*The title of this paper was borrowed from the title of Dr Manzoor Butt's Photo Essay of his journey into 'unreachable' parts of Kashmir.

This story starts with some background information from Professor Waris Qidwai Department of Family Medicine, Aga Khan University, Karachi.

"October 08, 2005 was a sad day for the people of Pakistan. A major earthquake struck northern parts of the country, killing tens of thousands of people and injuring manifold more. Hundreds of thousands residents lost their houses and have been rendered homeless.

This region is under developed with lack of proper housing, roads and basic infrastructure including schools and hospitals. The people already live a very hard life with poor housing, lack of proper water supply and heating during severe winters.

The earthquake has struck one of the most vulnerable populations. The lack of food, water, warm blankets, clothes and shelter is going to make life extremely hard for those who have survived the natural disaster but lost close family members, neighbours and friends.

The medical issues are going to be innumerable. The rehabilitation of the injured is the foremost tasks facing us. Supply of medicines and particularly antibiotics is required. Surgeons and Orthopedic surgeons in particular are needed. Make shift hospitals are required with staff and equipment. Intensive care facilities, operating facilities and good nursing are required. The rehabilitation is not going to be only physical but also psychological.

The lack of food and clean water supply is going to facilitate spread of infectious diseases and gastroenteritis in particular. The exposure to severe cold with inadequate clothing and shelter will lead to frost bite and respiratory infections. A lot of people will simply die due to exposure to cold is immediate measures are not taken to provide warm clothing, blankets and shelter. The incidence of psychiatric illnesses including depression and post traumatic stress syndrome is going to increase. The loss of near and dear ones and homes is going to increase the incidence of depression. The experience of trauma will increase the incidence of post traumatic stress disorder. Coupled with the increase in mental health illness is going to be the inadequate availability of psychiatric help including counseling. Those with chronic diseases such as diabetes, hypertension and heart disease will face problems getting adequate attention fro health care providers. The approaching winters are going to make things worse.

The social issues facing the earthquake victims are going to be manifold. The loss of near and dear ones will lead to lack of social support that was available. The social isolation will lead to further increase in mental health problems including depression. With approaching winters, mobility of people will be reduced and they will face increasing isolation and lack of social support. The burden of looking after the injured and the diseased with lack of resources will further limit the social activities. The destruction of infra structure will prevent travelers from coming into the area and the fear of another earthquake will also restrict people from freely moving around

The issues of rebuilding and rehabilitation will keep people preoccupied with less time to spare for socialization and recreation. The main problem is the issue of orphans and widows who are left behind. It becomes the collective responsibility of the society to provide them support. The presence of orphans and widows in the society will continue to remind us of the tragedy. The mental health problems will increase due to loss of bread earners of hundreds of families.
The disaster happened on a single moment on October 08, 2005 but the scars from the wounds will stay on for years to come. In this hour of their need, let us not forget our brothers and sisters and let's support them to the best of ability."

Emeritus Professor John Beasley, from the University of Wisconsin, who like myself was intimately caught up in the disaster through existing relationships with family doctors in the region, observes: "There are three phases to responding to a catastrophe such as that of the disaster of the Pakistan earthquake. The first is the initial emergency response. Inevitably this was inadequate - No country, even one with wealth and a robust infrastructure, can cope well with an unexpected event on that scale. Witness, for example, the limitations of the response to hurricane Katrina in the US even though this was a far small disaster in terms of scope and lives lost. (Not only that, but it was one which was predictable -- at least for a matter of some days.) During this time the lives that are lost are due to the direct trauma and immediate effects of the earthquake.

The second phase is the response to the immediate aftermath which involves caring for the surviving injured, the hungry and those without shelter. In this phase more resources, governmental, international and local as well as international philanthropy are brought to bear. Interest and support for the response tends to be high and is heightened by a sense of continuing crisis. The lives that are lost are more due to hunger, disease and exposure in the weeks to a few months following the disaster

The third phase is that of prolonged and sustained physical and social deprivation. New and continuing problems including general malnutrition, continued exposure, stress reactions and eventually the loss of such institutions as power, education, sanitation, public health systems, and medical care take their toll. Compounding the situation is the loss of the philanthropic and other support that is essential for the alleviation of the continuing suffering and the rebuilding of the physical and social infrastructure. Support dwindles as the event moves off the front pages (as it already has!) and new international situations erupt.

What good can come of this? First, we can all learn that we do live in one world and disasters can happen to all. The earthquake, as the tsunami, knew no national boundaries. We can turn our swords into ploughshares as our military helps in the responses to humanitarian needs. And we can learn to transcend national boundaries and religious differences as we work together to alleviate suffering and help with rebuilding."

Dr Tariq Aziz, General Secretary of the Pakistan Society of Family Physicians reports on the medical issues surrounding the relief and rescue effort: "Relief workers are experiencing severe depressive illness on their return to base camps and later to their homes. Now the Rehabilitation phase is on. Relief workers and people stranded in the area have severe logistic problems due to snowfall. Illnesses like pneumonia and gastro enteritis have also increased suddenly. Requirements of artificial limbs have suddenly become apparent. Some low cost material may be required, so that local manufactures can be encouraged to produce such on a mass scale. Besides big cities like Muzaffarabad (Capital of Azad Kashmir) all other towns and villages are located at variable height and distance, with difficult terrain in between and steep roads.

Some cities and towns have really disappeared as the mountains separated and colonies or habitations caved in the big crevices formed, which almost closed in the end. Even dead bodies of thousands of people and buildings could not be traced as if they did not exist at all. The jolts of earthquake were so severe that within 2 minutes every thing came to the ground or disappeared between mountains. Due to heavy landslides almost all roads disappeared. Total deaths exceed 100 thousand and injured are about ten times of this."

Our own understanding is that people are still afraid of further major quakes and are therefore reluctant to move into permanent accommodation in the affected areas, in case it should all fall upon them again.

As estimated by 'Finance Minister & Prime Minister himself 550 millions dollars are required for Acute Rescue & relief phase. UNO has given much higher figure.

Rehabilitation phase requires billions of dollars which we ourselves and UNO does not know right now.

Besides emergency management of wounded, "Artificial limbs" are required for millions of people. Perhaps such a centre (cost effective) can be established in the

We have lot of casualties in our Northern Areas. To day only I have send 19 doctors along with medicines & other emergency equipment on four ambulances.

We have problem with tents and blankets. I don't know if you can help us with that. Rest we are trying to manage as we have man power etc. We are preparing small packets of food etc along with emergency medicines. There is lot off trauma for which we are establishing small emergency field units who can reduce fractures and carry out surgical procedures at site.

Centre for 'Psychiatric illnesses' in the area is again, big need coming up. Single parents, orphan children require serious attention. Even relief workers have shown severe episodes of depression etc.

Immediate housing in the form of fibre glass houses instead of tents is required which shall provide insulation from extreme cold and snowfall (cost of reasonable sized tent & small fibre glass house is almost same size : 12x8x8 - 320$ US)."

These are the reports of our friends working in the region and while they give reason to be disheartened they also give us and their fellow countrymen hope.

The focus of our story however is a single journey of almost Tolkien proportions, made by a dedicated family doctor from Rawalpindi in Northern Pakistan. This gentleman, Dr Manzoor Butt, was already a one man relief organisation in his own community and while assisting refugees from the disaster zone, helping the Army and the local hospital Dr Butt decided he should also personally go to the zone and see the extent of the problem for himself.

Dr Butt has documented that journey through photographs and video and we include the photo essay of his journey in this journal. On a scale of human compassion and striving, the story of his journey could be deemed an epic. In hard practical terms it could be merely a symbolic 'tilting at windmills', a journey to 'reach the unreachable'.

Our story therefore becomes a metaphor, for what we can all achieve both in terms of practical aid to fellow humans in times of need and a striving for a cohesive humanity.

Dr Manzoor Butt, is a family physician in Rawalpindi, Shamsabad, Pakistan. He is well known in some international circles because he is a man who always looks at the big picture issues, while maintaining a down to earth medical practice, among the desperately poor.

We follow his journey via the reports he sent to international colleagues.

" …All of you have watched the role of various organizations on TV. I have personally visited major affected areas with my team and I want to share the following observations with you.

1. The most tragic part of this disaster is the death of school children through out the affected areas. In many schools, no one could be rescued. The main reason was poor quality of infrastructure in government buildings.
   
2. There was no Disaster Management Policy to follow and no Disaster Management Committee in Pakistan before this tragedy.
   
3. Lack of co-ordination between government, volunteers and NGOs was very evident
   
4. There was lack of initial interest and responsibility in most of government institutions- a large quantity of food and drugs are still at airports and there is no system to prevent their loss.
   
5. Most of people did not trust relief agencies [because of lack of transparency].They personally took relief essentials with them to affected areas. The result was an increase in transportation charges, roadblocks and repetition of efforts in many areas.
   
6. All aid went to areas where roads were accessible. The result was absolute absence of Rescue and Relief work in really damaged areas.
   
7. Absolute failure in rescue efforts - only one building got damaged in our capital city but we were totally unable to rescue the sufferers.

I have travelled through most of affected areas, initially to help relief efforts and last Thursday to take images. I have met so many people, organisations and NGOs engaged in this work. I believe this work will continue for months and years.

… This is Tuesday evening here and we will have Eid holidays from Thursday morning. It is not possible to go to the affected areas at this moment because of very high transport charges due to the festival . My volunteers are also leaving for their local villages and towns for Eid prayers today.

I will take images of hospital and the affected persons in Rawalpindi as soon as I get permission from commanding officer.

This hospital was set up and operated by 10-Corps of Pakistan Army. They need civil help in form of volunteers, medicines, daily food and other essentials to run it. They have an Operation theatre and labour room in it. At present, there are about more than sixty patients and forty attendants of patients in it.

… I am attempting to avoid duplication of efforts and corruption - very common nowadays. The sufferers, especially the children at this hospital are very worried by the cold. This is a privileged city, just imagine what would be the conditions elsewhere because all affected areas are hilly and snow is now in action.

There are more than eight thousand sufferers in Rawalpindi. I am using donated money mainly on medical help and for arrangement of food for them. Cantonment General Hospital is just 500 meters away from my home. My main concentration is now at this hospital because it is so near even our children can go there and enquire what is the most wanted help at this moment. I have created a drug bank at my home that mainly consists of live saving medicines, especially injectables used for treatment of intestinal and chest infections.

The most frustrating problem is duplication of efforts all over. It is not uncommon to see all doing the same. e.g, So many people bring food so that it becomes surplus. I daily survey the hospital to assess the need to avoid it. Initially tents were an urgent need but there was acute shortage throughout the country. The factories are operating in three shifts but the need could not be met. Now winter is becoming more and more and tents would not be able to prevent cold. I am now arranging blankets and warm clothes for women and children of this hospital and those elsewhere.

My family and I were busy today with the sufferers. My mother, my wife and wife of my real brother, all of them, did the following cooking in our home .
Breakfast plus Ramadan morning meal for at least 40-adults
Dated: 25-10-2005- Last Friday of Ramadan
Venue-Field Hospital of 10th -Corps of Pakistan Army, Rawalpindi-Cant.

Dinner for at least 40-adults.
Dated: 28-10-2005- Last Friday of Ramadan
Venue-Field Hospital of 10th -Corps of Pakistan Army, Rawalpindi-Cant.
By kind courtesy of Professor Dr John Beasley

6Th day after Tragedy:
Friday, 14-10-2005.8.45am PST.
-There was severe lack of co-ordination between our local volunteers and government.
-Government has announced a Federal Relief Commissioner and Local Relief Commissioners in all main provinces.
-When we tried to contact them, none of the above respond to volunteers and people who intend to donate. This is very common and private TV channels have confirmed it. There is a vicious cycle of referral to others.
-Prices of medicines have gone up by 30 to 50%. This is due to nonsense purchase by people on their own without any identification and prioritisation of need.
-Price of a tent has gone up to 7000/- Rupees [regular price was 2000/-]
-People have donated more than generously but their physical involvement in taking aid personally has caused lot of inconvenience, road blocks and delay in rescue work. There is 300% increase in transportation charges because everyone wants to reach there on his own
-Government has exempted all essentials from sales and other taxes after end of fifth day when most of purchases were already over.
-Visa fees and landing taxes were applied to foreign aid workers in first few days but now these are off.
-Landing permits granted to them were initially 72 hours which was extended to ten days and lastly to 30 days.

….. Today is the 12th day of tragedy, but more than sixty percent of the really affected areas are still without rescue and relief efforts.
A vast majority of beggars from all over Pakistan are now in affected areas busy in their work.
Lack of training of volunteers was the major shortcoming.

There was an urgent need for a Rapid Response Team in all communities. Towards this end, I have established "Shamsabad Rapid Response" with its headquarters at my clinic. I have temporarily suspended "Under -5 General Health Screening Project" and have initiated work on training of volunteers in Rapid Response.

The founder members of this team are staff at my clinic, my students and interested members from the immediate community. Medical aspects would be covered by me and the rescue work would be covered by Mr. Pervaiz Sheikh - who is a renowned civil defence trainer. He started this work in 1958 and got First Gold Medal in Rawalpindi district in social work. He has worked during major disasters of Pakistan, namely 1965 & 1970 wars, many floods, Rawalpindi Bomb blast tragedy in 1988 and in this recent event.

And then Dr Butt embarked on the journey itself - from Rawalpindi to the line of control between India and Pakistan, the final destination. He reports the following:

Day 1 - Camps are everywhere in the valley - it is difficult to reach theses
Day 2 - A car of relief workers fell in the river.
Day 3 - Heavy land slides while we were passing through
Day 4 - A woman playing with her children outside of a camp
Day 5 - People crossing a river on a trolley
Day 6 - Base camp of Mules [army property] for areas where nothing else could go
Day 7 - Pakistan army at work.
Day 8 - Water Filtration plant set up by army. See the young "Lt. Faisal" of Pakistan army
Day 9 - Sabit Qadam Hospital at Sawan, set up by army
Day 10 - CHINNARI, once a busy town - now, one whole side of it has gone into river
Day 11 - Two mountains collapsed to block the river. Army had to blast the obstacles to give way to river again
Day 12 - Relief truck snatched by angry people in the dark of night

When disasters occur in developing and impoverished nations, many existing problems are greatly compounded, however it may also offer an opportunity for the world to focus afresh on the needs of these countries and we observe that a 'little can go a long way' if the needs of the survivors can be met by 'local response' and targeted international aid. This has the greater longterm benefit, as the resource networks built up in response to the disaster remain established within the communities long after NGOs and world interest have gone.

The imperatives however are to get the aid rapidly to where it is needed and preferably to source that aid within the affected community (foodstuffs, tents) and thus benefit the local economy. This provides short-term benefit and medium term benefit and helps to quickly re-establish every day life.

The previous reports from colleagues in Pakistan, document several encouraging responses. Both the manufacture of tents and of prostheses within Pakistan has been geared up, both responding to the need and keeping any economic benefit in the country.

Everyday commodities are also relatively cheaper in developing economies, thus 'outside money' can be more effectively used as the exchange rate allows greater purchasing power within the local (affected) communities.

Of course those who have been necessarily displaced and dispossessed by the disaster, and those suffering ongoing medical needs, are the greatest challenge to the immediate and wider community. These require permanent responses.

We end our journey to the unreachable, now reached, with a more optimistic outlook.
The efforts of ordinary people can be quite extraordinary and it doesn't take that many good hearted people to make a major impact. We encourage the world to continue to support the people of Pakistan on an ongoing basis, and thus continue the healing that has begun.



FOOTNOTES

1. I'd like to thank the following for their contributions to, and assistance with this article: Professor Waris Qidwai, of the Aga Khan University in Karachi, Pakistan; Dr Tariq Aziz, General Secretary Pakistan Society of Family Physicians, Dr Manzoor Butt, General Practitioner, Researcher and Trainer, Rawalpindi, Pakistan and Emeritus Professor John Beasley, of University of Wisconsin, USA.
2. A pictorial essay of Dr Butt's journey to the unreachable is available from the menu.
   

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