Earthquakes are the shaking of the earth’s surface happening in a short time due to the release of stored energy in the earth’s lithosphere and usually because of the rupture of geological faults. The magnitude of an earthquake is proportional to the energy released by the earthquake. The earthquakes smaller than 3 Richter are often unrecognizable, and those greater than 6 Richter cause serious damage. There are two kinds of seismic waves: primary and secondary. Primary waves are safe and faster, which arrive first at the destination, and secondary waves are harmful and slower than primary waves and reach second at the destination.Reference Aki 1 , Reference Qazi, Malik and Soomro 2
COORDINATES AND DAMAGE OF THE KERMANSHAH EARTHQUAKE
The Kermanshah earthquake occurred on November 12, 2017, at 9:48 PM local time, 5 km away from Ezgeleh in the province of Kermanshah near the border of Iran and Iraq. It occurred 32 km southwest of Halabja, with a longitude and latitude of 45.9 and 34.84, at a depth of 11 km below the earth’s surface, with a magnitude of 7.3 Richter and, within 20 seconds, was felt throughout the northwest of Iran and parts of neighboring provinces, as well as parts of Iraqi territory. The earthquake had about 647 aftershocks until 11:00 AM on Sunday, November 28, 2017. The number of earthquake deaths were 620, and the number of casualties were 10,179. The highest number of deaths and injured victims was attributed to the cities of Qasr-e Shirin, Sarpol-e Zahab, and Salas-e Babajani. In this earthquake, 7 cities and 950 villages in Kermanshah province were damaged.Reference Rahmani Fazli 3 , Reference Ahmadi and Bazargan-Hejazi 4 About 12,000 urban and rural residential units were damaged 100%, and, in general, 15,000 residential units and all health centers (including 190 health houses and 22 comprehensive health centers) and some of the basic infrastructure of the region were damaged.Reference Ayazi 5 , 6 The main cause of this destruction was the old and unsustainable texture of houses and buildings, especially in rural areas.Reference Aki 1 In spite of being mountainous and some earthquake-affected areas being unavailable to health services, the martial and health care forces of the Islamic Republic of Iran Army (AJA) (with 3 brigades) and the Islamic Revolutionary Guard Corps (IRGC) (with 3 brigades) dispatched to the damaged urban and rural areas as soon as the earthquake occurred, and provided help and relief and needed health care services. 7
HEALTH CARE ISSUES
After the earthquake, at a radius of 75 km from the site of the earthquake, all health care centers were destroyed. The hospital that was newly built in April 2017 in Eslamabad-e Gharb was destroyed completely, so provision of health care services in this city was not possible, and medical personnel provided the required health care services in the hospital courtyard. Because of the intensity of the earthquake in the Sarpol-e Zahab and the earthquake-struck cities around it, most people were neglected from the villages and, therefore, the residents of these villages began to rescue the injured victims and remove the debris without getting help, and transferred them to the hospital using their own vehicles and sometimes using available ambulances.
As a result of a sudden mountain collapse in Balataghcol about 10 km away from Sarpol-e Zahab and the closure of the road between Sarpol-e Zahab and Dalahu County, traveling was not possible on the usual route, and people had to transfer injured victims using the road from Govaver and Sarmast to Islamabad and Kermanshah. In this earthquake, because of the damage and destruction of all health centers in the region, the field hospitals and relief posts of the military forces and the Iranian Red Crescent Society (IRCS) were used to help and provide services to the victims.Reference Ayazi 5 , 6 In the early hours of the earthquake, the Sarpol-e Zahab forces of the Basij and IRGC and the Imam Hossein battalions, as well as the 71st Abuzar Brigade and 35 of its army rangers, were quickly dispatched to provide aid for their fellow citizens and start joint rescue efforts with the people and the IRCS workers. Also, apart from the available ambulances in the region, 35 ambulances and 5 ambulance buses were dispatched to the region, and all medicines and equipment needed for health care centers were provided and transferred.
The day after the earthquake revealed illuminations in the sky, as well as relative openings in the roads, facilitating the transfer of injured victims to Kermanshah, which was done by ground transport and air, using helicopters; 150 ambulances and ambulance buses were dispatched to the region, and 20 helicopters and 3 planes were used for transferring the injured victims. Those who needed special care and follow-up were sent to Hamadan and Tehran. Initial medical treatment and measures were provided during the first 3 days.Reference Ayazi 5 , Reference Bandpey 8
Because of the collaborated efforts of some organizations to establish field hospitals and health services in various affected areas, earthquake victims received the health care treatments they needed. 7 The Health Clinic of Islamic Republic of Iran Army Ground Forces (NEZAJA) established 1 field hospital in the Abuzar Garrison, the Health Clinic of Ground Forces of the Army of the Guardians of the Islamic Revolution (NEZSA) established 6 field hospitals in different parts of earthquake-struck areas in the west of Iran (like other field hospitals such as the Shahid Ghazi field hospital in Sanandij, Javanrud County; Isfahan Shahid Sadoughi field hospital in Eslamabad-e Gharb; Imam Hossein field hospital in Sarpol-e Zahab; and a field hospital in Kermanshah), Qazvin University of Medical Sciences established 1 50-bed field hospital in Tazehabad in Salas-e Babajani County, Kermanshah University of Medical Sciences established a field hospital, and the provinces of Tabriz, Kurdistan, and Semnan established field hospitals.
In the Kermanshah earthquake, more than 7,000 victims were transferred to health centers in less than 20 hours after the earthquake through the collaboration of the Islamic Republic of Iran Army Aviation (IRIAA), Aerospace Force of the Islamic Revolutionary Guard Corps (AFAGIR), and the Emergency Operation Center (EOC). The rescue and transfer of such a large volume of victims was indicative of their efficiency in planning and carrying out the tasks at hand.Reference Rahmani Fazli 3 , Reference Ayazi 5 In this collaboration, the victims were transferred to the rescue centers directly from the earthquake-affected areas. Then, after triage was conducted and the individuals personally examined to assess their therapeutic needs, they were transferred to the operating rooms or other medical departments. During the rescue and treatment phases, about 1,505 surgical procedures were performed, among which 1,325 surgeries were performed in Kermanshah by dispatching surgeons and nurses, and 180 surgeries were performed in the hospitals of Tehran, Karaj, and Hamadan. The most injuries included fractures of the limbs (including hip, leg, and pelvis) and the skull, vertebral, and spinal fractures caused by debris.Reference Ayazi 5 , Reference Hashemi 9
Most of the injured victims (other than outpatients), after receiving critical care, were transferred to other health centers in other provinces to receive additional care, as needed, by available airborne facilities, including helicopters and heavy transport aircrafts (ie, C130 aircraft of the IRIAA, AFAGIR, and the IRCS). To transfer the victims, 145 IRIAA helicopters, 5 AFAGIR airplanes (2 Ilyushins and 3 Antonovs), and 3 NEZSA helicopters were used, which emphasize the role and importance of airborne rescue and transportation in disasters. 7
Unfortunately, during the Kermanshah earthquake and in Sarpol-e Zahab and its surrounding villages, about 120 people were disabled and 18 people suffered from spinal cord injuries.Reference Bandpey 8 Accommodation at the tents was not fully performed in the first days; however, the coordination in the health sector was very good, and the number of health care staff was quite favorable. Mental health and psychological support was provided for more than 400 victims who were hospitalized in Tehran, Alborz, Hamadan, and Kermanshah provinces, including 30 psychological support teams consisting of 60 psychologists); 20 psychological teams also went to the earthquake-struck areas, and about 14,570 affected people were screened, and mental health services were provided for 1,584 people with acute stress symptoms.Reference Hashemi 9 , Reference Janbabaei 10 The provision of physiotherapy services for the injured in Salas-e Babajani County began on November 12, 2017, and the State Welfare Organization was prepared for enrolling those families who had lost loved ones to death and severed limbs, including those who had required an amputation in Sarpol-e Zahab. To provide dental services, a number of shelters were set up in Sarpol-e Zahab on November 23, 2017.
HEALTH ISSUES
Regarding water supply, due to the supply of drinkable water from springheads and the water turbidity of these springheads in Sarpol-e Zahab, Qasr-e Shirin, Harsin, and Salas-e Babajani, as well as unusable water pumping systems due to power outages, and so forth, the water supply was disrupted from the beginning of the earthquake. As a result, the lack of water created problems with bathing, water closets, and dishwashing, and, consequently, the mobile water supply was carried out by water tankers. The subsequent aftershocks also led to the continued water turbidity, and so there were serious problems with the water supply to the people.Reference Takhtshahi 11 Because of the destruction of health houses and health centers, water outages, accumulation of dead animals, and lack of proper disposal of waste and garbage, the health problems in the earthquake-affected areas began from the start of the earthquake, which were partly addressed by continuous efforts.
A number of 100 damaged health houses were temporarily restarted for the provision of health care services in the shelters. About 8,000 people were vaccinated against diphtheria and tetanus. No specific disease epidemic was reported in the area; however, the city’s accumulated waste blocking the waterways and scattered around the tents caused epidemics of various diseases, including cholera. There were not enough water closets in the region, and sewage disposal methods were not sanitary. Proper areas for bathing were not available and therefore created the potential for skin problems. People jointly used the limited number of field bathrooms and water closets in the earthquake-struck areas. Also, with the onset of rainfall and cold weather, there was the possibility of a flu epidemic. Therefore, heating appliances and warm and suitable places should be provided quickly for earthquake victims. In this regard, providing shelters and the renovation of homes began, and heating appliances were provided for the people.Reference Shakiba 12 – Reference Shakiba 14
STRENGTHS
The strengths of the measures and performance in this earthquake were the rapid response to action of the military forces (AJA and IRGC) and the IRCS workers, the support of various influential people, the massive flow of volunteers and donations to the earthquake areas, and the tremendous national support and religious sympathy among the people. Sending the popular aid and donations was such that they resulted in the blockage of communication routes, heavy traffic on the roads, and disrupted the relief and rescue efforts process. However, the solidarity in delivering aid and donations helped to partly compensate for the lack of government aid in the first hours of the earthquake. One of the strengths of this earthquake was the unexpected and unnoticed presence of the Supreme Leader in the region and his visits to the earthquake sites, talking to the victims and encouraging them, as well as using his influence to instruct the workers and authorities to relieve the victims of their pain and problems as soon as possible.
WEAKNESSES
One of the functional weaknesses in this earthquake can be attributed to the lack of preparedness of the government systems and the lack of orderly management for appropriate assistance and relief. The management of the delivery and distribution of donations was not efficient and properly integrated, and so the popular aid and donations were distributed by different groups of people such as artistic figures, sports figures, various benevolent people, and well-known and trusted figures. Therefore, unfortunately, there was an inappropriate distribution of popular aid and donations among the earthquake victims, which resulted in the waste of available resources and people’s dissatisfaction from receiving donations and the misuse of some people. Little attention was paid to the people and victims’ physical and mental health in the first days of the earthquake, which caused some problems in the region, including increased psychological stress and anxiety about the future. Also, the lack of adequate bathrooms and water closets in most of the earthquake-affected areas, the accumulation of dead animals and waste and garbage, and the lack of shelters and heating appliances and warm clothing in such cold areas had increased the risk of diseases and epidemics.
Considering the principles of engineering and safety and the use of appropriate materials and locations is one of the essential requirements for constructing a hospital. The Sarpol-e Zahab Shohada Hospital and the Eslamabad-e Gharb Hospital were 2 hospitals that were damaged during the Kermanshah earthquake. According to the technical and local authorities, the second construction phase of the Eslamabad-e Gharb Hospital, although the hospital had not lasted long, was completely damaged during the earthquake due to the lack of proper attention to the technical and engineering principles and passive defense in its construction, the lack of proper supervision of engineering supervisors, and the use of nonstandard materials in its construction. Therefore, the hospital could not provide the proper health care services, whereas the old construction phase of the hospital (which had a 30-year history of construction and was more tightly constructed and built according to engineering standards) was not damaged in the earthquake and continued to provide health care services. The cause of a number of earthquake casualties was the destruction of the new construction phase of the hospital and its hospitalized patients’ injuries. In 2017, Sang-Hoon Kim and colleagues investigated the damage to 34 health care centers in 7 countries due to 9 earthquakes during 1994–2004 and concluded that the structural and architectural damage to the studied health care centers in the earthquakes had been different in their situation; however, the damage to the equipment and utility supplies was similar in most cases.Reference Kim and Das 15 In 2011, Achour and colleagues concluded that the structural and architectural damages were different and specific to the situations; however, utility supplies and equipment damage were similar in most cases.Reference Achour, Miyajima, Kitaura and Price 16 In 2015, Ardalan and colleagues analyzed data from 421 hospitals, submitting a complete Hospital Safety Index (HSI) assessment form on the Ministry of Health and Medical Education Portal System. They concluded that hospital safety from disasters had improved in Iran in recent years and recommended that the HSI be maintained to monitor the progress of Iran’s health system with regard to hospital safety from disasters.Reference Ardalan, Keleh and Saberinia 17
CONCLUSION
The rapid and relatively appropriate and efficient response of the military forces and relief and rescue workers in this earthquake was indicative of their experience and organized system of management and operation, although there were many problems as well. Unfortunately, similar problems had also occurred in other earthquakes such as the Bam and Rudbar earthquakes. The repetition of these problems indicates the authorities’ lack of readiness and commitment to troubleshoot weaknesses in their emergency response plan. Therefore, it is necessary for government officials to have the proper protocols in place and ready to implement during a natural disaster. Given that our country lies on many faults, strengthening the structure and design of buildings, implementing more supervision and enforcing stricter standards of the construction processes and safety, repairing and rebuilding old and worn buildings, and taking crisis management issues related to natural disasters more seriously are paramount in developing a successful emergency response plan.
