Dr. Mercedes Tatay is the Emergency Programs Manager for Médecins Sans Frontières (MSF) in Paris. She speaks about the magnitude of the devastation caused by the October 8 earthquake, describes the affected population's extreme vulnerability, and shares her concerns about a second wave of mortality. Dr. Tatay is currently in Mansehra, Pakistan, overseeing MSF's aid operations.

How does this disaster compare to the many others MSF has responded to in the past? Is it unique?

"The most impressive characteristic of this disaster is its sheer magnitude: the number of people in need of medical assistance is extremely high. We are talking about 3 million people affected who have directly or indirectly been deprived of shelter.

"The wounded caseload is unusually large and wounded are very difficult to access. To give you an idea of the scale, last year's South Asian tsunami resulted in an estimated 200,000 deaths and 20,000 wounded, a ratio of 10 wounded for every 100 deaths.

"In the October 8 earthquake, the wounded caseload is proportionately much higher with 60,000 deaths and around 80,000 wounded, a ratio of 130 wounded for every 100 deaths. Moreover reaching survivors of the tsunami was relatively easier given the flat terrain and their proximity to the coast.

"In the earthquake-affected areas, many people are so isolated in mountainous areas that we can only reach them by helicopter. Combined with extremely harsh living conditions, this means that the proportion of people that need help is very high. This also means that there is a real risk of a second wave of mortality: either we manage to help these persons or they will die. This is a race for survival."

What would be the causes of mortality in that second wave? How can we prevent this from happening?

"The main causes of mortality now will be related to the extreme vulnerability of the people. Other than trauma, our medical teams have already witnessed an increase in conditions related with the absolutely precarious living conditions: respiratory infections, hypothermia, skins infections, and diarrheal diseases.

"A key part of our operation has thus focused on delivering relief to improve living conditions by providing adequate shelter with heating, drinking water, and proper sanitation.

"One of the big questions in the coming days will be the extent of population movement. If this results in overcrowding and poor hygiene, it could increase the risk of disease outbreaks such as typhoid fever or cholera. So far our teams have not witnessed any high concentration of displaced people, but we are monitoring the situation very closely."

Why was the number of wounded so high and how does this influence the provision of medical assistance?

"It's partly linked to the type of constructions and to the hour of the disaster. In this area of South Asia, most of the houses are made out of concrete and were shattered with the quake, provoking severe wounds and fractures. Moreover, a lot of people were still at home when the first earthquake occurred.

"In terms of medical assistance, our teams are treating a lot of trauma. To respond to this, we have a set up a tented surgical ward in Bagh and Manshera, and our surgeons work within Pakistani hospitals in other locations to improve the quality of medical care and the follow-up for the severely wounded."

What are the biggest challenges that you are facing? How long is MSF planning to stay in the area?

"The combination of important medical needs, a destroyed health-care system and very difficult logistical constraints-both in terms of access and weather conditions-results in overall daunting challenges. The earthquake wreaked havoc on a lot of hospitals and aftershocks on the following days brought down whatever was still functioning, forcing patients and medical staff to operate outside in temporary and extremely precarious structures. That's for people who made it to the hospitals.

"We also need to find ways to reach a large part of the population that is dispersed in the mountainous region. Sometimes it's just impossible to reach them, even with helicopters. Winter is already there and as it progresses, roads will become even less passable. To say the least, the environment is hostile for emergency assistance. Given the information currently available, MSF is planning to stay at least for the winter and probably longer."