it occurs since,
most often, disasters affect a large area and affect a large population all at once [13]. While numerous researchers in
different studies attempt to analyze the impact of these disasters, most of the studies simply estimate the damage
created by disasters, and only an exceedingly small number of studies attempt to consider the epidemiological impact;
therefore, there is a need to look into real cases and determine precise data to depict the situation accurately instead
of approximately.

2. Methodology
2.1. Objective
We aimed to use selected indicators from the World Health Organization’s (WHO) global health indicators list
and those included in the Sustainable Development Goals (SDG) to assess how the Hindukush earthquake of 2015
impact the trends of prevailing health risks and vulnerabilities.
2.2 Study site
Khyber Pakhtunkhwa (KPK) is a province containing twenty-six districts in the north-west part of Pakistan.
The 2015 earthquake was the second deadliest earthquake in the area since 2005, badly affecting five districts of the
 Junaid Ahmad et al. / Procedia Engineering 212 (2018) 855–862 857
3 Junaid Ahmad, Mokbul Morshed Ahmad, Nafees Ahmad / Procedia Engineering 00 (2017) 000–000

province. According to the United States Geological Survey (USGS) [15], this earthquake had the epicentre located
forty-five km southwest of Jarm and about sixty-seven km north-west of the Chitral district in Pakistan. The
earthquake was initially given a magnitude of 7.7, though it was later revised to 7.5 by the USGS [15]

Figure 1. Study area map and selected districts indicating active seismic fault line and epicentre of earthquakes,
2005 & 2015

Source: Author’s own work using open-source Esri Delorme, USGS, NOAA

2.3 Study design, indicators and data source

This study employed a retrospective study design where we purposely select ten districts located in an area
highly vulnerable to earthquakes. These ten districts are then grouped into two categories, each containing five districts
(Figure 1). The District Health Information System (DHIS), managed by the provincial government, was used to
retrieve data about the selected health indicators at both pre- and post-earthquake intervals. Notably, information in
the database is entered by specially trained staff in the healthcare facility. The DHIS covers all twenty-six districts of
the province, and reporting compliance at the study site was noted at 100% [16]. The WHO uses one hundred
indicators to monitor health and wellbeing across the world [16]. We purposely select indicators in three major
domain, which are closely linked to the objectives of the study to consider i.e maternal health, child health and
communicable diseases. In our research, we use monthly prevalence and incidence trends reported from public health
facilities to avoid, or at least minimize, any bias within study. It is also worth mentioning that the data we utilize,
collected from the registry database of the earthquake-prone area of Khyber-Pakhtunkhwa, is actual data.

3. Results
3.1 Maternal health and pregnant women visiting ANC facilities
According to Glynn et al. (2001) [17], while earthquakes possess a significant public health risk to pregnant
women, their effect is usually not realized due to humanitarian services that bring antenatal clinics closer to these
women, increasing the number of women likely to utilize ANC services. Categorically similar to the findings reported
by Glynn et al. (2001) [17], we found that, in the area severely affected by the earthquake, the baseline number of
858 Junaid Ahmad et al. / Procedia Engineering 212 (2018) 855–862
4 Junaid Ahmad, Mokbul Morshed Ahmad, Nafees Ahmad / Procedia Engineering 00 (2017) 000–000

women attending the antenatal clinic in January 2011 was 3,718, and, throughout that year to 2016, there is a slow,
but steady, increase in the number of women visiting the antenatal clinics. Figure 2 shows monthly trends related to
antenatal care. In October 2015, when the earthquake occurred, 5,098 women visited ANC. This number, however,
cannot be definitively attributed to the earthquake as it continues on in a slow rise and, even after the earthquake, the
rising trend is still discernable in 2016. Hence, the earthquake did not significantly affect the visits paid to ANC in
this group. Among the second group of ANC visits in areas least affected by the earthquake, the trend is similar to the
first group; these incidences increase steadily from the year 2011 to 2016, uninterrupted in any way by the disaster. A
similar trend is also seen in women attending ANC for the first time in both regions of the study. It is, therefore,
apparent that the earthquake did not create any real form of interruption to this critical public health service.
Group-I-Antenatal Care revisit in the facility -
Number of patients reported

Group-I-First Antenatal care visits (ANC-1) in the facility -

Group-II-Antenatal Care revisit in the facility -
22000
Group-II-First Antenatal care visits (ANC-1) in the facility -
Group-II-Pregnant women received TT-2 vaccine -
Group-I-Pregnant women received TT-2 vaccine -

17000

12000

7000

2000
Jul-11

Jul-12

Jul-13

Jul-14

Jul-15

Jul-16
Jan-11

Jan-12

Jan-13

Jan-14

Jan-15

Jan-16
Oct-11

Oct-12

Oct-13

Oct-14

Oct-15

Oct-16
Apr-11

Apr-12

Apr-13

Apr-14

Apr-15

Apr-16

-3000

Figure 2. Monthly trend in antenatal care visits and revisits by the pregnant women who received TT-2 vaccination.
Source: Authors own calculation using the data sets retrieved from provincial government DHIS

3.2 Child health and immunization

Figure 3 shows monthly trends related to children’s immunization statuses. During the baseline year 2011,
among the people residing in the area least affected by the earthquake, the number of children fully immunized at
twelve months is relatively low at 3,000 children. There is a slight fluctuation toward 2016, but the overall trajectory
rises steadily; however, in August 2012, there is a great decline in the number of children fully immunized, though
the number starts picking up again and is restored within a month. The same month of earthquake, fully immunized
children drops significantly October 2015, likely due to the interruption of regular health services provided in the
aftermath of earthquake. After the low prevalence of full immunization during that October, though, the trend picks
up again, but at a very slow pace, and then plateaus from November 2015 to 2016, in the same month. Grais et al.
(2011) [18] explains that, on the one hand, humanitarian services in earthquake-stricken areas do usually shield the
victims from experiencing the full effect of the disaster as these services provide necessary undertakings, such as
offering immunizations to children. On the other hand, in 2011 when the research started, the baseline in the area hit
severely by the earthquake has relatively high numbers as more than ten thousand children received full immunization.
 Junaid Ahmad et al. / Procedia Engineering 212 (2018) 855–862 859
5 Junaid Ahmad, Mokbul Morshed Ahmad, Nafees Ahmad / Procedia Engineering 00 (2017) 000–000

The prevalence of immunization then increases drastically in the following months to about twenty thousand children.
Starting from January 2013, though, the rate drops to almost the same number attained during the baseline year,
marked with occasional rises and falls before stagnating until November 2016 when it drops to its lowest ever in the
region. It does, in more recent years, rise again. In this case, the earthquake cannot be associated with the constant
fluctuations in the prevalence of immunization.

32000
Group-I-Children under 12 m fully immunized -

Group-I-Children under 12 m received 1st Measles vaccine -

Number of Patients reported

Group-I-Children under 12 m received 3rd Pentavalent vaccine -

27000
Group-II-Children under 12 m fully immunized -

Group-II-Children under 12 m received 1st Measles vaccine -

Group-II-Children under 12 m received 3rd Pentavalent vaccine -

22000

17000

12000

7000

2000
Jul-11

Jul-12

Jul-13

Jul-14

Jul-15

Jul-16
Jan-11

Jan-12

Jan-13

Jan-14

Jan-15

Jan-16
Oct-11

Oct-12

Oct-13

Oct-14

Oct-15

Oct-16
Apr-11

Apr-12

Apr-13

Apr-14

Apr-15

Apr-16

-3000

Figure 3. Monthly trend of children immunized and reported from January 2011 to Nov 2016
Source: Authors own calculation using the data sets retrieved from provincial government DHIS

3.4 Patients on intensive phase of TB-DOT

The geographic area most affected by the earthquake in 2015 is, coincidentally, the area with the highest
prevalence of tuberculosis (TB) for the two regions, so many new people acquired the infection constantly,
contributing to this high incident rate. In the same group, even though drug adherence was high, there were still a
few cases between 2011 and 2014, where patients missed their medication, a situation that resulted in an increased
number of new infections. From 2014 on, however, the drug-adherence rate is exceedingly high, and, even during
the period of the earthquake and after, the drug adherence does not substantially alter.
 860 Junaid Ahmad et al. / Procedia Engineering 212 (2018) 855–862
6 Junaid Ahmad, Mokbul Morshed Ahmad, Nafees Ahmad / Procedia Engineering 00 (2017) 000–000

Figure 4 shows monthly trends related to TB-DOT. According to Tang et al. (2015) [19], during an
earthquake the internal and external migration is likely to interfere with anti-tuberculosis adherence and diminishes
follow-up effectiveness. Similarly, the second region in the study, which was less affected by the earthquake, shows
relatively low prevalence of TB throughout the period of study as compared to the areas largely affected by the
earthquake. Firstly, this region had a good drug adherence policy throughout the intensive face, which contributes
significantly to its low incidence rate. Secondly, the stability of the trend is not interrupted by the earthquake’s
impact in both the regions, therefore demystifying the notion that the earthquake had any effect on public health
agenda in this sector.

2000
of Patients reported

1800 Group-II-Intensive phase TB-DOTS patients missing treatment >1 week -

Group-II-Intensive-phase TB-DOTS patients -
1600 Group-I-Intensive phase TB-DOTS patients missing treatment >1 week -
Group-I-Intensive-phase TB-DOTS patients -
reported

1400

1200
Number
Number of Patients

1000

800

600

400

200

0
Jul-11

Jul-12

Jul-13

Jul-14

Jul-15

Jul-16
Oct-11

Oct-12

Oct-13

Oct-14

Oct-15

Oct-16
Apr-11

Apr-12

Apr-13

Apr-14

Apr-15

Apr-16
Jan-11

Jan-12

Jan-13

Jan-14

Jan-15

Jan-16

Figure 4. Trend of intensive phase TB-DOTS patients missing treatment and intensive-phase TB-DOTS patients
from January 2011 to November 2016
Source: Authors own calculation using the data sets retrieved from provincial government DHIS

4. Discussion
Of the 1.35 million people killed by natural disasters over the past twenty years, more than half of this number
died in earthquakes with the remainder having succumbed to weather- and climate-related hazards, though more
thorough data is needed on overall disaster mortality [20]. The number of empirical studies that have validated how
much and why certain groups of people are more vulnerable than others during disasters is exceedingly limited,
especially those studies regarding public health [8]. In the early 1970s a series of well-publicized disasters triggered
the scientific interest of the international public health community. These studies emphasize elderly people, pregnant
women, children under the age of five years, and disabled people as they are the most vulnerable population, but until
recently, no concrete evidence has been presented to validate such data [21].
None of the databases that look into these disasters fulfil the demands of the healthcare system so that health
professionals can have the answers to how healthcare institutions and the people they serve are affected by earthquakes
 Junaid Ahmad et al. / Procedia Engineering 212 (2018) 855–862 861
7 Junaid Ahmad, Mokbul Morshed Ahmad, Nafees Ahmad / Procedia Engineering 00 (2017) 000–000

[22]. It is worth mentioning that no database to date contains health-related objectives for natural disasters, which
includes but is not limited to the Emergency Events Database (EM-DAT), the United Nations International Strategy
for Disaster Reduction’s (UNISDR) Disaster Statistics, DesInverter, and the Index for Risk Management (INFORM)
[22]. The lack of healthcare-related data when it comes to earthquakes and other natural disasters certainly is a major
gap in disaster risk management [24]. This is true within the context of our study, as well. We retrieved data from
DHIS, but no single data set maintained by this database specifically links relevant information to earthquake events.
One of the ignored areas in the response-and-recovery phase of disaster management in Pakistan is disease
surveillance. Disease surveillance in the area affected by disasters is very important in order to comprehend the impact
of disasters on illness and deaths by communicable diseases. Obtaining significant surveillance information in these
situations, however, is often challenging. The destruction of the established public health infrastructure can exaggerate
or eliminate what may have already been weak pre-disaster systems of surveillance and response. Surveillance
personnel and other public health workers may be killed or missing, as in the earthquake of 2015. Also, population
displacement can misrepresent census information, which makes the verification of rates for comparison more
difficult.
From past events in Pakistan, like the earthquake of 2005 and floods of 2010, it is apparent that health services
were severely disrupted during such disasters, especially the 2005 earthquake. During these tragic events, health
facilities are often damaged directly or they remain inaccessible because of road blockages and damage; lack of a
clean water supply and power failure also make health facilities inaccessible or non-functional [23]. It is evident from
our findings that, at the present time, the gaps in the healthcare system need to be studied seriously through a disaster
management perspective.

5. Conclusions
This study used the earthquake of 2015 in Pakistan, to provide a baseline for future research regarding how
and what aspect of public health can be affected by natural disasters. Our findings are notable in that we propose
earthquakes do impact the health status of communities and the utilization of such services as well as their access to
healthcare institutions in many areas. It is possible to build or enhance community health resilience fortifying against
these disasters, but knowing the risks and vulnerabilities in that specific area is the key. Applying existing knowledge
and data-based decision making is especially challenging in disaster situations because of the nature of the risks and,
subsequently, the lack of relevant, reliable data. A critical factor that further compounds this challenge is the limited
development of, or partial (or total) collapse of, systems for routine information collection and analysis as a result of
a disaster. Therefore, it is a pressing need to enhance the compromised information systems that often suppress the
process of prioritizing the response and preparedness interventions at all levels and to limit the capacity to detect,
analyze, and monitor the trends regarding earthquake impact.
Acknowledgments: The primary author is thankful to the Higher Education Commission of Pakistan for funding the
author’s doctoral study. We are also grateful to the Government of Khyber Pukhtunkhwah Pakistan, and the
Directorate General Health Services for allowing us to access the complete District Health Information System (DHIS)
database.
Conflicts of Interest: The authors declare no conflict of interest. The founding sponsors had no role in the design of
the study; in the collection, analysis, or interpretation of the data; in the writing of the manuscript, and in the decision
to publish the results.

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