Rehabilitation of earthquake victims: social and health aspects (the Cairo 1992 experience)

M. Gabr¹

¹ M. Gabr is Professor of Pediatrics, Cairo University; past president of the Advisory Committee on Health Research, WHO; immediate past president of the International Pediatric Association; and Secretary General of the Egyptian Red Crescent Society, Cairo, Egypt.

On the afternoon of 12 October 1992, an earthquake of a magnitude of 5.9 on the Richter scale struck the greater Cairo area. The centre of the earthquake was 30 kilometres south of Cairo at Dahshour in Giza. It mainly affected the governorates of Cairo, Fayoum, Giza and Kalioubia. Other governorates as far away as Menia also suffered some damage. Because of its population density and the high number of squatter areas and buildings more than 1000 years old, the greater Cairo area suffered the greater loss of life. The official recorded death toll was 560, while the number of injured exceeded 2000. More than 5000 buildings collapsed, leaving more than 8000 families immediately homeless. During the next few weeks the number of homeless families grew to more than 25 000 as they were obliged to evacuate buildings that were in danger of collapsing.

Egypt does not register severe earthquakes often, as shown in Table 4.1 (7). None resulted in such a high toll of casualties as that in Cairo in 1992.

Table 4.1. Recent earthquakes in Egypt

Curative care of the injured was carried out through a coordinated effort between the Ministry of Health and the Egyptian Red Crescent which was also responsible for social and psychological-follow up and support.

Through a coordinated effort between the government, the army and the Egyptian Red Crescent Society, more than 50 temporary shelters (camps) were erected for the victims, chiefly in urban areas. Many of the affected families in rural areas preferred to move in with their relatives.

A system of recording involved the use of special registration cards which included information on family members, those affected, original residence, and social and economic status. An additional table covered a needs assessment, i.e. for covers, clothes, food, etc.

Health in temporary shelters

A physician, nurse and volunteers were assigned to each camp. The guidelines for assessment of health and nutritional status established by UNHCR were followed (2). Assessment was carried out by trained Red Crescent volunteers under the guidance of the camp physician. The assessment included individual medical check-ups as well as water supply and sanitation. Public health education, which is known to maximize the effectiveness of health measures (2), was also provided.

Sanitation

Within three days, all camps were supplied with safe running water. In the first few days temporary portable water containers were made available to supply 10-20 litres per person. Occasionally pumps were needed so that water could reach camps on high ground. The Egyptian Red Crescent supplied household equipment such as clean water containers, soap, refuse disposal bags, and cooking and eating utensils. Volunteers supervised cleanliness and basic hygiene. Disposal of excreta was a major concern. If there was a public building near the camp, its sanitary facilities were used by the camp-dwellers. In most camps, however, ditch latrines were dug, to be replaced after the first few days by deep latrines in accordance with WHO and UNHCR guidelines (2).

Nutrition

Appropriate canned food was distributed during the first week. Special attention was given to the needs of children, pregnant and lactating women, the elderly and the undernourished. A modification of the United Nations guide to food and health relief operations in disasters was adopted (4). Food aid was gradually discontinued after the first week to avoid creating dependency, except for those persons in need on medical or social grounds. Kitchens were erected in the camps.

Psychological care and social support

All volunteers were trained by a group of psychiatrists according to the guidelines of the International Federation of Red Cross and Red Crescent Societies (3,5). This helped to minimize the well known psychological effects of disaster syndrome, especially for those who lost a family member or source of income as well as children (6,7). Acute psychological trauma was rare. Relatively few persons suffered from anxiety, depression or lack of emotional control. Psychological and social care greatly alleviated those cases. Equity in social care and donation of supplies was another factor that helped to minimize the aggressive attitude that may occasionally be encountered in such situations.

Control of infectious diseases

There were no outbreaks of foodborne, waterborne or respiratory diseases. The earthquake occurred in October when the climate is temperate. The diarrhoeal disease season was over and the respiratory disease season had not yet begun. Scabies was a problem, however, because of overcrowding and the difficulty of maintaining personal hygiene, especially during the first few days. Medication was distributed and the need for personal hygiene was emphasized. Children and young persons aged 3-20 years received antimeningococcal vaccine. Because of the high vaccination coverage during infancy, routine vaccination schedules were performed only on those in need.

Other health issues

Other issues that were addressed included care of the sick, the elderly, the handicapped and the chronically ill. Violence, robbery and occasional attempts at sexual assault occurred during the first few days after the earthquake but were overcome by security measures such as 24-hour supervision by volunteers and proper lighting at night.

Resettlement

The government successfully resettled families in four settlement areas around Cairo in modest apartment houses that had originally been built three years before for newly-married couples. Because of lack of funds these buildings lacked basic infrastructure (streets, water, sanitation and electricity supply). Thanks to government donations, the basic infrastructure was completed three months after the earthquake. All refugees moved to their permanent resettlement area by the end of January 1993.

The urban development project for earthquake victims in Nahda

The Egyptian Red Crescent was given responsibility for providing social support and rehabilitation to the new residents of Nahda City. This was a real challenge. Nahda City, 20 kilometres east of Cairo, is the largest of the four main settlement areas for persons made homeless by earthquake and accomodated 12 000 families. The population was heterogeneous; people came from three governorates (Cairo, Giza and Kalioubia), were from a mixture of rural, semi-rural and urban areas, and had differing cultural, social and economic backgrounds. A survey was conducted by the National Institute of Sociology on the early settlers to evaluate their socioeconomic status (8). Recording of all residents was carried out and regularly updated. A comprehensive rehabilitation project was developed between the Red Crescent, Cairo governorate and UNICEF to care for the residents of Nahda City through community participation, the establishment of community groups and organizations, the appointment of community leaders, and the coordination of government services and the voluntary Egyptian Red Crescent efforts. Red Crescent volunteers supervised the activities through regular twice-weekly visits. The project is still running successfully.

Socio-economic conditions

The age distribution of the inhabitants of Nahda was similar to the age distribution for Egypt as a whole: 40.8% were below 18 years of age. The proportion of elderly (above 65 years), however, was 5.4% in Nahda against 2.9% for Egypt as a whole.

The average income per capita was 151 Egyptian pounds (L.E.) per month (1 US$ = 3.40 L.E.). The lowest income group (below 100 L.E. per month) represented 26% of the population, most of them belonging to single parent families headed by females. The higher income group (500 L.E. per month) represented 8.4% of the population.

The unemployment rate was slightly higher than the average rate for Egypt. The unemployment rate for males of working age was 15% while that for females was 66% (most of them were housewives). Of those who were working, 66% of the males and 34% of the females had a regular job. It is interesting to note that, in spite of the low income of most families, 66.2% had electric refrigerators and 50.4% owned a television set. The importance of refrigerators for food safety in Egypt, a subtropical country, is obvious.

More vulnerable groups in Nahda such as women, children and the elderly suffered from moderate malnutrition. Prevalence of gastroenteritis, hepatitis and other communicable diseases was similar to that in Egypt as a whole. The most common health problems are shown in Table 4.2. The survey indicated that 2.4% of the population suffered from a handicap or disability, the commonest being hemiplegia, loss of one or more limb and mental retardation (Table 4.3). Only two cases with loss of one or more limb were the result of the earthquake.

Table 4.2. Health problems of the Nahda population

The inhabitants of Nahda had several common social and psychological problems. They were uprooted from their communities and many had lost their source of income. They shared similar anxieties regarding their identity and their future. However, there was little evidence of traumatic stress disorders characteristic of the disaster syndrome (6). Almost all survivors belonged to a deprived social class that had been living under chronic stress before the earthquake and who had a strong belief in destiny and acceptance of fate.

Table 4.3. Prevalence and type of handicap at Nahda

All houses had clean water and sewage disposal. During peak hours, however, the water supply was insufficient. Steps were taken to build a new water pipeline. Health services were provided through one government health unit and one ambulance. The regional hospital was six kilometres away. Main roads were paved and lighted but smaller roads between the houses were not. Two public telephones and four buses provided communication and transportation services but these were insufficient.

Objectives

The objectives of the rehabilitation project in Nahda were:

- to develop a sense of belonging, integration into society and a productive life;

- to carry out cultural, recreational and communal activities to bridge the gaps of alienation and anonymity;

- to help the people to define their problems and find relevant solutions through self-help in cooperation with government services;

- to improve the standard of living through the creation of job opportunities, combating illiteracy, promoting better health, improving nutrition, and improving the social and environmental situation.

Implementation

A project director was appointed and community coordinators were selected from among the young people of Nahda. A geographical area was assigned to each coordinator. Residents elected community leaders for each cluster of apartment houses and organized local committees. Each committee elected a representative to be a member of the regional committee which met every month and included the project director, the chief Egyptian Red Cross volunteer and the chairman of the local government council- A Supreme Committee for Planning, Supervision and Evaluation chaired by the governor of Cairo and representatives from the regional committees and local authorities met every three months. Rehabilitation plans were developed on an annual basis.

The Egyptian Red Crescent erected a social health centre which served as headquarters for the project. Training and educational activities for the trainers were carried out there. Rehabilitation activities were carried out in 12 smaller centres throughout the Nahda area.

Consultants developed a comprehensive rehabilitation programme. Community participation was mandatory during the planning and implementation of the programme. Whenever possible, trainers were selected from among the community and given proper training by consultants and professionals. Evaluation was built into the project.

Three sociocultural clubs were established for children, women and the elderly. Three public libraries and 30 mobile libraries began functioning within six months. Recreational trips for children, young people, housewives and the elderly were carried out with great success. Social programmes to promote better living habits were conducted regularly, and theatre shows and other artistic activities were performed.

Many of the young people of Nahda were organized into sports teams - football, table tennis, volleyball, handball, basketball and so on. More than 100 tournaments were carried out. Prizes and incentives from the local community were offered to the winners. This was very effective in distracting the young people from harmful activities such as drugs and violence. Although the Nahda area was notorious for its drug-dealers before the resettlement they have now completely disappeared.

An indoor gymnasium was opened for women in the women's club and was surprisingly successful. It is very rare in Egypt for women of this social class to get involved in gymnastic activities. Its results reflected positively on their health.

Because of the high illiteracy rate, 22 literacy classes were established in different areas of Nahda. Astonishingly, most of those who enrolled were housewives. More than 650 received literacy education. Again the positive reflection on health of this activity is evident. Tuition classes for school children needing support, as well as for drop-outs from compulsory primary education, were carried out and have served more than 3000 pupils during the past three years. A number of efforts were made to promote upgrading of the environment. These included seminars, involvement of young people in environmental projects, the establishment of a refuse disposal system by the community, school programmes, and care for trees and green areas.

Attempts to overcome the poverty and high unemployment were carried out through various innovative vocational training and educational programmes aimed at encouraging income-generating activities. Training covered topics such as home repairs, food preservation, computers, electronics, and electrician's and plumber's skills. Programmes to train young girls as babysitters and to take care of the elderly and handicapped were highly successful.

Many of these activities reflected positively on health. A system to promote better health nutrition and family planning through community participation was established. Female community health leaders were selected from among the community, taking into consideration age, educational background, willingness to serve and geographical distribution. The training of 100 female health leaders was carried out by consultants through a two-week special programme involving household hygiene, primary health care, first aid, psychological support, appropriate nutrition, promotion of family planning, drug abuse, AIDS and so on. Apart from public seminars on health education by professionals, female community health leaders greatly facilitated health promotion through direct communication.

At the beginning, only the free government health unit existed but within six months five private clinics and two pharmacies had started functioning. The Egyptian Red Crescent's social health centre was inaugurated one year later and provided health care at nominal fees as well as a 24-hour first aid ambulance service to the nearby hospital. This centre provided services to more than 1500 persons a month. As an example of the success of the health component of the project, 2567 women of child-bearing age sought the use of contraceptives in the social health centre during 1996. Vaccination coverage exceeded 90%.

Disabled persons received social care. The Red Crescent supplied wheelchairs and basic physiotherapy equipment. Young women from the community, trained in the care of persons with handicaps, facilitated their home care. Cases needing advanced physiotherapy or surgical intervention were referred to appropriate hospitals.

Depression, insomnia, agitation and other psychological manifestations of post-disaster syndrome (5) were rarely encountered. Only occasionally did people need psychological support, which was provided by the trained community health leaders. This was more successful and reassuring than consulting a professional psychiatrist whose role was limited to diagnosis, advice and follow-up.

Evaluation, constraints and solutions

The Nahda resettlement project faced a number of constraints but efforts were made to overcome them. For instance, the supply of clean piped water was insufficient at the beginning but was remedied within 18 months. Two new bus lines were established at an affordable fare. This greatly facilitated transportation of pupils to their original schools until new schools were established. The telephone and telegraph communication system was also strengthened.

Health and environmental education changed the behaviour of the inhabitants in respect to hygiene and cleanliness. The Egyptian Red Crescent's social health centre supported a comprehensive health, family planning and nutrition education programme through a network of voluntary female community health leaders, as well as providing health care at nominal fees.

Housing thousands of families from different social, cultural, economic and geographical backgrounds in one new settlement area was a unique experience. Community development is still proceeding with great success. This success is related to community participation at all stages of the project, and regular meetings between the government authorities and the social, health, educational, cultural and recreational programmes. The residents of the area today are proud to say that they belong to Nahda.

References

1. Sedki A. Report of the Egyptian Prime Minister to the Senate. Cairo, Press of the Egyptian Parliament, 12 Nov. 1992.

2. Handbook for emergencies, Geneva, UNHCR, 1982.

3. Disaster rehabilitation and reconstruction. Geneva, IFRC, 1994.

4. Protein Advisory Caloric Group of the United Nations. A guide to food and health relief operations for disasters. New York, 1977.

5. Guidelines to develop psychological support programs for disaster victims. Geneva, IFRC, 1993.

6. Lazarus RS, Folkman S. Stress Appraisal and Coping. New York, Springer, 1984:578-615.

7. Coping with Natural disasters: the role of health personnel and the community. Geneva, WHO, 1989.

8. Fahmy N. Comprehensive survey of the population of Nahda City. Cairo, National Institute of Childhood and Motherhood Publications, 1993.