The line of people had already formed outside the makeshift doctors' office by the time the sun started to rise in the Himalayan foothills.
Men and women, some cradling sleeping children, waited outside in the cold, standing on the rubble of what was once a major hospital in Muzaffarabad, Kashmir. They came with tuberculosis and pneumonia, broken bones and post-traumatic stress, the aftermath of the earthquake last October magnified by a shortage of medical help in the region.
Inside the 10-by-10-foot tent, Amherst's Dr. Khalid J. Qazi and three other doctors treated more than 550 patients a day. Water was available but sporadically. Electricity was running but only for a few hours a day.
"If power was there, power was there. If not, people would use flashlights," said Qazi, director of internal medicine at Sisters Hospital and a member of the Williamsville School Board. "They did have three big hospitals there. All collapsed completely. Everything had been completely destroyed -- just rubble."
At least two-thirds of the buildings in Muzaffarabad were leveled, according to some estimates.
"People who lost their houses were severely affected," said Dr. Dana van Alphen, who directed the World Health Organization's emergency project in that region for three months. "In those areas, most people live in the tent."
Qazi and his wife, Tabassum, spent 10 days in the capital city of free Kashmir, volunteering at the Pakistan Islamic Medical Association's field hospital, one of many erected there by groups and militaries from around the world, from Cuba to Turkey. The Qazis were joined by Dr. M. Akram Dar, a pulmonary specialist from Ohio, and Waleed M. Shah, a medical student from Temple University.
Knowing that the clinic lacked even the most basic supplies, Qazi brought several boxes of gloves, scissors, stethoscopes, bandages, aspirin, antibiotics and other essentials. They were purchased using a portion of the $45,000 that the Muslim Public Affairs Council raised for earthquake relief during a Dec. 12 fund-raising event at the International Institute of Buffalo.
Qazi also brought cash to buy supplies in the area around Muzaffarabad.
"It's very sad," he said. "The needs are so much."
The volunteers arrived Dec. 21 and spent 10 days in the region, part of a continuing rotation of physicians flying in from around the globe to donate their time. The doctors bundled up in five or six layers of clothing, hoping to stay warm enough throughout the day as they treated patients in the tent.
Muzaffarabad is the capital of Azad Kashmir, a disputed area between India and Pakistan. The town is near the epicenter of the quake, which killed 73,000 people and left about 3 million homeless.
Before the earthquake, the Muzaffarabad region's population was nearly comparable to Erie County's. The earthquake claimed the lives of one in every 20 residents; half of them were children.
"You can't go to any house and not have some loss. Not just injury, but some actual loss," Qazi said.
The medical needs are substantial. Acute respiratory infections are topping the list of illnesses in that region, a problem tied to the low temperatures, van Alphen said. Temperatures in January hovered around freezing.
Tuberculosis is common among earthquake survivors.
"I saw several dozen patients [with] tuberculosis," Qazi said. "People do not have an understanding of how lethal this disease is and what they need to do on a daily basis. There was a gap in understanding."
The cultural divide also created other problems. Women living in the area suffered from a lack of female doctors participating in the relief work.
"Culturally, in some villages which are more traditional, women have to see a female," van Alphen said. "They usually go to a 'lady health worker,' it's called. The problem is, wherever the lady health workers were working have collapsed also. All these foreign agencies who came in with field hospitals, there was a shortage of female doctors."
Throughout the winter, as temperatures dropped, relief workers have been trying to persuade the people living above 5,000 feet to come to lower elevations. The effort has met with limited success. Some people cannot be reached; many roads are impassible because of snow or landslides. Others refuse to leave their homes, afraid of losing their land.
Thanks to the help of volunteers like Qazi, the gap between the medical services that are available and the need for them has closed considerably, van Alphen said. Now, many foreign military hospitals -- including a MASH unit from the United States -- and relief agencies are preparing to pull out of Kashmir once the winter is over.