'We will continue to struggle with enormous challenges'

The Asian earthquake caused massive destruction, a huge death toll and a terribly high number of wounded in a hard-to-reach mountainous area where the harsh winter climate will soon further deteriorate living conditions of survivors. During the initial rescue phase, MSF faced huge logistical challenges in getting first aid and surgical care to the wounded. There are more difficulties ahead, says Vincent Hoedt, MSF emergency coordinator in Muzaffarabad.

About four weeks into the relief effort, how would you describe the situation?

"Having dealt with the initial priorities, we are now starting to worry about the longer term problems. On the one hand we have a collapsed health structure, on the other hand we have an increased medical need of people who are weakened by lack of shelter, exposure, less food, shortage of clean drinking water, poor hygiene conditions, and psychological stress.

"How many people will decide to move in search of aid? And what if in these attraction points there is no form of medical care neither? Those are the biggest question marks. And now you have to extrapolate this variety of risk factors to a huge area which is difficult to access and has a high population size. In short, we will continue to struggle with enormous challenges for a long time."

What are the practical challenges of providing aid for the teams on the ground?

"Providing aid under these circumstances means that you have people queuing up in front of the MSF warehouse because they see that you are loading tents on a truck. You would tell them: 'Sorry, these tents are meant for a particular village where people have lost everything.'

But the desperate people will reply: 'Why don't you give me a tent.' And there will be no doubt that they also deserve one. That is basically the painful way of setting priorities in this type of distributions. It means that you meet a poor old grandmother who has to look after three small children because, by accident, every one in the middle of this family died.

"In this situation it seems odd to give him a tool kit and to suggest to rebuild the house or to say: 'Well, there is a health post only ten kilometres down the hill.'"

How about the psychological impact of the earthquake on the survivors?

"You might think that mental health is not life saving, but it is a tremendous problem and dealing with trauma is very difficult. Up in the mountains, I have seen a child who hasn't spoken since the earthquake struck. I have seen people who are completely bereft of any kind of hope for the future because they lost the house and half the family and the social structure. Half the people that may have helped them somehow are recovering from what is left. That is basically the cruel reality in the field."

UN General Secretary Kofi Annan warned of a second wave of deaths unless more aid was sent immediately. Do you share his view from a medical point of view?

"In any crisis where you have got poor hygiene conditions, a lack of health care and many people living on top of each other in displaced camps you should always be alert to outbreaks of communicable diseases.

"Apart from some tetanus cases, which were to be expected in a situation where we deal with lots of wounded, we have not seen any disease outbreaks up to now.

"There have been isolated measles cases here and there in a village but nothing that you would call an outbreak. However, in this setting a couple of cases could quite fast develop into one. That is why measles vaccination of children has become part of our health assistance to the population.

"Especially in the displaced camps, you could imagine a worst case scenario where you have all kind of infectious diseases purely related to people living too weak, too long, too close to each other in too poor hygiene conditions. But this is what we try to prevent as much as we can.

"In the displaced camps in Muzaffarabad, for instance, our water and sanitation experts have put latrines into place and MSF provides chlorinated drinking water to thousands of people. Chlorination is the key way to at least stop transmission of water borne diseases."

Big parts of the earthquake affected region lie in a highly militarized conflict zone. Has this in any way affected MSF's ability to bring assistance to the victims?

"Until now, MSF's limitations in terms of access to the victims are purely physical which means that the difficult mountainous terrain, wrecked roads and limited air transport capacities are the greatest challenges. We are being supported by the Pakistani government with flights, but it is still hard to work as helicopters are limited."

There are plans to move thousands of quake survivors from cut-off mountain villages to displaced camps in order to protect them from the harsh Himalayan winter. Do you think this is the right approach?

"Thousands of people are already displaced and more people will displace themselves. At the moment people are staying on heli-pads, in football stadiums, in old school buildings and on university compounds. So if the government intends to provide these people with something better, with decent camps and so increase the chances that they can cope with the situation, then this in itself is a good principle.

"And if there is a need for health care in these camps, MSF should look into it if no other actor does it. Encouraging people from hard-to-access areas to leave for a camp in itself is not bad neither, provided the people have the capacity to make their own choices. But at this point indeed you get into a very difficult discussion: Do people have the right to stay in their village and say: 'You should help me where I am because this is my home, here is the land I own and this is where I want to rebuild my house!' Or do aid providers have the right to say: 'Sorry, we cannot bring the aid there. You should come out of your place to get help.'

"It is very difficult to draw a line here. MSF's guiding principle is that people need to have the right to make their own choices. Actually, aid should enable them to restore their dignity and to increase their ability to make those choices. But in reality, our aid - the material, the staff, the logistical capacity - is limited.

"In the end, MSF puts a mobile clinic in one village and asks the people from the surrounding villages to come to that place for medical aid. Even if it's only five kilometres, this is already saying to the people: 'Sorry, I kind of make the choice for you just by putting the health structure here and not there.' In an ideal world, it is easy to say 'No big camps, please, unless it is the people's free choice to live there.' But I think that we have to accept that aid is always somehow selective. And people's choices are more limited than we wish they would be.