A Case Study for the Setting of Water Supply & Sanitation Priorities in the PAK Emergency

1. A Case Study for the Setting ofWater Supply & Sanitation Priorities in the PAK Emergency

2. Choices, choices. . . . . • Much of life is about making choices. Even in – if not especially in - the practice of public health, one is faced with choices, the outcomes of which are likely to show how correct those choices were. Standard texts will often portray situations where the choices are clear, but in real life, this clarity of choice is rarely on offer.

3. The Kashmir Earthquake • On Oct 8th, 2005, at approx 8:50am, an earthquake struck northern Pakistan. It measured 7.6 on the Richter Scale. Destruction was widespread and while the precise number of dead may never be known, some 100,000 are thought to have perished. • This case study is of the Bagh District in PAK. Bagh lies south and slightly east of Muzaffarabad which itself was close to the epicentre of the quake.

4. Background to Water & Sanitation • In Bagh District, the town of Bagh suffered extensive destruction, and immediate attention was focused on the urban area because of the fear of diarrhoeal epidemics. Later, attention was drawn to the choices of where next to concentrate relief efforts. What emphasis should be given to water supplies – and where; and what specific sanitation interventions should be undertaken, and where and, for all choices, why ?

5. Priority 1 • Soon after the earthquake, spontaneous tented villages appeared in Bagh Town. These were considered most likely to be the focus of any epidemic because of crowded and unsanitary conditions. • Those not having access to safe or chlorinated water supplies were given safe water; and all tented villages were provided latrines (separate for women and men), with those for women being lit for security. • Bathing cubicles were provided as well

6. The Sphere Project +++++ • The Sphere Project was the guide for minimum levels of service though, until the supply chain was properly established, the first guide was 1 latrine per 50 dropping to 1:20 as soon as possible thereafter; • Separate facilities for men and women are a cultural imperative in Kashmir; • Latrines for women must be lit at night; and • Latrines and bathing cubicles for women must have a roof covering.

7. The Sphere Project +++++ • Water is abundant in Kashmir, particularly from springs. Few waters are turbid so that generally, simple chlorination is all that is required to ensure that water is safe; • In general, people take care about the quality of the water they drink; • The majority of Kashmiris exercise reasonable standards of personal hygiene; so • If soap is provided, nearly everyone will use it for clothes’ washing and washing themselves

8. Priority 2 • Spontaneous tented villages tended to be created by those from a specific area. For formal ‘camps’ to be created by UNHCR or the Army or the Government, it was felt that people who were going to be persuaded to settle in them, were likely to be those who were poor, or who had been driven down due to heavy snows. They were likely to be even more crowded than the spontaneous tented villages. Thus these had to be the next priority.

9. Priority 3 • After tented villages and camps, urban areas represent the next most concentrated areas – so they had to be the next priority; • Areas where groups of householders concentrate should be provided emergency latrines, separated by gender, with lighting for women’s latrines and bathing cubicles; • Where variable voltage affects water supplies, standby power should be considered; and • Soap should be provided

10. Priority 4 • Clinics without latrines must be the next priority. The majority of patients attending OPDs are ill by definition, so that containing excreta where patients are concentrated is essential; but • While latrines must be segregated by gender, lighting is probably not necessary since clinics do not operate at night. Also, bathing cubicles are not necessary here.

11. Priority 5 • Hospitals normally are provided latrines, especially where emergency facilities are provided by international NGOs. However, where they do not have latrines, they must be provided together with systems for the disposal of medical wastes (including sharps)

12. Priority 6 • Schools – particularly those operating out of tents – are the next priority; • Latrines must be segregated by gender BUT girls MUST have greater access to latrines than boys particularly during puberty, or drop-out rates will rise; and • The final aim of 1 latrine per 20 pupils is ideal but may depend on available funding in the early phases. Some latrines are better than none at all.

13. Priority 7 • Sparsely populated areas probably do not carry immediate urgency after the event. Water quality is usually excellent and the risk from open defecation is very low, and besides, people nearly always select defecation sites away from their water source. Soap availability can have an impact on personal hygiene and should be considered. Only when other priorities have been satisfied should latrines be considered for these areas.

14. Commentary 1 • Communities which had a working water supply before the earthquake and have had parts of their long water pipeline swept away by a ‘slide’ should carry a higher priority than those for whom a short walk to a nearby spring is an inconvenience; • Areas which suffered minimal damage should wait in favour of those more seriously affected; and • Spurious requests should be eliminated

15. Commentary 2 • Perhaps the most serious risk in Kashmir is still to come. Present temperatures are quite low and epidemic risks are proportionately low. In spring with the snow melt (March, April or May depending on altitude), temperatures will rise as will the risk of epidemics. Also, snowmelt waters are likely to be turbid making chlorination ineffective unless prior flocculation/coagulation has taken place.

16. Commentary 3 • The most powerful set of indicators to test the effectiveness of water supply and sanitation interventions probably include the weekly statistics of cases reported of: • Watery diarrhoea • Bloody diarrhoea • Suspected infectious hepatitis • Scabies • but beware how these statistics are analysed and investigated if above the anticipated base ‘load’

17. Recapitulate the Priorities • Spontaneous tented villages • Formal camps • Un-served urban areas + standby needs • Clinics (and hospitals) • Schools (particularly tented schools) • Broken, long pipelines; and eliminate spurious requests • BEWARE THE SNOWMELT PERIOD WHEN TEMPERATURES RISE !