ORIGINAL RESEARCH
Foreign Field Hospitals in the Recent
Sudden-Onset Disasters in Iran, Haiti,
Indonesia, and Pakistan
Johan von Schreeb, MD;1 Louis Riddez, MD, PhD;2 Hans Samnegård, MD, PhD;3
Hans Rosling, MD, PhD1
1. Division of International Health IHCAR,
Karolinska Institutet, Stockholm, Sweden
2. Department of Molecular Medicine and
Surgery, Karolinska Institutet
3. Independent Consultant, Stockholm
Sweden
Correspondence:
Johan von Schreeb
Division of International Health IHCAR
SE-171 77
Stockholm, Sweden
E-mail: [email protected]
Funding/Support
This study was funded by a grant from the
Swedish National Board of Health and Welfare.
Keywords: disaster; foreign field hospital;
Haiti; Indonesia;Iran; Pakistan
Abbreviations:
FFH = foreign field hospital
GDP = gross domestic product
ICRC = International Committee of the Red
Cross
IFRC = International Federation of the Red
Cross
MSF = Médecins sans Frontiéres
OCHA = United Nations Office for the
Coordination of Humanitarian Affairs
PAHO = Pan-American Health
Organization
WHO = World Health Organization
Received: 29 May 2007
Accepted: 03 August 2007
Revised: 10 September 2007
Web publication:
Prehospital and Disaster Medicine
Abstract
Introduction: Foreign field hospitals (FFHs) may provide care for the injured
and substitute for destroyed hospitals in the aftermath of sudden-onset disasters.
Problem: In the aftermath of sudden-onset disasters, FFHs have been
focused on providing emergency trauma care for the initial 48 hours following the sudden-onset disasters, while they tend to be operational much later.
In addition, many have remained operational even later. The aim of this study
was to assess the timing, activities, and capacities of the FFHs deployed after
four recent sudden-onset disasters, and also to assess their adherence to the essential criteria for foreign field hospital deployment of the World Health Organization.
Methods: Secondary information on the sudden-onset disasters in Bam, Iran
in 2003, Haiti in 2004, Aceh, Indonesia in 2004, and Kashmir, Pakistan in
2005, including the number of FFHs deployed, their date of arrival, country
of origin, length of stay, activities, and costs was retrieved by searching the
Internet. Additional information was collected on-site in Iran, Indonesia, and
Pakistan through direct observation and key informant interviews.
Results: Basic information was found for 43 FFHs in the four disasters. The
first FFH was operational on Day 3 in Bam and Kashmir, and on Day 8 in
Aceh. The first FFHs were all from the militaries of neighboring countries.
The daily cost of a bed was estimated to be US$2,000. The bed occupancy
rate generally was <50%. None of the 43 FFHs met the first WHO/PanAmerican Health Organization (PAHO) essential requirement if the aim is
to provide emergency trauma care, while 15% followed the essential requirement if follow-up trauma and medical care is the aim of deployment.
Discussion: A striking finding was the lack of detailed information on FFH
activities. None of the 43 FFHs arrived early enough to provide emergency
medical trauma care. The deployment of FFHs following sudden-onset disasters should be better adapted to the main needs and the context and more
oriented toward substituting for pre-existing hospitals, rather than on providing immediate trauma care.
von Schreeb J, Riddez L, Samnegård H, Rosling H: Foreign field hospitals
and the recent sudden-impact disasters in Iran, Haiti, Indonesia, and
Pakistan. Prehospital Disast Med 2008;23(2):144–151.
Introduction
Earthquakes, tidal waves, tropical storms, volcanic eruptions, and landslides
are sudden-onset events that have killed an estimated 800,000 people, injured
more than one million, and affected the lives of approximately one billion
people during the last 30 years.1 Proportionately, the human toll from sudden-onset events and the disasters they produce is 100 times higher in lowincome countries (gross domestic produce (GDP) <US$85 per capita) than in
high-income countries (GDP >US$10,726 per capita).1,2
After a sudden-onset disaster in a resource-poor area, national and international humanitarian assistance may be needed to meet urgent, vital needs
such as shelter, water, food, health care, and long-term recovery. Funding for
international humanitarian assistance has more than doubled each decade
since 1975, and the United Nations Financial Tracking System indicates that
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foreign governments for humanitarian assistance contributed US$7.6 billion during disasters associated with
natural hazards around the world in 2005.3
The major healthcare needs following a sudden-onset disaster are: (1) emergency medical trauma care; (2) care for secondary effects such as wound complications; and (3) regular
healthcare needs following the damage sustained by health
facilities and the loss of staff. Foreign field hospitals (FFHs)
can satisfy each of these needs, but have been criticized for
being too focused on emergency trauma care.4–6 In addition,
the relevance, timing, and cost-effectiveness of FFHs in the
aftermath of sudden-onset disasters have been questioned.
Studies of FFHs mainly have assessed services at a single hospital in one setting.7–13 One article describes aspects
of several FFHs in Bam, Iran, and another reports on a few
in Aceh, Indonesia.5,14 Another article broadly analyzes
the role of surgeons following a sudden-onset event,15 but
no study that systematically describes and analyzes how
FFHs were used in recent disasters due to sudden-onset
events was found.
The aim of this study was to assess the timing,activities,and
capacities of the FFHs deployed during the first four weeks
after four contemporary and prominent sudden-onset events,
and the extent to which World Health Organization/PanAmerican Health Organization (WHO/PAHO) essential
requirement for FFHs intended for early emergency medical
care and follow-up trauma and medical care were met.
Methods
Four recent, prominent disasters due to sudden-onset
events were studied: (1) the 2003 earthquake in Bam, Iran;
(2) the 2004 tropical storm in Guanavaca, Haiti; (3) the
2004 earthquake/tsunami in Aceh, Indonesia; and (4) the
2005 earthquake in Kashmir, Pakistan. The WHO/PAHO
definition of a field hospital; “a mobile, self-contained, selfsufficient healthcare facility capable of rapid deployment
and expansion or contraction to meet immediate emergency requirements for a specified period of time” was
used. Domestic field hospitals were not studied.
Secondary Data Review
For each disaster, researchers searched the Internet for information on the context, local pre-disaster availability of hospital beds, the impact of the sudden-impact disaster, the human
toll in each affected area, the number of FFHs deployed, the
date of arrival and length of stay and country of origin of each
FFH, as well as its location, number of beds, activities and cost
from the onset of the disaster to one month after each disaster.The search engines Google, Google Scholar, and Pub Med
were used with the keywords “field hospital”, “Aceh”, “Bam”,
and “Kashmir”, alone or in combination. For the disaster in
Guanavaca, “Haiti” was used as the search word. The search
was conducted between January and December 2006.
Additional information was retrieved from the Humanitarian
Information Center homepages for each disaster,WHO operational updates, the emergency-related postings at Reliefweb,
and the homepage and database of the Organization for
Coordination of Humanitarian Assistance (OCHA).
March–April 2008
Key Informant Interviews
Semi-structured questionnaires were used to interview
decision-makers involved in the deployment of FFHs by
the Norwegian Red Cross and the International Committee
of the Red Cross (ICRC). The interviewees were asked for
personal experiences from each disaster, and copies of all
available statistics on FFHs deployed during the four disasters were requested. In December 2004, two of the
researchers visited Iran and interviewed key informants in
Tehran and Bam. National decision-makers involved in the
Bam relief work were asked specifically for information on
the FFHs.
Observations
The authors are surgeons with experience in international
humanitarian emergencies, and two have field experience from
either work in the ICRC field hospital in Aceh or the Médécins
sans Frontiéres (MSF)-supported hospital in Kashmir.
Analyses
The retrieved information was read, compiled, and listed.
For all of the disasters studied, except Haiti, the period of
deployment, number of beds, and country of origin for each
FFH were plotted in Figures 1, 2, and 3. To judge whether
the timing of the FFH deployment was according to the
expected needs, a conceptual model based on the empirical
experience of the authors and the available literature, was
used.16 In the model, (Figure 4) the first phase lasts about
three days and is dominated by immediate hospital care
needs due to injuries. The second phase is dominated by an
increased need for the care of secondary complications
caused by delayed initial injury treatment. The third phase
is characterized by an increased need for hospitalization
due to regular health problems such as obstetric, pediatric,
and psychological conditions exacerbated by the disaster.
During the last phase, an accumulated need for elective
care is noticeable. It should be noted that routine medical
emergencies must be treated during all of the phases. The
conceptual model was compared with the retrieved data on
FFH deployment, length of stay, and activities. Service output was calculated by dividing the total number of surgeries
and the number of outpatient visits with the number of
active FFH days.
Validation of the results was done by triangulation. Only
information that was consistent and reported from at least
two different sources was included.
Identified FFHs were compared with the WHO/PAHO
first essential requirements for:
1. Early emergency medical care (48 hours), which
states that to provide life-saving emergency medical
care for trauma, foreign field hospitals must be onsite within 24 hours of the impact of the event;
2. Follow-up trauma and medical care (days 3–15),
which states that in order to provide hospital care
that meets the immediate needs of the affected population, FFHs must be operational three to five days
following the disaster impact.16
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Foreign Field Hospitals
vonSchreeb © 2008 Prehospital and Disaster Medicine
Figure 1—Foreign field hospital deployed in Bam, Iran and number of beds available before and after the earthquake
vonSchreeb © 2008 Prehospital and Disaster Medicine
Figure 2—Foreign Field hospital deployed in Aceh Indonesia and number of beds available before and after the
earthquake/tsunami
Prehospital and Disaster Medicine
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vonSchreeb © 2008 Prehospital and Disaster Medicine
Figure 4—Foreign field hospital deployed in Kashmir and Northwestern Province Pakistan and number of beds
available before and after the earthquake
Results
The Google Internet search yielded approximately 10,000
hits for both Haiti and Bam, 20,000 for Aceh, and 23,000
for Kashmir. The top 200 Google hits for disasters due to
sudden-onset events were examined for relevance, and 50
documents per disaster were read. Google Scholar and Pub
Med yielded 25 and two articles, respectively. Searches on
Reliefweb yielded 40 operational updates from OCHA
and WHO, while the Humanitarian Information Center
homepage for Aceh and Kashmir generated 15 documents.
These 82 documents were read to search for FFH information, which was retrieved and compiled.
A striking observation was the scarcity of detailed information, especially numerical data for input, output, and
cost. Most documents were quotes from press releases concerning spectacular activities that occurred at individual
FFHs. The operational updates from OCHA and WHO
provided some non-systematic information on FFH presence. Key informant interviews with agencies did not provide any additional information. There were missing data
on cost in 80% of the FFHs, on the number of operations
in 82%, and on the number of consultations for 86%,
respectively. The limited availability of data only allowed
calculations of crude daily costs per FFH bed (Table 1),
which did not allow for detailed assessment. Comprehensive
data were found for four of the 43 foreign field hospitals. More
than half (24) of all FFHs were of military origin.
March–April 2008
The sudden-onset disaster context and pre-disaster infrastructure in each affected area varied considerably (Table 2).
The urban city of Bam had paved roads and an airport in contrast to the mountainous and rural Kashmir, which had a limited road network. In Aceh, Indonesia, the affected area was a
thin strip of a 600-km-long coastline, and only one main road.
Bam, Iran
At 05:30 hours on 26 December 2003, an earthquake measuring 6.5 on the Richter scale struck the area of the
ancient city of Bam (Table 2). Approximately 80% of hospital capacities were lost. Within hours, domestic rescue
services, headed by the military and the Iranian Red
Crescent17,18 started relief operations and mass evacuations. During the first days after the earthquake, approximately 10,000 injured persons were evacuated by air and
road to 72 unaffected hospitals in Iran.19,20 The eight hospitals in the neighboring city of Kerman (bed capacity = 1,500)
admitted approximately 6,500 patients during the first two
days. On the evening of the earthquake, Iranian authorities
requested international assistance and asked specifically for
field hospitals. An “open sky” policy was adopted, allowing
anyone with a relief mission to enter the country. Within
the first week, an estimated 1,800 aid workers arrived from
44 countries.19 On Day 3, a Ukrainian field hospital was
the first to arrive. In total, 11 FFHs (five military) were
deployed, with a maximum of 550 hospital beds on Day 8
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Foreign Field Hospitals
vonSchreeb © 2008 Prehospital and Disaster Medicine
Figure 4—Conceptual model for the variation over time of needs/use of hospital resources for non-trauma emergencies,
trauma complications and elective surgery before and following a SID
Iran
Haiti
Indonesia
Pakistan
70
0.8
245
155
GNI per capita in US$
(Atlas Method)
2,770
Human Development
Index
0.736
Population (in millions)
450
1,130
0.475
0.697
690
0.427
vonSchreeb © 2008 Prehospital and Disaster Medicine
Table 1—Demography of countries included in the study (GNI = gross national income)
(Figure 1). A majority of the FFHs were erected next to
one another, and five were operational for <7 days. One
year after the earthquake, the International Federation of
Red Cross and Red Crescent Societies (IFRC), the only
FFH had been upgraded to a 100-bed container hospital
staffed with domestic staff.
Two articles21,22 report on surgical activities at the
United States field hospital that arrived one week after the
earthquake. During their four-day mission, the staff of 80
did two caesarean sections, one appendectomy, and four
minor operations. Since priority was given to surgical trauma equipment, they lacked obstetrical surgical instruments.
The maximum occupancy rate at the 200-bed IFRC hospital during the first two months was 25%. During this
time, 818 patients were admitted, and 34 caesarean sections
were performed. The cost per hospital bed per day was at
least US$1,700 (Table 1). One report estimated the cost for
all FFHs in Bam to be >US$10 million.23
Guanevaca, Haiti
Between 17 and 19 September 2004, Tropical Cyclone
Jeannie caused torrential rains in northeastern Haiti. The
two main hospitals in the city of Gonaives were destroyed.
Prehospital and Disaster Medicine
Local and international agencies, including a Cuban team,
supplied human resources and supplies for trauma care
without deploying specific hospital facilities. On 14
October, four weeks after the tropical storm, the
Norwegian Red Cross and the IFRC opened a 100-bed
capacity field hospital (Table 1). By the middle of
November, an improved health situation was reported.
Following two months of activities, the hospital was dismantled, and at the end of February, the equipment was
transferred to the repaired main hospital. Output activities
were low for surgery, while about eight deliveries were performed per day during the first two months following the event.
Aceh, Indonesia
On the morning of 26 December 2004, an earthquake
measuring 9.0 on the Richter scale struck an area off the
western coast of Sumatra, Indonesia. The earthquake
caused destruction and triggered a tsunami that devastated
the coastline (Table 2). The main road was destroyed, and
helicopters or boats were the only means to reach the
affected areas. Hospital capacity in the area was reduced to
<25%. An estimated 10% of all wounded persons (7,200) were
reported to be severely injured and requiring hospitalization.14
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Sudden Impact
Disaster
Bam
Haiti
Aceh
Country
France
Belguim
United States
India
IFRC
NRC
Denmark
Portugal
Australia/NZ
ICRC
Czech Republic
Kashmir
NATO
Belguim
France
149
Days on site
8
Number of daily Number of daily
consultations
operations
--
--
150
2
9
100
85
20
4
365
-2
--
120
100
65
US$/bed/day
25
1,800
60
60
75
40
2,000
50
--
--
53
230
7
100
75
150
1
35
16
--
15
10
--
6
100
---
--
100
65
42
1,700
4
1
80
Beds
6
--
--
--
---
20
--
450
1,000
--
20
3,300
10
1,600
20
1,600
2,500
vonSchreeb © 2008 Prehospital and Disaster Medicine
Table 2—Foreign field hospital service output during first month, number of beds, length of stay, and estimated cost
per bed per day (ICRC = International Committee of the Red Cross; IFRC = International Federation of the Red
Cross; NATO = North Atlantic Treaty Organization; NRC = Norweigan Red Cross)
International assistance was requested on 27 December,
but response initially was slow due to a lack of information
and access problems. On Day 5, naval vessels from three
countries arrived to assist with helicopter evacuations,
while international relief teams began to provide assistance.
On Day 8, a FFH from Singapore was the first to become
operational (Figure 2). Soon, there was an oversupply of
trauma surgical services. By Day 15, the WHO officially
declared that no more FFHs were needed, but they continued
to arrive until Day 20. By then, a total of nine (five military)
FFHs were operational in three districts. The occupancy rate
generally was <50%. Six weeks after the tsunami, a US hangar
ship with 12 operating rooms and a 1,000-bed capacity
arrived at the coast of Aceh. A lack of health sector coordination severely limited the efficiency of the relief work.
One study concluded: “It was a matter of guesswork which
facility had beds or surgical capacities available”.14
The Australian and New Zealand Defense Force Field
Hospital (ANZAC) reported 173 operations on 71
patients starting on Day 15 and for two months onward. A
total of 70% of the interventions (42% of all patients) were
for injuries caused by the tsunami, while the rest of the
operations were for unrelated emergency conditions. No
elective surgeries were reported.9 The ICRC hospital performed 355 surgical interventions during its first two
months of activity. A total of 30% of the operations were
tsunami-related, 30% were elective hernia operations, and
March–April 2008
the remaining 40% were regular surgical interventions for
obstetric emergencies, non-tsunami trauma, and other
common surgical conditions.7 Nine weeks after the tsunami, the same hospital reported that of the 120 outpatients
seen daily, 12% experienced at least one problem directly
related to the disaster.24 The 53 tsunami victims who were
hospitalized during the first six weeks required 103 operations and an even larger number of wound dressing
changes.7 The Danish field hospital reported 385 operations,
but the type of operations and diagnoses were not reported.
The Independent State of Azzad Jammu and Kashmir (AJK)
and the North Western Frontier Province (NWFP), Pakistan
On 08 October 2005, an earthquake measuring 7.6 on the
Richter scale struck Azzad Jammu and Kashmir and the
North Western Frontier Province of Pakistan (Table 2). It
reduced hospital capacity by 75%. The Pakistan Army and
other local and national agencies began to provide care at
several locations in the affected area immediately, but
access remained difficult and transportation largely was
dependent on helicopters. The Army quickly started air
evacuation of the wounded, and within 10 days, 10,000
were transported to towns in northern Pakistan for care. After
10 days, trauma patients continued to arrive at health facilities.
International assistance was requested on the day of the
earthquake. During the first nine days, the WHO highlighted the need for light and mobile FFHs. A Turkish
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Foreign Field Hospitals
FFH was the first to arrive, and was operational early on
Day 3 (Figure 1). A total of 150,000 outpatient consultations and 1,500 operations were reported from 10 FFHs
during the first three months of the post-earthquake period. The ICRC hospital reported 379 operations, 142 of
which were wound-debridements.8
The North Atlantic Treaty Organization (NATO) FFH
opened one month after the earthquake. It initially was
staffed with four male trauma surgeons. It took several
weeks before a female gynecologist became part of the
team. The daily bed cost at four FFHs was approximately
US$2,000 (Table 1). The occupancy rate at the FFHs varied substantially with regard to time and location. During
the initial first weeks, it remained >60%, since it was difficult to discharge patients because they had nowhere to go.
Two FFHs opened temporary hotel structures in order to
discharge patients.
Several agencies supported damaged hospitals, such as
MSF’s support of the district hospital in Bagh. No detailed
information on capacities, time of arrival, activities, location, and cost of the so-called Cuban FFH has been found.
One month after the earthquake, 1,200 Cuban health professionals reportedly provided in-patient care at about 38
FFHs. Although extremely rudimentary in terms of equipment, Pakistan’s authorities highly praised this contribution.
Observations in three of the sudden-onset disasters
indicate that most FFHs were equipped and staffed to care
for emergency trauma rather than to provide care for the
most common disease burden, routine medical emergencies
Adherence to WHO/PAHO Essential Requirements
None of the 43 foreign field hospitals fulfilled the
WHO/PAHO essential criteria for FFHs emergency trauma care deployment, while 9% of the FFHs in Bam, and
23% of the FFHs in Kashmir fulfilled the essential criteria
for deployment for follow-up trauma and medical care.
None of the FFHs deployed in Aceh or Haiti met these
essential criteria.
Discussion
Lack of Information
A striking finding is the lack of detailed information on the
service output and costs of FFHs. Surprisingly, agencies
were unwilling to share internal reports. It may be that the
reluctance to provide information on services provided
because FFH agencies are aware of the discrepancy
between the expectations and realities of intercontinental
emergency trauma care and do not wish to make it known
to the general public.
Timing
None of the 43 FFHs were operational early enough to
provide life-saving, emergency trauma care. The first FFHs
to arrive came from neighboring countries. It is noteworthy that the high-income countries of West Europe and
North America with well-organized military and plenty of
development resources were unable to provide services
within the first three days in any of the sudden-impact disasters. A Bam earthquake study concludes: “However large
Prehospital and Disaster Medicine
the number of casualties, life-saving trauma care should be
provided by local or national health services and not by
outside rescuers”.6 The ICRC and IFRC deployed FFHs
in all of the studied sudden-impact disasters, but were
never operational before Day 7. The reason may be logistical and human resource problems associated with deploying a
large, multidisciplinary, FFH that is to stay for a long period.
Activities, Capacities, and Cost
Despite a thorough search on the Internet, repeated
inquiries to agencies, key informants interviews, and onsite visits, the authors only could retrieve basic activity output data from 14% of all of the FFHs. Undoubtedly, most
FFHs focusing on emergency trauma in all sudden-onset
disasters arrived too late (except in Haiti). This is supported by the short stay of FFHs in Bam, especially the low
surgical output activities at the US FFH. Clearly, there was
a competition for patients. A similar scenario was noticed
in Aceh, even though the needs were larger. In Kashmir, the
situation was different, due mainly to the large area and
vast number of people affected as well as the massive
destruction and lack of infrastructure. Therefore, the
WHO asked for mobile FFHs to facilitate transportation
to remote areas. In Kashmir, the need for multidisciplinary
FFHs remained for a significantly longer period than in
the rest of sudden-impact disasters. It could be that in this
setting, the basic Cuban foreign field hospital was better
adapted to provide cost-effective, long-term FFH care.
More evaluations and studies are needed to determine how
to most effectively cover long-term hospital care needs following sudden-onset disasters in low- and middle-income settings.
Within days following a sudden-onset event, the needs
for hospital care returns to normal (mainly caring for routine medical problems). Nevertheless, it is important not to
neglect the resource burden of disaster-inflicted injuries. This
was experienced in Aceh, where tsunami victims required
repeated operations and wound dressings, as well as anesthesia and long hospitalizations.7 One task for FFHs that
arrive more than a week after the precipitating suddenonset event is to care for such victims, while its main role is
to substitute for the damaged hospitals.
It is likely that the daily bed cost is higher than the estimated US$2,000. This crude estimate was based on a 100%
occupancy rate, and did not allow for the inclusion of military FFH costs.14 In Aceh and Kashmir, helicopter evacuations were of considerable importance, but it took longer
to get them started compared to Bam. Studies are needed
to define the optimal balance between transporting the
wounded from and bringing FFHs to the affected area. In
some contexts, it may be better to send helicopters than FFHs.
Adherence to WHO/PAHO Essential Criteria for Deployment
The fact that none of the FFHs adhered to the first essential criteria for emergency trauma care deployment must be
studied further. It is vital that the objective for deployment
matches the time of arrival, equipment, and staff. Based on
the Kashmir experience, the 15-day exit deadline suggested in the criteria for follow-up trauma and medical care
deployment must be re-evaluated, as the hospital needs
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during this sudden-onset disaster remained for a considerable time. It seems relevant to regularly update the
WHO/PAHO guidelines for the use of FFHs following
sudden-onset disasters.
Limitations
The conceptual model used in this study only provided a
simplified overview. Depending on the type of precipitating event, there may be an overlap between Phase 2 and
Phase 3, and the level of secondary infections also may vary.
Most information was retrieved from non-peer-reviewed
sources (primarily the Internet and situation reports). Some
FFH activities may have been missed, and the exact timing
of when each FFH began and ended its activity may deviate slightly from the findings. Hopefully, such limitations
will stimulate for increased transparent reporting.
Conclusions
The lack of available information and the reluctance to
share data on the activities of FFHs following suddenReferences
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