Nepal earthquake response: WHO South-East Asia Region

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Nepal ISBN 978-92-9022-507-2 (NLM classification: WB 105) 1 NEPAL EARTHQUAKE RESPONSE: WHO SEAR Preface from the Regional Director Two earthquakes rocked Nepal on 25 April and 12 May 2015 causing massive devastation in 14 districts - killing more than 8,000 people and injuring over 20,000. The health sector response to the earthquake was immediate. Within two hours of the earthquake on 25 April, Ministry of Health and Population and World Health Organization officials met at the Health Emergency Operations Centre, set up with WHO support. I spoke on the phone with the Minister of Health and Population to discuss immediate measures and needs. WHO rushed medicines and medical supplies to hospitals in Kathmandu which continued to function and attend to the injured. Within 24 hours of the earthquake, WHO also released the first tranche of South-East Asia Regional Health Emergency Funds (SEARHEF) to meet the immediate critical health needs of the earthquake response. The Nepal earthquakes put to test and proved effective WHO South-East Asia Region’s preparedness measures and the capacity-building initiatives to respond to emergencies. Understanding of risk is key - Nepal is unique in that several sectors of government, civil society, and communities knew an earthquake like this was going to happen and were preparing for it - together. As part of emergency preparedness, hospitals in Kathmandu had been retrofitted, their utilities secured, which enabled them to withstand the earthquakes and continue to provide the space to deliver health services. Most of all, it was about building people’s skills. The years of training of several hundreds of health staff in Kathmandu and in other districts in mass casualty management and proper triage were seen in action saving people’s lives and providing care to the injured. WHO had also pre-positioned emergency medicines and equipment needed to treat trauma patients, as part of its emergency preparedness measures. The package to deliver health care – property, people, and essential assets were all in place to serve the population when it is needed the most. WHO South-East Asia Region is a disaster prone region. As the Deputy Regional Director at that time, I led the WHO response to the December 2004 tsunami which affected six of the 11 countries in the Region. WHO steered some landmark measures for the Region to better handle such mega disasters if they struck again. The Region has since been investing in measures for prevention, preparedness and response to health emergencies. WHO has developed 12 benchmarks to measure preparedness which countries like Nepal have used to review their capacity. SEARHEF was established following the tsunami, and we saw once again in this Nepal catastrophe NEPAL EARTHQUAKE RESPONSE: WHO SEAR 2 that it has been most useful at this critical time of need. However prepared, every disaster is a reminder of the need for better risk reduction and preparedness. This is an essential public health function that needs to be prioritized. For Nepal, there is a long way ahead to recovery and this is where once more – WHO engagement and support will be critical. Aligned with the Sendai Global Framework for Disaster Risk Reduction through our strategic direction in emergencies, we are committed to helping Nepal build a health system that will be more resilient and ready for the next emergency. Since the outset, WHO has been supporting the Ministry of Health and Population, co-leading the health sector response to the earthquake. Post-earthquake the response focused on trauma management and temporary reinstatement of the critical health services. It has now transitioned to early recovery and reconstruction. Rebuilding requires rethinking together with partners and experts, we will work hand-in- hand with them in Nepal in the coming years. This compilation of stories from Nepal demonstrates both the need and the effectiveness of emergency preparedness, as well as best practices in emergency response to save lives and build resilient health systems. Investments in disaster risk reduction and preparedness pays dividends - they need to be scaled up so that development, especially in the health sector, becomes truly sustainable even with the shocks that an earthquake brings. Dr Poonam Khetrapal Singh, Regional Director, WHO South-East Asia Region 3 NEPAL EARTHQUAKE RESPONSE: WHO SEAR Dr Poonam Khetrapal Singh, Regional Director for World Health Organization (WHO) South-East Asia, met UN Secretary-General Mr Ban Ki-moon, in New York on Wednesday, 03 June 2015. Dr Poonam Khetrapal Singh, an Indian national, became the first woman to assume the office of WHO Regional Director for South-East Asia in February 2014. The Secretary-General congratulated Dr Khetrapal Singh on her success, specially for eradicating polio from a Region which is home to a quarter of humankind (1.8 billion). Dr Khetrapal Singh briefed the Secretary-General on her vision for the Region including the flagship priorities. She mentioned the Nepal earthquake of April 25 which killed more than 8 702 people and injured 19 000. Commending the Secretary-General’s initiative on ‘every woman every child’ she highlighted the special needs of pregnant women and lactating mothers in crises situations. With the rainy season due to start anytime, WHO is supporting Nepal’s Ministry of Health and Population in scaling up the health needs of women and children, psychosocial support and preventing communicable disease outbreaks. The Secretary- General appreciated WHO’s efforts in coordinating health sector response on the ground in Nepal. Dr Khetrapal Singh stressed that continuing health-related challenges demand the unflagging solidarity of UN system and health partners. “We are committed to building back a better and stronger health system in Nepal,” she added. She thanked the UNSG for his leadership and strong support for the people of Nepal and assured him of WHO’s commitment to transmute health systems in Nepal. Briefing the UN Secretary-General in June 2015 by the Regional Director NEPAL EARTHQUAKE RESPONSE: WHO SEAR 4 Contents n Preface from the Regional Director 1 n Briefing the UN Secretary-General in June 2015 by the Regional Director 3 n WHO Response Timeline: Infographics 6 n Emergency preparedness pays as Kathmandu hospitals respond to earthquakes 7 n SEARHEF emergency funds reach Nepal within 24 hours 9 n Retrofitting hospitals 10 n Triage - Prioritizing the seriously injured 11 n Nepal ramps up disease surveillance after earthquakes 12 n Nepal’s first responders continue to be critical part of quake response 14 n WHO supports Nepal to set up first sub-national hub at Gorkha 16 n WHO flags spinal care as critical medical gap 18 n WHO works with Spinal Injury Rehabilitation Centre 20 n Wheelchair assembly post earthquake in Nepal 21 n Psychosocial support a critical need after an emergency 22 n May 2015 visit of Regional Director to Kathmandu: WHO commitment 23 5 NEPAL EARTHQUAKE RESPONSE: WHO SEAR n Nepal Earthquake 2015: One month later 24 n Medical facilities and teams: Infographics 26 n Medical resources delivered: Infographics 27 n In Nepal, mobile health clinics show the way to build back better 28 Number of national medical teams: Infographics 30 n WHO’s disease investigation and rapid response system in post-quake Nepal 31 n Nepal’s TB patients continue to seek care amid trying circumstances 33 n Access to maternal and child health care in Nepal brings joy amid destruction 35 n Medical Camp kits provide essential services in remote Nepal town 37 n Building Medical Camp kits 38 n In Dhading, Medical Camp Kits set to replace damaged primary health facilities 39 n Medical Camp Kits: Infographics 41 n Sindhupalchok: Infographics 42 n Nepali, international medical teams join forces to fill health care gaps in Sindhupalchok 43 n One month on, Sindhupalchok’s field hospital adapts to a changed scenario 45 n In Nepal, risk communication supplements pre-existing health interventions 47 n From Kit to camp: Delivering primary health care in post-quake Nepal 49 n Addressing mental health needs in quake-hit Nepal 50 n In the long haul: Rehabilitation and Nepal’s ‘step down’ process 51 n Regional Director in Kathmandu: June 2015 53 n WHO sets up advisory group to guide post-quake recovery support in Nepal 54 NEPAL EARTHQUAKE RESPONSE: WHO SEAR 6 Emergency Humanitarian Action Team meeting WHO approves USD 175,000 of South East Asia Regional Health Emergency Fund Four more IEHKs, dispatched from various WHO warehouses to reach Nepal Surge team of experts marshalled to strengthen WHO support to Nepal Health Cluster meeting held WHO team assesses emergency response operations and health gaps Emergency coordination meeting UN country team meeting held WHO Nepal office and South-East Asia Regional Office holds first teleconference on emergency operations WHO takes the lead role in Health Cluster coordination WHO and MOHP begin Rapid Needs Assessment in severely affected districts Experts join from WHO SEARO, WHO headquarters and various WHO country offices More WHO public health and logistics experts arrive The Ministry of Health and Population holds emergency committee meeting chaired by the Minister Epidemiologist from WHO-SEARO arrives to support emergency surveillance system WHO disburses four Interagency Emergency Health Kits (IEHKs) to take care of 40,000 people for three months Preparation to tackle the spread of communicable diseases, mental health and psychosocial support Water and Sanitation and Communication experts join WHO emergency response team WHO teams conduct field visits in Kathmandu Valley to assess the status of health facilities, water and sanitation and immediate needs April Saturday 25 7.8 magnitude 11:56 AM WHO gives MoHP four more IEHKs 2:00 PM 6:00 PM Regional Director WHO South-East Asia holds emergency meeting with Minister of Health and Population April Sunday 26 Plans to fill health care gaps in the 14 most affected districts are made 4:00 PM April Monday 27 April Wednesday 28 April Thursday 29 April Friday 30 May Saturday 01 The eight IEHKs now provided can cover health needs of 80 000 people for a period of three months WHO surge team in Nepal WHO support WHO Response Timeline NEPAL Earthquake 2015 D es ig n: w w w .in fo na ut s. in 7 NEPAL EARTHQUAKE RESPONSE: WHO SEAR The earthquakes and the continuing aftershocks in Nepal highlight the importance of the efforts the Ministry of Health and Population and WHO have had in place for more than a decade to ensure key hospitals, health facilities and health workers would be ready and able to function well in an emergency or natural disaster. The first earthquake on 25 April measuring 7.8 on the Richter scale and the second on 12 May measuring 7.3 failed to disrupt services at Kathmandu’s largest public hospitals, including Tribhuvan University Teaching Hospital (TUTH), Patan Hospital, Civil Service Hospital, Birendra Army Hospital and the trauma centre at Bir Hospital. As of today, more than 8200 people are reported to have been killed in the earthquakes and over 19 000 injured. In Nepal, hospital retrofitting, which involves everything from repairing cracks in walls to installing seismic belts and roof bracing, has been a core part of preparedness plans. “Retrofitting meant that when the earthquakes struck the hospitals did not collapse,” said Dr Roderico Ofrin, WHO’s Health Response Leader. “It is clear that the investment in time and resources paid off.” Emergency preparedness: Emergency preparedness pays off as Kathmandu hospitals respond to earthquakes In more than 15 years, WHO has supported Nepal’s Ministry of Health and Population to prepare health facilities in the Himalayan country that sits on a fault zone. In 2009, WHO focussed global attention to the need for safe health facilities in emergencies through its World Health Day campaign. The campaign underscored the need to build strong health systems able to provide medical care in times of disaster and emergency – an aim which the Organization has long been supporting with both technical and material support. The earthquakes and the continuing aftershocks in Nepal highlight the importance of the efforts the Ministry of Health and Population and WHO have had in place for more than a decade to ensure key hospitals, health facilities and health workers would be ready and able to function well in an emergency or natural disaster. Emergency preparedness pays off as Kathmandu hospitals respond to earthquakes NEPAL EARTHQUAKE RESPONSE: WHO SEAR 8 The first earthquake on 25 April measuring 7.8 on the Richter scale and the second on 12 May measuring 7.3 failed to disrupt services at Kathmandu’s largest public hospitals, including Tribhuvan University Teaching Hospital (TUTH), Patan Hospital, Civil Service Hospital, Birendra Army Hospital and the trauma centre at Bir Hospital. As of today, more than 8200 people are reported to have been killed in the earthquakes and over 19 000 injured. In Nepal, hospital retrofitting, which involves everything from repairing cracks in walls to installing seismic belts and roof bracing, has been a core part of preparedness plans. “Retrofitting meant that when the earthquakes struck the hospitals did not collapse,” said Dr Roderico Ofrin, WHO’s Health Response Leader. “It is clear that the investment in time and resources paid off.” “These hospitals that are standing and were retrofitted went through a process of prioritization. Emergency rooms, maternity wards, and operating theatres were some of the first areas retrofitting was applied,” said Ofrin. Still, retrofitting alone does not ensure an adequate health-care response in times of disaster. Capacity building and staff training is equally important, Dr Pradeep Vaidya, director of TUTH’s Trauma Centre and coordinator for the WHO- supported Hospital said. Preparedness for Emergency Programme says the response to the earthquake by health care providers was resilient because of pre-planning and training initiatives. “The most helpful part during the earthquake response was the hospital emergency preparedness plan. People knew what to do, where to meet and how things will flow when the earthquake happened,” he said. “The roster management system worked well.” Training in triage management has been an ongoing aspect of WHO’s working Nepal, putting into practice its guidelines and strategies in mass casualty management systems, released in 2007. Because of the training, when large number of injured patients began to arrive, the emergency responders could quickly prioritize the injuries and save lives. Though the devastation caused by the earthquakes is enormous, the strength of the retrofitted health facilities and the quick response of the health workers show that investment in preparedness pays off. 9 NEPAL EARTHQUAKE RESPONSE: WHO SEAR After the mega disaster in 2004 when massive tsunami waves struck multiple countries in the WHO South-East Asia Region, WHO and Member States together set up the South-East Asia Regional Health Emergency Fund (SEARHEF) to meet the surge of needs in the first few days following an emergency. The SEARHEF, proven to be a rapidly mobilized resource, was immediately made available to Nepal, approved within six hours and released within 24 hours of the earthquake on 25 April 2015. “The earthquake struck at noon, and within two hours, I was in the Ministry of Health and Population. The Health Minister requested for the release of SEARHEF. I made a phone call to the Regional Director, and the first tranche of US$ 175 000 SEARHEF funds was approved within six hours of the earthquake. This kind of fast-track mechanism to help Member States by releasing funds within the first 24 hours of a disaster helps countries with their immediate response,” WHO Representative to Nepal, Dr Lin Aung, said. A major portion – over US$ 125 000 of the first tranche of SEARHEF – was used to procure essential medicines. Dr Gunaraj Lohani, Member Secretary, Health Emergency Operation Center, said, “The immediate monetary support provided by WHO was very supportive. This fund was used for getting emergency medicines and also for financing other contingency expenditures that had to be immediately mobilized.” SEARHEF comprises WHO budget and voluntary contributions from Member States of the South-East Asia Region, other agencies and donors. It is in addition to other assistance such as Flash Appeals, the Consolidated Appeals Process and the Central Emergency Response Fund, which come in later based on needs assessment. Set up in January 2008, the SEARHEF has funded many emergencies thus far with funds up to US$ 350 000 made available for a single catastrophic event. In the last two years, SEARHEF funds have helped save lives in Sri Lanka following heavy floods and landslides in November-December 2014; in Indonesia after a volcano eruption in February 2014; and in Myanmar after a communal conflict in May 2014. The experience of these countries indicates that the operation of SEARHEF goes a long way to help save lives. SEARHEF emergency funds reach Nepal within 24 hours WHO / M. Vurens van Es WHO / P. Garwood NEPAL EARTHQUAKE RESPONSE: WHO SEAR 10 On 25 April 2015, when the 7.9 magnitude earthquake struck Nepal, Kathmandu’s Tribhuvan University Teaching Hospital withstood the impact. No one was injured in the hospital. The furniture, beds and equipment stayed in position and nothing was damaged. The hospital had undergone retrofitting with WHO support in 2014. The services ceased only for a while, to soon resume with vigor to match the huge flow of injured people says Nursing director Gopila Shresthra. “The duty nurses and staff working at the time of the earthquake were able to continue their work soon after the quake”. During a disaster, health centres and hospitals are critical life-lines. They become the central focus for dealing with those directly affected by the emergency. Not only do they need to cater to existing patients, but must be ready to attend to the hundreds who will suffer the outcomes of the disaster. It is imperative that health facilities survive Retrofitting hospitals the disaster and that health workers within do not become casualties due to the disaster. During an earthquake what kills people is collapsing buildings and heavy equipment and furniture crashing on victims. At the Tribhuvan University hospital non-structural retrofitting that was done included fastening equipment and shelves to the wall, as well as securing water and power sources. Retrofitting is hence an important initiative. WHO has been strongly advocating Member States to make health facilities resilient. Hospitals must prepare to prevent becoming victim to a disaster long before an emergency strikes. This functioning hospital was able to provide care for thousands of mass casualties. 11 NEPAL EARTHQUAKE RESPONSE: WHO SEAR Preparedness to respond to emergencies proves its worth when disaster strikes. On 25 April when the earthquake struck, Dr Rasila Amatya, Medical Superintendent from Dhading District,in Nepal and her colleagues rushed to hospitals and health posts in the district. As a flood of patients began pouring in, many with multiple fractures, spinal cord and head injuries, the situation was quite overwhelming. However, Dr Amatya was able to provide leadership to coordinate the triage efforts. “I knew that in a post- disaster situation, unless a coordinated triage effort is maintained, the seriously sick can easily be overlooked and be left neglected queuing up behind the less seriously sick. Triage allows patients to be segregated according to the seriousness and urgency of their injuries. As I had been given a Triage management training some months ago, organized by WHO and the Ministry of Health and Population of Nepal, thankfully I could oversee the efforts of the health teams to ensure that the seriously injured received priority attention”. Triage – Prioritizing the seriously injured Dr Amatya, sorted and moved patients between hastily- erected tents and the open space at the entrance, to operating theatres. Apart from ensuring patients received timely treatment, Dr Amatya also tasked groups of orthopedic surgeons, specialist surgeons, and paramedics that came to help. Dr Amatya proudly showed the WHO team the triage cloth bands she used in the week following the quake. Triage cloth bands are given to patients to identify them based on the urgency of health care they required. NEPAL EARTHQUAKE RESPONSE: WHO SEAR 12 Every morning since the first of two recent earthquakes struck Nepal on 25 April, Dr Sharmila Shrestha and researcher Sanjita Thapa have made the hour-long journey from Kathmandu to Kavrepulanchok, a district east of Kathmandu valley, with one goal in mind – to protect people against disease outbreaks. Following the buckled Araniko Highway toward the hilltop town of Dhulikhel, the district headquarters, the pair pick up Chief District Health Officer Rajendra Prasad Shaha before arriving at the district health office for their morning meeting. Amid the pleasantries, the strength of their working relationship – which predates the recent disaster – is clear. Such ties are proving critical to addressing immediate public health challenges, including monitoring and controlling communicable diseases, such as diarrhoeal disease, seasonal flu and upper respiratory tract infection. There is a heightened risk of outbreaks following the first and subsequent 12 May earthquakes due to disruption of shelter, water and sanitation, as well as the coming rainy season. “Before the earthquakes I was a WHO surveillance medical officer monitoring routine immunization drives in four districts. Now I am focusing on one district, Kavre, which I visit daily” says Dr Shrestha, who now works for the WHO supporting the Ministry of Health and Population’s (MoHP) Emergency Disease Surveillance programme (EDS). The EDS programme monitors the 14 most affected districts, using nine surveillance medical officers from pre- existing WHO monitoring programmes in Nepal, in addition to five Nepali staff drafted in from WHO offices around the world. Nepal ramps up disease surveillance after earthquakes WHO / A.Khan 13 NEPAL EARTHQUAKE RESPONSE: WHO SEAR According to Dr Shrestha, familiarity with the “zero- reporting strategy,” first implemented in Nepal as a result of WHO’s worldwide polio eradication campaign that began in 1988, has allowed authorities to gain daily intelligence on disease prevalence in outlying areas since the earthquakes. “Zero reporting means that every ward, every day, must report to the district office on each and every case they have received during that day. If no cases have been received, then they must still report,” says Dr Shrestha. Sharing of information at each level of Nepal’s governance structure – from ward to village, and then district and national levels – enables local authorities to investigate any risks and potential outbreaks that may arise, while also feeding into a central, national database at the Health Emergency Operations Centre at the Ministry of Health and Population in Kathmandu. Rather than being solely a reactive mechanism, this infrastructure is disseminating public health messages, including advice on sanitation and hygiene developed by WHO to prevent possible outbreaks. “We have Female Community Health Volunteers in each ward. Through them we communicate with the public and provide community health awareness programmes,” says Narayan KC, Kavrepulanchok’s focal person for post-disaster communications.According to KC, mothers’ group meetings convened by the female volunteers are vital to ensuring that health messages reach vulnerable populations. “All the mothers of the ward gather and they have a meeting. Mostly they focus on children because they are the most susceptible to communicable diseases,” he says. The Female Community Health Volunteer system means that WHO-approved messages are disseminated in local languages, by local community leaders. “If the mother is aware, then the family and community will be protected,” says KC.As the rainy season draws close, the realignment of pre-existing WHO and MoHP health surveillance and reporting mechanisms provides the best opportunity to guard against possible disease outbreaks. At the same time, local communities are empowered, and Nepal’s health system made more resilient. WHO / A.Khan NEPAL EARTHQUAKE RESPONSE: WHO SEAR 14 When Nepal’s 25 April and 12 May earthquakes caused devastation, death and injury across the country, health care workers were placed under severe strain: as well as dealing with personal losses, their professional and volunteer obligations meant that they had little time to pause. Nirmala Acharya, a Female Community Health Volunteer in Kavre District, just east of the Kathmandu valley, is a case in point. Despite the destruction of her house and the economic burden that the loss of her family’s goat caused, Acharya (pictured center) insisted on performing her civic duties in the immediate aftermath of the quake. “I have gone to every village within the ward and talked to the mothers in the community regarding hygiene and sanitation, and have been explaining the importance of using boiled water. I have been going to all the households,” she says. Despite the emergency phase having ended, Acharya will go on disseminating Ministry of Health and Population and WHO-approved messages within her community during the rainy season, when the risks of communicable disease outbreaks are most pronounced. “I want to do social work and assist my community,” Acharya asserts. Nepal’s first Responders continue to be a critical part of the MoHP and WHO-coordinated health care response, and remain frontline defenders of the health of their communities. According to Dr Santosh Manandhar, director of Gajuri’s primary health center, 60 to 80 patients come to the MCK every day – a figure consistent with pre-quake numbers. The new facility is located directly opposite the damaged health center. People need not go elsewhere to seek health care. Nepal’s first responders continue to be critical part of quake response WHO / J.Swan 15 NEPAL EARTHQUAKE RESPONSE: WHO SEAR At 10 am each morning, Gajuri’s MCK begins receiving patients. Janak Bhandari and his 10-year-old daughter arrived at the facility for opening time after a one-and-a- half-hour walk from his village followed by a 15 minute bus ride to town. A week ago the 45-year-old farmer stepped on a thorn bush, and is now concerned that the wound is infected. Waiting on a wooden bench with his daughter, Bhandari says, “I don’t have any complaints, I’m quite happy with it.” Seventy-five-year-old Laxmi Maya was diagnosed with chronic pulmonary obstructive disorder seven months ago. After her 20-year-old grandson Shree Chepang brought her to the facility from their home in Mahadevsthan, an adjacent village development committee, Maya has received oxygen and hydrocortizone to open up her lungs and decrease her shortness of breath. Both spent one night in the in-patient wards. “We are still scared about the quakes and aftershocks, it’s good we’re being treated here,” says Chepang. Lalita Bista (57), Amrita Paudel (32), and Anusha Thakali (21) staff the facility’s maternity ward. According to Bista (pictured far right), who has worked at Gajuri’s primary health center for the past 17 years, there has been a slight increase in the numbers of those seeking family planning, ante-natal and post-natal services. “The pregnant patients are curious to know if the babies are safe in their womb because of the belief that the earthquake might have given some problems,” she says. The nurses say they perform around 30 consultations each day. Eleven-year-old Rupesh Pariyar fell out of a tree, hurting his arm and ribs. After studying Pariyar’s X-ray (taken at another facility), Dr Sudin Kayastha says that nothing is broken and the boy will be ok. Pariyar’s mother was pleased. Rabi Neupane and Nagendra Pokhrel from Nepali NGO NTAG look after the nutrition corner of the outpatient department. According to Neupane, the risk of food insecurity and malnutrition after the earthquakes has increased. “We are screening all the children in the district so we can prevent and treat malnourishment,” he says, explaining how Female Community Health Volunteers are visiting villages throughout the district and referring malnourished children and their parents to the facility. The NTAG project is funded by UNICEF and is expected to run for six months. In recent weeks, the monsoon’s arrival has resulted in rain deluging the mid-hill town on a daily basis. WHO Nepal’s chief in-country logistician Michel Tomaszek says that the design of the MCKs, protects them from the season’s excesses. “The facilities are situated in areas that allow for drainage. Each MCK has wide concrete gutters surrounding the tents, as well as the facility’s perimeter,” he says. Dr Santosh Manandhar, Director of Gajuri’s primary health center for three years, says the new facility has allowed his team to provide continuity of services until the previous facility can be repaired. He has received a lot of positive feedback. “The patients have been saying that they are feeling comfortable and safe. This has been their main concern. They have also been impressed by the quality of the latrines and the water supply availability,” he says. NEPAL EARTHQUAKE RESPONSE: WHO SEAR 16 In a major step to boost the health-care assistance to earthquake survivors who have been unreachable since last week’s disaster, the World Health Organization in coordination with the Nepalese government and other humanitarian partners has established a new field office in the Gorkha district of Nepal. From there, WHO and the national authorities will be able to coordinate land and air support to reach medicines, health care professionals and other life-saving resources to some of the most remote regions impacted by the earthquake. Gorkha is a 3-4 hour drive northwest of the capital and was selected as the first major health hub outside Kathmandu. It is one of the districts most affected by the earthquake, but also provides a good base from which to access other severely impacted areas. The new field office started operating from Monday 4th May and is part of a major push by Nepalese authorities and the humanitarian sector to reach into remote, mountainous communities in urgent need of support. The new base is the first of several and will also help shore up the emergency and routine health- care services that have arrived already in the area. “Health care services are being delivered in built-up areas in Gorkha and those that still can be reached by road,” says Hyo-Jeong Kim, WHO Emergency Operations Manager, during a 2 May field visit to the hilltop village of Katteldanda in Gorkha. The village was devastated by the earthquake. “But we have also identified seven communities beyond the Himalayas in an area not easily accessible, and where there are about 6000 people who have not been reached with services since the earthquake struck. Below those villages, there are about 7000 additional people who have not been reached, she added.” At this stage it is critical, that health workers and medical supplies reach these areas immediately. It is essential that people are treated for injuries or infections and also protected against diarrhoeal diseases, and respiratory and other infections. It is also important that the needs of vulnerable populations including children are met. WHO supports Nepal to set up first sub-national hub at Gorkha 17 NEPAL EARTHQUAKE RESPONSE: WHO SEAR Community concern is that pregnant women should have access to care for safe deliveries and ensure that any complications of pregnancy or birth are rapidly addressed Nischal Kattel, an earthquake survivor in Katteldanda, where almost all of the 90 houses were leveled in the earthquake, says his community’s most important health needs relate to safe drinking water, sanitation and hygiene. “We worry about the toilets. Along with the houses, most of the toilets were destroyed by the earthquake. We want to build some toilets in this area so we do not become sick,” Kattel explains while walking through his ravaged village, stepping over piles of broken bricks, snapped planks and sharp nails. “We have our own water source, but there is no safe drinking water, so we have to purify it.” Kattel built a makeshift tent for 20 members of his family all of whom cram into it each night since the quake struck. “We are living in close quarters, and we have to be careful with our hygiene so not to get sick. People are still scared of aftershocks and want to remain outside in tents,” he said. “They are worried about their health, and they have nightmares about the quake.” A 15-minute drive away down a bumpy, red dirt road, is the main hospital for the district of Gorkha. The hospital workers have seen an upsurge in patients needing care for injuries, including broken bones and lacerations, along with the delivery of more regular health services, such care for children and pregnant women. The hospital’s director, Dr Sudha Devkota, says immediately after the earthquake, the 15-bed facility was overwhelmed by injured people seeking treatment. But in the days following, hospital staff, supported by foreign medical teams from Switzerland, Spain and India, were able to manage the huge caseload. But greater needs remain. “The greatest need right now is the space for our outpatient department and pharmacy, because they have been damaged and we cannot work there. The patients need somewhere safe to be,” Dr Devkota says. “So we need tents, and thanks to severel international and humanitarian agencies including WHO and the Swiss Humanitarian Aid Unit, we are receiving these.” Care of children and pregnant women is also a priority. In a welcome initiative, the emergency medical specialists from Switzerland, deployed as part of the WHO-coordinated foreign medical team surge response, are shifting their skills to looking after these patients, including newborn babies. “It is very important to take care of the most vulnerable population, and that is the children,” explains Dr Olivier Hagan, of the Swiss Humanitarian Aid Unit, whose team is planning to remain at the hospital for at least one month. “That is why it is so important to focus on them, and to ensure safe deliveries. In the past four days we have delivered 10 babies What this shows is that life goes on.” NEPAL EARTHQUAKE RESPONSE: WHO SEAR 18 When Nepal’s devastating April 25 earthquake hit, Nanda Thami was safe. The forty-two-year-old resident of Phopa Chaku, a small village in Dolakha district east of Kathmandu, was in an open space, away from the mud-brick structures dotted throughout his village. When Nepal’s devastating earthquake hit on 25 April, Nanda Thami was safe. The forty-two-year-old resident of Phopa Chaku, a small village in Dolakha district east of Kathmandu, was in an open space, away from the mud- brick structures dotted throughout his village. Nanda rushed into the house to rescue his five-year- old son Gopal who was still inside the family house as the earthquake’s aftershocks continued with terrifying frequency. While the boy was saved with only minor injuries, Nanda bore the brunt of the family home structure as it collapsed. According to Nanda’s nephew Kumar, members of the village banded together and carried Nanda to the district headquarters of Charikot, which is four hours away. From there he was able to hitch a ride in a local police vehicle to Kathmandu to seek medical care. Nanda now lies in a bed in the foyer of Bir Trauma Centre, Kathmandu’s primary critical care provider, and cannot move from the shoulders down. His head remains in a fixed position. Though Nanda’s condition is stable, the spinal cord injuries he sustained provide challenges for medical service providers. Among the estimated 14 000 injuries, approximately one in three (or around 4700) will require follow-up rehabilitation treatment. Of this number, approximately 12% have damage to their spinal cord. According to Dr Ganesh Gurung, who is coordinating operations at Bir Trauma Centre, Nepal has neither the human resources nor medical facilities to deal with the needs of those suffering spinal injuries, making delivery WHO flags spinal care as critical medical gap, long-term health need of Nepal WHO / J. Swan 19 NEPAL EARTHQUAKE RESPONSE: WHO SEAR of such resources critical to the wider relief effort. “The number one need now is spinal cord rehabilitation – human and medical resources related to that are the most important because we do not have those kinds of resources,” said Dr Gurung. WHO, in coordination with Nepal’s Ministry of Health and Population, is deploying foreign medical teams to areas that lack access to services, or whose medical infrastructures were destroyed by the quake. The UN health agency is calling all donor agencies and emergency relief partners to make the long-term needs of affected populations a priority, and to ensure that spinal care and rehabilitation is taken into account. “Treatment, proper handling and care of those injured are essential to prevent future disabilities,” said Damodar Adhikari, Programme Manager at WHO Nepal Earthquake Response, adding, “If people are not properly cared for, spinal cord injuries could lead to paralysis.” According to Dr Roderico Ofrin, WHO’s Overall Health Response Manager in Nepal, spinal care has been identified as a critical medical gap, and is being flagged for funding, reflecting WHO’s long-term commitment to the health and welfare of the Nepalese people. Sarah Blin, Nepal Country Director at Handicap International, says her organization is currently working within Nepal’s health system to ensure that spinal cord injuries are not overlooked. “We are working in four major hospitals in the Kathmandu valley, supporting the medical teams once a patient has been discharged, and ensuring that the right care and equipment to address spinal cord injury is provided,” she said. Handicap International is supporting spinal cord injuries in hospitals and indicated that additional human resources and equipment is being sought by Kathmandu’s Spinal Injury and Rehabilitation Centre to ensure adequate provision of long-term care. For those such as Nanda Thami who were injured in the quake, the delivery of such care will ensure not only their own health, but also theirs and their family’s future economic security. WHO / J. Swan WHO / J. Swan NEPAL EARTHQUAKE RESPONSE: WHO SEAR 20 Since Nepal’s 25 April and 12 May earthquakes, Keshab Prasad Sitaula has been a busy man. The thirty-three-year- old occupational therapist, who has been working at the purpose-built Spinal Injury Rehabilitation Centre (SIRC) since 2002, says that immediately after the first quake he provided vital support to those presenting with spinal injuries at Kathmandu’s major hospitals. “I was at Bir Trauma Center for around two weeks teaching people with SCI and their family members how to use spinal braces, how to prevent pressure sores – and how to manage their bladder and other things,” he said. “At that time I also trained the nurses there.” This intervention saved lives and helped to develop effective referral pathways between the major hospitals and SIRC. Now back at SIRC, Sitaula is working tirelessly to rehabilitate the many patients in his care. In order to meet the post- quake need for specialized rehabilitation services, SIRC is willing to expand its capacity by four times. The WHO in coordination with Nepal’s Ministry of Health and Population (MoHP) has designated the facility a key part of Nepal’s post-acute rehabilitation and ‘step down’ process to meet the rehabilitation needs of the injured. According to Dipesh Pradhan, SIRC’s Director of Administration, despite being a non-profit facility the center has worked closely with health care partners to provide quality services to those in need. “We are a member of the WHO-coordinated rehabilitation sub-cluster and are a focal point for spinal care issues,” he said. “The MoHP has been supporting us since the first day and has been sending the message to all government and private hospitals that those with spinal cord injuries should be referred to us. We feel very proud to be a partner of the MoHP.” Sitaula is unlikely to get a break from his hectic schedule anytime soon, but that does not affect his dedication. From the expansive rehab therapy room he manages, Sitaula affirmed his commitment to providing the best long-term care possible to his countrymen and women: “We are ready,” he said. WHO works with Spinal Injury Rehabilitation Centre WHO / J. Swan WHO / J. Swan 21 NEPAL EARTHQUAKE RESPONSE: WHO SEAR Kshetra Gurung is a workshop technician at Nepal’s Spinal Injury Rehabilitation Centre (SIRC), a dedicated spinal care facility just outside the Kathmandu valley. The former occupational therapy assistant, who has worked at the centre since it first opened in 2002, has spent the past two year’s custom-fitting wheelchairs for the facility’s patients. After Nepal’s 25 April and 12 May earthquakes, Gurung’s workload has increased significantly: SIRC, a project of Spinal Injury Sangha Nepal, scaled up its bed capacity from 51 to 200, and is still accepting referrals from across the country. Thankfully, Gurung has the technical expertise to cope with this fourfold increase. “I did basic and intermediate training for wheelchair assembly given by WHO in Pokhara last year and three months of basic prosthetics and orthodics training in Thailand,” he said. “We assemble our wheelchairs according to the WHO guidelines on the provision of manual wheelchairs in less-resourced settings.” For Gurung, whose workshop is plastered with detailed diagrams of wheelchair design and assembly, the job is, however, greater than simply constructing the machines. “When we provide a patient with a wheelchair we teach them basic and advanced wheelchair skills – how to use a wheelchair and how to take care of them. We also have a wheelchair follow up program once a year. If they have a problem with their wheelchair they call us and we fix it,” he said. According to Damodar Adhikari, WHO Nepal’s disability and rehabilitation focal point, this kind of long-term engagement is a critical aspect of meeting post-disaster health care needs. “After any disaster these services are crucial. If they are not provided, the quality of life for the injured is greatly impacted. In Nepal, we are working closely with the Ministry of Health and Population to ensure that these services are prioritized,” he said. With facilities such as SIRC, and technicians like Gurung, Nepal’s earthquake-injured are being given the best opportunity to recover and lead mobile lives. Long after the emergency ends, the health care needs of Nepal’s citizens are being secured. Wheelchair assembly post earthquake in Nepal WHO / J. Swan WHO / J. Swan NEPAL EARTHQUAKE RESPONSE: WHO SEAR 22 12 year old Nikesh Pahari has been living in a tent with his parents and neighbours. However since the earthquake he has refused to speak or eat and is afraid to go near his house. Psychiatric social workers can help to teach children to slowly normalize, and one such worker from the mobile mental health team taught Nikesh a pretend ‘balloon blowing’ breathing technique, which eventually calmed the child, and even coaxed a smile out of him and his friend. Days since the after shocks of the earthquake have stopped, a 70-year-old woman still feels as though the ground is moving. Since the earthquake she suffers from back pain and headaches, which the doctor has diagnosed as an anxiety disorder. Even in normal times, Nepal has a serious problem with alcoholism and heavy episodic binge drinking. Post the earthquake many habitual drinkers are likely to suffer withdrawal symptoms and the psychiatric social workers will need to provide treatment for all mental health issues related to alcohol. A major disaster can trigger depressive and traumatic disorders as well as prolonged grief disorders among survivors which can severely undermine a person’s daily functioning. At several temporary clinics set up in the outlying districts of Kathmandu, at least 10% of the 500 or so patients seen daily, report mental health issues , as many survivors are experiencing mental health problems. Even as doctors treat the physical wounds, it is the deeper, psychological traumas which will require longer treatment. Psychosocial support is an important service for the affected population. WHO is supporting MOHP with guidelines and mapping of partners providing mental health and psychosocial support, and creating a link with those providing care for mental health illness. Psychosocial support a critical need after an emergency WHO / A. Bhatiasevi 23 NEPAL EARTHQUAKE RESPONSE: WHO SEAR The World Health Organization is committed to supporting Nepal’s health system to deliver life-saving and essential services to its people and build back resilient health facilities that will be safe in emergencies, affirmed Dr Poonam Khetrapal Singh, World Health Organization (WHO) Regional Director for South-East Asia, in Kathmandu on 7 May 2015. “WHO stands with the Government of Nepal as it strives to overcome this crisis,” Dr Singh said during a visit to the capital-city. “I am moved by the terrible human impact of the devastating earthquake and truly impressed by the resilience of the people of Nepal to respond so bravely and effectively in the days following the earthquake.” WHO has allotted over US$ 1.1 million for the emergency operations in Nepal. US$ 175 000 was released within hours of the earthquake from the South-East Asia Regional Health Emergency Fund to meet immediate financial needs and fill critical gaps in the aftermath of the 25 April disaster. WHO has 20 emergency response staff in Nepal and is sending medicines and other health supplies to treat tens of thousands of people. More than 50 000 patients have been treated in hospitals in the 14 districts most affected by the earthquake as of 5 May. During her visit to Nepal, Dr Khetrapal Singh met with the country’s Minister of Health and Population and other senior government officials, as well as the leadership of the United Nations system in the country. High on her agenda were preparations to prevent disease outbreaks ahead of the oncoming rainy season, WHO’s commitment to support the country’s health system, and to assist its heroic WHO committed to helping Nepal deliver health care to its citizens health workers as they recover from the disaster once the emergency phase has passed. Dr Singh stressed, however, that more must be done to protect the health of Nepal’s people. This included ramping up Nepal’s disease outbreak surveillance and response system, providing large quantities of necessary medical supplies, and supporting the recovery of the health system, parts of which were shattered by the disaster. “We are very concerned about the increased risk of communicable diseases, including diarrhoea, in areas where hygiene and sanitation systems are disrupted,” said Dr Singh. “We have a four-week window to preposition medical supplies in affected districts and strengthen the country’s water, sanitation and hygiene systems so as to shield it against the threat of disease outbreaks. These include water-borne and vector-borne diseases such as dengue and malaria, along with acute respiratory infections. WHO will continue working with UN partners, governments and non-governmental organizations to ensure the health of the affected people living in these harsh conditions is protected,” Dr Singh added. NEPAL EARTHQUAKE RESPONSE: WHO SEAR 24 Two earthquakes struck Nepal on 25 April and 12 May killing over 8000 people and injuring 18 000. Measuring 7.8 and 7.3 on the Richter scale, the earthquakes affected 35 of the country’s 75 districts, 14 of them severely. Twenty six hospitals and over 1100 health facilities were damaged in the earthquakes and 90% of health facilities outside the main towns rendered non-functional. Responding to the urgent health needs of earthquake- hit Nepal, WHO has been supporting the Government of Nepal for providing medical relief to the nearly 5.6 million affected people, 2.8 million of whom have been displaced, with many still living in shelters fearing the continuing aftershocks and landslides. Within hours of the earthquake on 25 April, WHO and the Ministry of Health and Population (MOPH), met at the Health Emergency Operations Centre, set up jointly to work in such crisis. WHO immediately sanctioned emergency funds, disbursed emergency medicines and sent in a surge team of experts to strengthen WHO’s support to MOHP. WHO conducted a rapid needs assessment with MOHP in the worst affected districts, within a week of the disaster, to guide the health response. Co-chairing the Health Cluster with MOHP, WHO has been coordinating medical relief efforts of 148 partners to reach medical services to the severely affected areas in the most affected districts. WHO is also coordinating deployment of the over 100 Foreign Medical Teams (FMTs) that came into Nepal to support emergency response. Nepal Earthquake 2015: One month later 25 NEPAL EARTHQUAKE RESPONSE: WHO SEAR A month since the devastating earthquake, WHO is now focusing on district response and planning. WHO has stationed District Support Officers in all the 14 highly affected districts, to coordinate response, strengthen disease surveillance, management of services, while prioritizing assessment and outreach efforts to reach remote areas. WHO has strengthened its presence in Sindhupalchok, Gorkha, Nuwakot and Rasuwa – the worst affected among the 14 severely hit districts. The departure of FMTs is being planned with partners and MOHP to avoid gaps in services. WHO has helped enhance disease surveillance by establishing an early warning response and alert system and surveillance sites in the key districts to collect information on any suspected cases of communicable diseases. WHO continues to bring in medical supplies including emergency health kits, diarrheal disease kits, maternity kits, surgical kits and medical tents to meet the shortage of essential medicines and revive, even temporarily, primary health care services. The ongoing priorities are to manage the injured, provide rehabilitation support to those discharged from the hospitals and psychosocial support to the affected population, while ensuring the regular services for maternal and child care, communicable diseases such as TB etc. The challenge is to address all the issues before the approaching rainy season, less than a month away. NEPAL EARTHQUAKE RESPONSE: WHO SEAR 26 N E P A L medical teams Foreign Health Cluster Partners Medical facilities and teams NEPAL Earthquake 2015 Total number of medical teams deployed in the past month to meet health care needs and fill gaps in services Health facilities completely damaged 236 NURSES 264 DOCTORS 302 OTHER D es ig n: w w w .in fo na ut s. in Health facilities partially damaged 484 474 medical teams National currently working in the 14 most affected districts to reach remote VDCs and provide critical health care to vulnerable populations. Composition of these foreign medical teams 188 27 NEPAL EARTHQUAKE RESPONSE: WHO SEAR WHO in partnership with Nepal's Ministry of Health and Population deployed 141 Foreign Medical Teams (FMTs) to quake-ravaged areas throughout the country. WHO is deploying 50 Medical Camp Kits (MCKs) to provide continuity of primary health care services as Nepal's monsoon nears. WHO has procured 26 tons of medical equipment and supplies and has been distributing them on a needs basis 141FMTs WHO, upon the request of MoHP, provided 80 medical tents to health facilities throughout the country.' medical equipment and supplies tons of26 NEPAL Earthquake 2015 Medical resources delivered D es ig n: w w w .in fo na ut s. in80 Medical tents for Health Facilities 50 MCKs NEPAL EARTHQUAKE RESPONSE: WHO SEAR 28 Accessing health care in Nepal’s Western district of Gorkha can be difficult at the best of times. The district’s terrain is marked by steep mountains and plunging valleys, while a lack of motor-able roads means travel is slow, laborious and inconvenient. As with the rest of Nepal, qualified doctors are present only at the primary level and above, meaning that for much of Gorkha’s 271 000 residents they are often tough to access. After Nepal’s 25 April and 12 May earthquakes, the need to overcome these systemic challenges and encourage health-seeking behavior has never been clearer. On 15 July, Gorkha’s District Public Health Office (DPHO) held a mobile health clinic in Bhumlichok, a Village Development Committee in the district’s south with a population of approximately 5000. Despite being just a few kilometers from the country’s mid-hill Prithvi Highway, Bhumlichok is marked by poor health indicators. After arriving at midday, the DPHO team, comprising of a general practitioner, two eye doctors, a lung disease expert, a lab technician, and a reproductive health expert, arrived at Bhumlichok’s makeshift health post and began receiving patients. Around 300 people showed up – a figure that the health assistant in-charge Nara Rawat was pleased with. According to WHO Surveillance Medical Officer Usha Kiran, who accompanied the mobile health clinic, before leaving Gorkha Bazaar the team made sure they procured the necessary supplies to restock the health post. “District officials have been in touch with the health post to register what they are short of. This a good opportunity to deliver medicines and supplies,” she says while helping to unload two pick-ups full of medical items including surgical blades, antibiotics, doxycycline, antacid and paracetamol. 34-year old lab technician Narayan Babu Aryal says that mobile health clinics provide opportunities to find and treat TB cases. According to Aryal, health authorities In Nepal mobile health clinics show the way to build back better WHO / M. Vurens van Es 29 NEPAL EARTHQUAKE RESPONSE: WHO SEAR Samundra Chepang, 60, says that though she visited the mobile clinic to receive treatment for her own ailments, the services offered are important for her family. “I’m finding the health clinic good, and the target on reproductive health is nice, especially for my son and daughter-in-law’s baby,” she says while motioning toward her family. Her daughter-in-law is 20 years old and has three kids, none of whom had supervised births. “This kind of camp does make us want to access facilities more,” Samundra says. Dhiraj Chepang 26, regularly uses the health services present in Bhumlichok, however limited they may be. Regardless of the mobile clinic’s visit, Dhiraj says he was planning to come to the facility for his seven-year-old child to have a health check-up. “I’m happy with the services provided in the village, but we often have to buy the medicines,” he says. “I’m pleased that the mobile health camp came as I was able to get my child’s medicines for free.” estimate that 10% of the people in Nepal have TB, though only 2-3% of cases are known. “I smear the sputum, collect and bring samples to the Gorkha DPHO and test them,” he says. “If they are TB positive we start the TB treatment regiment. The medicines are available at health posts accessible to villagers.” Since the 25 April earthquake, there has been a total of 85 mobile clinics in Gorkha District. This Ropai – Nepal’s annual rice-planting season – Shanta Maya Kumari struggled to perform her farming work due to vision problems. According to the 49-year-old, the mobile health clinic’s visit was an opportunity she couldn’t pass up. “My eyes are not good and I cannot see things clearly. This affects my farming work,” she says. After consultations with the clinic’s specialist eye doctors, Kumari was provided prescription glasses free of charge. “My vision is now clear. I’m happy with the glasses which are useful for my day to day activities”, she says. WHO / A. Bhatiasevi NEPAL EARTHQUAKE RESPONSE: WHO SEAR 30 MoHP has mobilized a total of 47 National Medical Teams with 163 doctors, 82 nurses, and 102 allied health personnel in 12 of the most affected districts -- Bhaktapur, Dhading, Dolakha, Gorkha, Kathmandu, Kavre, Lalitpur, Makwanpur, Nuwakot, Ramechhap, Rasuwa and Sindhupalchok. National Medical Teams 47 Doctors163 Nurses82 Allied health personnel 102 D es ig n: w w w .in fo na ut s. in NEPAL Eartquake 2015 Number of national medical teams SINDHULI RAMECHHAP KAVREPALANCHOK SINDHUPALCHOK KATHMANDU BHAKTAPUR LALITPUR MAKAWANPUR NUWAKOT DHADING GORKHA RASUWA DOLAKHA OKHALDHUNGA N E P A L 31 NEPAL EARTHQUAKE RESPONSE: WHO SEAR In post-quake Nepal, investigating and verifying rumors of disease outbreaks is the mainstay of Usha Kiran’s work. The WHO Surveillance Medical Officer (SMO) is stationed in Gorkha District, the epicenter of the 25 April quake and one of the 14 most affected districts in Nepal. Kiran says the possibility of a disease outbreak among its 271 000 residents remains a core concern. “Since the initial days following the quake disease outbreaks have been something we have all been cognizant of and active in regards to – especially the public. The prospect that endemic diseases could gain greater traction than usual as a result of the quake’s impact on water and sanitation has been of concern.” On 7 July, rumor spread in Gorkha Bazaar, the headquarters of the western region district, that deaths had occurred as a result of an outbreak of diarrheal disease in Kerauja, a village development committee in the district’s north-east. Contingency plans were executed immediately, says Kiran. “The District Public Health Office (DPHO) dispatched a health worker within hours to investigate and report back to the DPHO where it’s Rapid Response Team was waiting.” After speaking with officials at the local health post as well as villagers in the area, Bijay Kumar Shrestha, the health worker conducting the investigation, concluded that no outbreak had occurred. Rather, it was found that the deaths were caused by a landslide. The news came as a relief. However, procedures are in place to act swiftly in the event of a confirmed outbreak, says Kiran. Dr Nani Babu Daani, the focal point for Gorkha DPHO’s Rapid Response Team (RRT), says that the role of the unit he leads is clear. “In the event of an outbreak the RRT will mobilize resources and personnel to the affected area to treat patients and prevent further spread of the disease,” he says. RRTs are present in each of the 14 most affected districts and comprise of members from key areas of WHO’s disease investigation and rapid response system in post-quake Nepal WHO / A. Khan NEPAL EARTHQUAKE RESPONSE: WHO SEAR 32 To this end, Water, Sanitation and Hygiene (WASH) cluster partners are working diligently. Henk Veerdig, Gorkha WASH Cluster co-lead and team leader of CARE Nepal WASH team, says that there has been steady progress in providing access to drinking water and sanitation facilities in the district. “In the beginning the emphasis was on provision of hygiene kits and implementing the needs assessment. More recently, focal agencies have focused on providing access to sanitation and water supplies by supporting the construction of emergency toilets (which serve 4-5 families, or about 20 people), replacing damaged pipes and providing reservoir tanks,” he says, adding that these initiatives are extremely important in diminishing the risk of water-borne diseases. According to Veerdig, who has spent the past twelve years in Nepal and speaks fluent Nepali, much of the progress made is a result of the strong working relationship between WASH Cluster partners and local officials. “The WASH Cluster has been working closely with the Gorkha District government,” he says, adding, “There is a bridge of trust and confidence between the international agencies and government.” As WASH sector progress continues, Usha Kiran and 11 other WHO SMOs across the country will continue to monitor potential disease outbreaks while coordinating with each of the 14 RRTs to ensure rapid and, effective response is delivered if required. In post-quake Nepal, preparedness is key to achieving public health outcomes. public health concern, including immunization, nutrition, reproductive health, as well as logistics. RRTs are equipped with inter-agency diarrheal disease kits for treatment and preventative support to 500 people, and contain a range of drugs and supplies, including doxycycline, erythromycin and zinc tablets. According to Daani, there is no shortage of medical supplies. The greatest concern is Gorkha District’s terrain and accessibility. “Mobilizing a helicopter in the event of an outbreak is the best option, as reaching the affected area by foot could take up to ten days if it occurs in the northernmost areas. In many parts of the district there are no motor-able roads. Weather, suitable landing points and availability of helicopters are the other challenges,” he says. 33 NEPAL EARTHQUAKE RESPONSE: WHO SEAR The challenges Nepal’s recent earthquakes pose for Tuberculosis (TB) care and control are significant. In Nepal, TB remains an ongoing public health burden, with health officials keen to ensure that advances in recent years are not threatened. In the wake of the disaster, Nepal’s National Tuberculosis Centre formed a rapid response team and with logistical support from WHO have started tracing TB patients in the 14 most affected districts, with a priority on reaching those with Multiple Drug Resistant (MDR) TB. On 21 May, NTC and WHO staff met with District TB and Leprosy Officers in Bhaktapur to explore issues surrounding post-quake TB care and control in the district. The team also met with MDR TB patients living in temporary camps in order to identify patients’ immediate needs and ensure their continued care and access to treatment. According to the NTC, addressing living conditions in camps, increasing patient access to infection control measures and minimizing stigma have been identified as key areas for action. Tara Sharma, District Tuberculosis and Leprosy Officer for Bhaktapur says she and her colleagues have been working since the first earthquake hit to ensure that patients are traced and afforded access to the medicines they need to continue treatment. “There are 109 Tuberculosis patients whose houses are completely damaged, they are living in camps.” Sharma updates WHO and National Tuberculosis Centre staff on the status of TB patients in the district. “We take care of local residents and are linked to Kavre and Sindhupalchok districts. We know of six patients missing in Bhaktapur and three in Sindhupalchok. We are trying to track missing patients but mobilization of volunteers to visit their houses is difficult in this scenario.” Krishna Sundar Bhaila, 37, an Extra Pulmonary TB (EPTB) patient is committed to continuing with his anti-TB medication after the earthquake. Nepal’s TB patients continue to seek care amid trying circumstances WHO / Korver NEPAL EARTHQUAKE RESPONSE: WHO SEAR 34 Binod Khotea, 37, who is a relapse case of TB and has multiple drug resistant-TB (MDR-TB). When the earthquake hit he only had a one day supply of anti-TB medicine. He had been sputum smear negative (meaning his TB is non- contagious) for four months so it was important for him to seek out medicine the day after the earthquake to keep it under control. Khotea travelled of his own accord in search of anti-TB medication after the earthquake. He went to visit the house of a National Anti TB Association scout volunteer known to him. “I found her, she had been trapped inside her demolished house. Once she got out, she went back inside the house to get me medicine for 5 days. It was important to the both of us.” Sitaram Ghatuwa, 43, has sputum smear negative MDR- TB, and has been living in a temporary camp in Bhaktapur since the first earthquake demolished his home. He stays with eight members of his family including his wife Laxmi Ghatuwa, 35, and his 12-year-old nephew Sujan Ghatuwa. Twenty-five others also sleep under the same shelter in an adjoining tent. “We belong to a farming group. We do not have much at this time. If they provide medicine close by it will be easier. The 30 rupees I spend on travel could buy me two eggs to eat.” Ghatuwa had a six-day supply of anti-TB medicines from before the earthquake as he was attending the Deo Puja festival and did not want to be without his drugs in case clinics were closed for the festival. After the earthquake he continued taking his drugs in the temporary camp. He keeps them safe in a Bhujia (snack) packet, “it is waterproof,” he says, “it protects them from the rain and sun.” Nhuchhelal Ghatuwa, 70, Sitaram’s father, has Chronic Obstructive Pulmonary Disorder, and is vulnerable to contracting TB in this environment. The WHO and NTC arranged for his sputum to be tested for TB bacilli and will ensure he is provided with free treatment if needed. In the meantime he wears a mask to protect his family. WHO / Korver WHO / Korver 35 NEPAL EARTHQUAKE RESPONSE: WHO SEAR In the maternity tent of a makeshift hospital in Nepal’s quake-ravaged Sindhupalchok District, Sunita Tamang and Milan Lama dote over their 3-day-old son. The baby boy, who was born just days after a second earthquake compounded Nepal’s 25 April disaster, remains unnamed, as is customary for newborns in Nepali culture. Still, according to his parents, the boy’s defining features are clear: he is healthy and strong. “We came as soon as Sunita got the labour pains,” says 29-year-old Milan. With Sindhupalchok District severely affected by each of Nepal’s recent earthquakes, the continuity of maternal and child health care services has been of critical concern amid the flood of incoming trauma patients. Dr Nirmal Kandel, WHO’s Medical Officer for Sindhupalchok, says that with around 90% of the district’s health infrastructure damaged beyond repair, supporting the Ministry of Health and Population (MoHP) in meeting maternal and child health care needs is a priority. “We are not only supporting the District Health Office on disease surveillance and overall coordination, we are also supporting the continuity of essential services. We are focussing on providing access to maternal and child health care services with the help of UNFPA and UNICEF,” he said. According to Kandel, health partners in the district are working to restore maternity clinics and health care facilities demolished by the quake, such as the one that Sunita and Milan would ordinarily have visited. Fifteen of the district’s twenty-two maternity clinics are reported to have collapsed. “We are primarily focusing on replacing the damaged maternity clinics with temporary arrangements to restart delivery of services immediately,” he said. In the meantime, District Health Officer Sargar Rajbhandari says that since the first quake hit, all efforts have been made to ensure women in outlying areas unable to access Access to maternal and child health care in Nepal brings joy amid destruction WHO / A. Khan NEPAL EARTHQUAKE RESPONSE: WHO SEAR 36 Dr Ritesh Thapaliya, a District Health Office medical officer who helped deliver a newborn in an open field in the midnight hours following the first quake, says that Integrated Management of Newborn and Child Illness Training provided by WHO has given him the knowledge and confidence to provide ongoing care for his district’s new arrivals and their mothers. “Last year’s training helped us a lot – there are guidelines that WHO gave us and we follow them,” he said. According to Zainab Naimy, WHO Nepal’s Technical Officer for maternal, newborn, child and adolescent health, WHO’s guidance in ongoing campaigns to decrease maternal and child mortality in the country will inform a long-term, integrated approach to strengthening the health system. “WHO has been instrumental in maternal and perinatal death surveillance and response. This has helped track progress towards the reduction of maternal and newborn morbidity and has highlighted the need to invest in these aims,” she said. As Nepal recovers from the quake and faces the challenges of rebuilding and moving forward, for new mothers like Sunita Tamang, the delivery of healthy babies amid death, destruction and trauma provide some consolation to the pain that they have suffered. With a broad grin, and her baby boy lying next to her, she said, “I am so satisfied, so happy.” facilities are airlifted to maternity clinics at a Norwegian Red Cross field hospital in Chautara and a Japanese Red Cross Society primary health care facility in Melamchi. The hospitals were deployed by WHO in coordination with MoHP at strategic locations across the district. “We have airlifted so many women who have gone into labor. On the day before yesterday a woman was brought in from Tatopani, a town near the China border, and she delivered a baby here. Yesterday we airlifted a woman who had gone into pre-term labour, and then referred her on to Kathmandu, ” he said. According to Rajbhandari, approximately 100 babies have been delivered by health workers in the district since the first quake, including two within 24 hours of the disaster. As local health workers continue to provide critical services, WHO’s ongoing investment in educating midwives, Skilled Birth Attendants and General Practitioners throughout the country ensures that the delivery of maternal and child health care services will continue for mothers and their newborns. WHO / A. Khan 37 NEPAL EARTHQUAKE RESPONSE: WHO SEAR The green mountains of Nepal’s Sindhupalchok and Dolakha districts are punctuated by clusters of orange, blue and yellow tarpaulins, while mounds of nearby mud-brick debris mark the tragic consequences of Nepal’s 25 April and 12 May earthquakes. Around 80 percent of health care facilities have succumbed to the quakes’ ravages in the two districts northeast of the Kathmandu valley, leaving gaps in the health care system that threatened to outlast the emergency phase. To restore primary health care services in each of the districts, as well as the 12 other most affected, WHO continues to roll out Medical Camp Kits (MCKs) that will provide critical services to outlying areas over the next six months. While delivering an MCK to Khopachagu, a remote town in Dolakha’s west, WHO logistics specialist Aziz Adkhamov reiterates the need to move efficiently and address the Medical Camp kits provide essential services in remote Nepal town specific health needs of communities. “We are continuing to deploy the MCKs. The positioning of the MCKs matches the previous health-seeking behavior of communities, and each kit is being tailored to meet the areas’ requirements,” he says. WHO-procured Medical Camp Kits will be operational until at least the end of the monsoon, providing the opportunity for more permanent structures to be built. In the meantime, WHO continues to support Nepal’s Ministry of Health and Population in planning the country’s long- term health system recovery. NEPAL EARTHQUAKE RESPONSE: WHO SEAR 38 For Ram Chandra KC, Nepal’s 25 April and 12 May earthquakes affected both his property and livelihood. KC’s fertilizer warehouse, which also doubles as his home, was damaged beyond repair in the magnitude 7.8 and 7.3 quakes. The resident of Gajuri, a small town in Dhading district just off the mid-hill Prithvi Highway, now sleeps under a tarpaulin in a space adjacent to the quake-ravaged building. Despite his own misfortune, KC was pleased to be given the opportunity to help his community by allowing a WHO-procured Medical Camp Kit (MCK) to be set up on his land, which is directly opposite the town’s damaged primary health care facility. “It’s important for a medical tent to be set up as it’s for the public’s sake. The old health centre is not safe,” he said. In the past week, 36 MCKs have been deployed by WHO in coordination with the Ministry of Health and Population and other health partners to replace primary health centres damaged in the country’s recent disasters. Gajuri’s MCK is planned to be operational for around six months, and is likely to receive between 60 and 80 Building Medical Camp Kits patients per day. As a result of KC’s generosity, upwards of 40 000 people can now access a facility at a location that reflects their previous health-seeking behaviour. WHO / M. Vurens van Es WHO / M. Vurens van Es 39 NEPAL EARTHQUAKE RESPONSE: WHO SEAR A few hundred meters off Nepal’s mid-hill Prithvi Highway, a construction site in the town of Gajuri, Dhading district, is a hive of activity. Despite the searing heat, gravel and stone- dust is being shoveled, waste and sewage pits dug, and the foundations for the laying of concrete slabs prepared. In three days’ time, a WHO-procured Medical Camp Kit (MCK) will be fully assembled and able to provide care to the over 40 000 residents within the town’s vicinity dependent on access to outpatient facilities. In the past week, WHO in coordination with Nepal’s Ministry of Health and Population and other health partners has deployed 36 MCKs to replace damaged facilities throughout the 14 districts most affected by Nepal’s 25 April and 12 May earthquakes. As the monsoon arrives, the MCKs will ensure access to health care facilities in outlying areas while providing the opportunity to recover and rebuild damaged health centres. Measuring for new health centre: According to Dr Santosh Manandhar, the in-charge of Gajuri’s primary health center, Gajuri’s MCK, which is being set up in an open space opposite the existing facility, is important for those seeking medical care as well as health workers. “This facility is too damaged right now,” he said. “After the earthquake the people have been too scared to go inside the building, so we moved the outpatient department over here,” he added, gesturing toward a makeshift tent in the facility’s courtyard. According to Manandhar, Gajuri’s health center ordinarily receives between 60 and 80 patients per day. Each MCK will be located as per the demands of the local terrain and the the composition of the kit would vary according to local health care needs. Yudhir Khadka, a civil engineer for World Food Program, is responsible for determining the layout of Gajuri’s MCK and preparing the infrastructure to host it. The MCKs include provisions for male and female wards, one male and one In Dhading, Medical Camp Kits set to replace damaged primary health facilities WHO / M. Vurens van Es NEPAL EARTHQUAKE RESPONSE: WHO SEAR 40 female toilet, a staff room, consultation room, six solar panels, one 2000 liter water tank, as well as one waste and one sewage pit. Each MCK will be located as per the demands of the local terrain and the composition of the kit would vary according to local health care needs. Getting the camp’s specifications right is of critical importance for ensuring its sustainability. “Our biggest concern is that it is hygienic. The sewage pit will be three meters deep and will soak up the fluid material for up to six months. Anytime longer than that and we will have to make another pit,” he said. Positioning the solar panels to ensure a steady supply of power is also a pressing concern. Pointing to a series of stakes marking where six south-facing solar panels will be situated, Khadka said, “solar panel has been positioned to receive maximum sunlight.” Ram Chandra KC owns the land upon which Gajuri’s MCK is being set up. His fertilizer warehouse, which also doubles as his home, was damaged beyond repair in the quakes. He is now sleeping under a makeshift shelter near the camp. Despite his own misfortune, KC was pleased to be able to help the community by allowing the MCK to be set up on his land. “It’s important for a medical tent to be set up as it’s for the public’s sake. The old health center is not at all safe,” he said. Sudin Kayastha (center) has been working at Gajuri’s primary health care facility for just over a year. Since the earthquakes he has been tending to patients at a makeshift shelter in the facility’s courtyard. According to Kayastha, Gajuri’s MCK will be important in providing peace of mind and services to the patients: “We are looking forward to it,” he said, adding, “Patients are scared of getting treated inside the building.” Acting WHO Representative to Nepal, Payden, says the deployment of MCKs will fill a critical gap in Nepal’s health care system and will ensure and enhance access to health care services in the coming months. “Nepal’s health system has been compromised by the recent earthquakes.. We continue to work closely with Nepal’s Ministry of Health and Population to ensure that the health needs of the population are met throughout the monsoon period. Ensuring equitable access to affected communities in remote areas is an ongoing concern of WHO and we are pleased to be facilitating this via the deployment of the MCKs.” WHO / M. Vurens van Es WHO / M. Vurens van Es 41 NEPAL EARTHQUAKE RESPONSE: WHO SEAR MCK (Medical Camp Kit) Nepal 2015 Per Ward: 6 x mattress 1 x fan 2 x bulb 2 x mobile partition 1 x extra tarpaulin + ropes 4 x mattress 1 x fan 2 x bulb 2 x mobile partition 1 x extra tarpaulin + ropes 15 x hygiene kit 1 x solar refrigerator 2 x table + 3 x chair 1 x autoclave 1 x mattress + pillow 2 x fan 2 x bulb 1 x stationary kit 1 x extra tarpaulin + ropes 2 x toilet slab + tarpaulin + ropes Medical Camp Kits NEPAL Earthquake 2015 Partners supporting MoHP with WHO on MCKs 250 to 300 m2 surface required for MCK operations Female ward Toilet Toilet Water tank Waste pit 24 m2 Male ward 24 m2 Staff room 24 m2 Consultation room 42 m2 Power storage Solar panel = 100 watts Battery = 200 amps D es ig n: w w w .in fo na ut s. in Interagency Emergency Health Kit essential medicines and supplies 1x 1x AmeriCares FairMed IOM UNFPA UNICEF WFP NEPAL EARTHQUAKE RESPONSE: WHO SEAR 42 People treated Referred Surgery Major Source: Health Emergency Operation Centre/MoHP 14 May 2015 Admitted D es ig n: w w w .in fo na ut s. in Sindhupalchok N E P A L NEPAL Earthquake 2015 Sindhupalchok- The worst affected district Surgery Minor 2111 32 1491 76220 714 As of 14 May 2015: 43 NEPAL EARTHQUAKE RESPONSE: WHO SEAR This is a 60-bed mobile field hospital established in Chautara, Nepal by the Norwegian Red Cross Working side-by-side to treat the injured, heal the sick, and deliver babies, Nepali medical staff and international teams are striving to deliver health services in the earthquake-ravaged district of Sindhupalchok. In the district capital of Chautara, around 320 kilometres northeast of Kathmandu, the main hospital was badly damaged by the 25 April earthquake. WHO with the support of foreign medical teams, including the Norwegian Red Cross, stepped in. They arranged for the deployment of a 60-bed mobile medical unit to deliver a wide range of essential health services, from treating wounds and setting broken bones to delivering babies and dispensing medicines from a well-stocked pharmacy. ‘Worst affected district in Nepal’ : “The Sindhupalchok district is the worst affected in all of Nepal, with over 2000 people dead and many more injured,” says Dr Elena Mulmi, a medical officer from Chautara District Hospital. “Our entire hospital was totally damaged and we shifted here,” she adds, pointing to a series of tarpaulins and other makeshift shelters that serve as clinics. The temporary structures include a large rainbow-coloured big top, dubbed the ‘circus tent’ by locals. “We were unable to bring all the equipment from our hospital for wound dressing and sutures. But the new mobile hospital is well equipped. They are planning for orthopaedic surgery and have taken some of our patients already,” she explains. “I think the people from Sindhupalchok will benefit a lot from this hospital.” The Norwegian Red Cross team deployed a large team to Chautara, including doctors, nurses and logisticians. But Ranveig Tveitnes, deputy team leader of the mobile hospital, says the critical ingredient is the teaming up with the area’s local health staff. Nepali, international medical teams join forces to fill health care gaps in Sindhupalchok WHO / M. Vurens van Es NEPAL EARTHQUAKE RESPONSE: WHO SEAR 44 “The Nepali doctors worked in a nearby makeshift clinic for the first week after the earthquake, and they did a fantastic job,” she says. “Now they are integrating with us. Their doctors and nurses are working with ours. Their pharmacist is in charge of our pharmacy. We are working as one team.” Challenges of setting up a new mobile hospital Ranveig says her team encountered several challenges setting up the new mobile hospital. They had to wait several days for their equipment and medical supplies to pass through the congested Kathmandu airport, which has seen an enormous increase in traffic since the earthquake. And delivering the materials to the remote Chautara township meant navigating rubble- covered roads that snake through the mountainous region. “But we managed. We did a lot of road clearance, and it took a bit longer than expected to get here, but it is an earthquake, so what do you expect?” she asks. The mobile hospital expects to treat more than 150 patients daily. Health problems will include hygiene and sanitation concerns, the risk of communicable disease outbreaks, including diarrhoeal diseases, as well as the difficulty of reaching remote regions. Close co-operation: Coordination of the various medical teams – Nepali and international – is key, says Dr Ramesh Vikram Singh, Director of Health for Nepal’s Central Region, which includes Sindhupalchok district. “Many health facilities are damaged and daily hospital services have been interrupted. This is a big problem,” says Dr Singh, standing in the shadow of the damaged district hospital. “Now the challenge is the damage of the peripheral health services.” Addressing this problem will need continued close collaboration between Nepali and foreign teams, according to Dr Ian Norton, head of the WHO Foreign Medical Team initiative. He believes it is crucial to combine Nepali expertise and local knowledge, with the skills, logistics and experience in emergencies of the Norwegian Red Cross. “What we will start to see soon is one single team – Nepali and Norwegian Red Cross - working together in Chautara and branching out to villages around,” says Dr Norton, while inspecting the mobile clinic. Such teamwork will be vital ahead of the approaching monsoon season, where disrupted hygiene and sanitation systems will increase the risk of incidence of communicable diseases, including diarrhoea. WHO / M. Vurens van Es WHO / M. Vurens van Es 45 NEPAL EARTHQUAKE RESPONSE: WHO SEAR For a month now, a Norwegian Red Cross field hospital has provided critical medical care for the residents of Sindhupalchok, a mountainous district northeast of Kathmandu that was significantly affected by the devastating earthquakes that rumbled across Nepal. Though the district’s premier health facility in Chautara was rendered unserviceable by the first quake, local medical staff provided emergency care under tarpaulins for days on end in the dusty field where the camp now stands. Babies were delivered, bones were plastered, and emergency, life-saving health care provided. Since the Red Cross facility opened on 4 May after being deployed by WHO in coordination with Nepal’s Ministry of Health and Population, 4 410 patients have been treated. One hundred-and-sixty-five surgeries have been performed and 17 babies delivered. The facility is staffed by Nepali medical professionals that ordinarily work at the district hospital next door, as well as around 30 Norwegian Red Cross staff. With aftershocks decreasing in severity and frequency and emergency needs giving way to more routine care, the hospital is now working much the same as the district facility usually would. According to Norwegian Red Cross Deputy Team Leader Ranveig Tveitnes, Nepali doctors and nurses and their Norwegian Red Cross colleagues are doing their best to replicate the working methods of the district hospital. “We try to follow what people are used to and how the district hospital normally works,” she said. At present, the hospital is receiving between 150 and 200 outpatients daily, while an emergency unit continues to be staffed around the clock. When the Chautara field hospital first opened, between 50 and 60 X-rays were carried out daily. According to Jay Kumar Yadav and Lillian Lunden (pictured), demand for the service One month on, Sindhupalchok’s field hospital adapts to a changed scenario WHO / M. Vurens van Es NEPAL EARTHQUAKE RESPONSE: WHO SEAR 46 Ganesh Bahadur Tamang, 78, lives eight kilometers from Chautara. He suffers from chronic asthma and regularly seeks treatment at the district hospital. For the past month he has experienced increased difficulty in breathing, and finally checked himself in to the field hospital on 1 June. He now keeps a nebulizer by his bed, and says he is happy with the treatment he is receiving. Asdis Gudmundsdottir, medical logistician at the facility, will be looking after the camp’s stores until the field hospital is eventually replaced by a permanent facility. “If I’m not here nobody can do anything as they won’t find the supplies, and will run out of them,” she said, adding, “The most important thing is to be organized from the beginning.” As Nepal’s rainy season approaches, the importance of building sustainable facilities that hold up under adverse weather conditions cannot be overstated. Before erecting the tents, Red Cross staff in collaboration with district health officers ensured that drainage systems were dug around each tent, and then filled in with pebbles. Massive gutters surround the camp’s perimeter, while water, sanitation and hygiene facilities are visible throughout the facility. District Health Officer Sagar Rajbhandari says that it has been a pleasure working with the Norwegian Red Cross as their assistance has allowed health care officials in his district to ensure a rapid and thorough response to the disasters. “It’s our privilege to work with the Norwegian Red Cross,” he said. “In such conditions I’m very happy that we are providing medical services to the residents of Sindhupalchok. It is our duty to provide these services to the public at all costs.” has now returned to normal levels. Since the facility opened, 624 X-rays have been carried out. Deputy Team Leader Tveitnes says that before the camp was set up, local doctors were effective in tending to the fracture cases presenting: “The doctors here had done an amazing job evaluating whether a bone had been fractured or not, just by feeling. They are very good doctors. They’re young, and often in their first or second year out of medical school,” she said. The tent outside the X-ray machine once sheltered crowds from the blazing pre-monsoon sun as they waited for their suspected fractures to be diagnosed. As the number of those requiring X-rays decreases, the tent now gives shelter to those with less urgent needs. These days, the field hospital’s surgery room is used less often. According to staff, the difference in the workload over the past two weeks has been significant as the emergency phase comes to an end. In total, 165 surgeries have been performed at the facility. Sushma KC, 18, had been working at Sindhupalchok’s district hospital for five months before the 25 April earthquake hit. After the field hospital was set up to replace the district’s damaged facility, she began working in the maternal and child health care ward looking after newborn babies and their mothers. “I’m very satisfied working with the Norwegian team here,” she said. According to hospital staff, three babies requiring urgent medical care would not have survived had pre-existing facilities not been replaced. 47 NEPAL EARTHQUAKE RESPONSE: WHO SEAR Umesh Yadav is keenly aware of the post-quake health needs of his community. For the past 12 years, the 37-year-old has staffed the only health post in Bhimtar, a village of approximately 900 households perched above Sindhupalchok’s roaring Indrawati River. The mountainous district northeast of Kathmandu was one of the worst affected by Nepal’s 25 April and 12 May earthquakes. “Before the earthquake we planned to declare Bhimtar as open defecation free,” he says. “Due to the disaster, however, many houses have collapsed and the open defecation free program has been postponed.” Since 2011, Nepal has strived to eliminate open defecation in order to diminish the transmission of communicable diseases. In the immediate aftermath of the 25 April disaster, Nepal’s government and humanitarian partners have been prioritizing the restoration of water, sanitation and hygiene facilities to protect communities against a range of endemic diseases, including those associated with diarrhea, typhoid and hepatitis. The WHO and Ministry of Health and Population, meanwhile, implemented a rigorous disease surveillance system that involves daily reporting of case prevalence in the 14 most affected districts. According to Yadav, who has been diligent in ensuring the provision of emergency latrines in his village, the risk of an outbreak is becoming increasingly acute as the emergency phase ends and new challenges present. “Now, due to the monsoon, there is a greater chance of epidemics,” he explains. As a means to supplement present water, sanitation and hygiene initiatives, WHO and Nepal Health Education, Information and Communication Centre (NHEICC) are disseminating a series of health messages among the communities that will amplify and reinforce safe water, sanitation and hygiene practices. In Nepal, risk communication supplements pre-existing health interventions WHO / J. Swan NEPAL EARTHQUAKE RESPONSE: WHO SEAR 48 Joe Swan, a WHO risk communication specialist, says that engaging with communities directly is essential for promoting a ‘bottom-up’ approach to disease prevention. “It’s important that communities be given the tools to defend themselves. Our primary focus is to reach each and every member of at-risk communities by disseminating messages via written, graphic and spoken mediums,” he says. According to Swan, the range of messages being disseminated must, however, go beyond those related to water, sanitation and hygiene (WASH) and embrace the full spectrum of health-related challenges the country now faces. “WASH is clearly an important part of what we’re doing, though it is integral that we provide material related to other health issues, such as vector-borne diseases, or how best to deal with animal carcasses, for example,” he says. “If we narrow our focus we may fail to adequately address other health risks.” Flipcharts and flex banners being rolled out feature the aforementioned messages, along with those pertaining to snakebites, rabies, tetanus, flu and food safety among others. Nepal’s Female Community Health Volunteers (FCHV), who perform a vital role extending the health system’s reach in remote areas, are also being trained to impart the messages to their communities. Nirmala Acharya, an FCHV in Kavrepalanchok, a district bordering Sindhupalchok, says that the WHO and NHEICC resources and training are of immense use in supplementing the post-quake work she has already performed. “These will be very useful in communicating the messages to the community,” she affirms while thumbing through one of the flipcharts. Acharya’s colleague Sita Bika, who works mostly with Dalit communities, agrees. “These messages are really going to be helpful. The images will make it easier to deliver the messages to the community. If we show the pictures along with the message hopefully people will be convinced,” she says. Back in Bhimtar, as a result of his concerns regarding the change in weather, Umesh Yadav remains committed to ensuring there are no disease outbreaks during the rainy season. “I love this place and want the community to be healthy,” he says. Communicating risk and ensuring people have the knowledge and tools to diminish their vulnerability is a good place to start. To this end, WHO and NHEICC’s health communication strategy is vital. WHO / J. Swan WHO / J. Swan 49 NEPAL EARTHQUAKE RESPONSE: WHO SEAR Less than five weeks ago, a plot of land opposite Gajuri’s damaged primary health center was little more than a dusty mélange of building materials, tents and debris. The damaged health center continued to provide services from its courtyard. For residents of Nepal’s Dhading district, one of the 14 worst affected by the country’s 25 April and 12 May earthquakes, going indoors amid the continuing aftershocks was a hazard best avoided. Since 16 June, a WHO-procured Medical Camp Kit (MCK) consisting of consultation and staff rooms, male and female wards, a maternity room and a range of medical and logistical supplies has provided access to primary health care services on this plot of land. Over 40 000 people reside within the catchment area of the damaged health facility, making its replacement crucial for the community’s health. At present, things are running smoothly. The MCK will be operational for at least six months, allowing time for the damaged facility to be repaired, for the rainy season to pass, and for long-term health system recovery. From Kit to Camp: Delivering primary health care in post-quake Nepal WHO / M. Vuren van Es NEPAL EARTHQUAKE RESPONSE: WHO SEAR 50 Before Nepal’s 25 April earthquake, Agatha Thapa was well known for her pioneering work on early-childhood development in the Himalayan country of approximately 30 million. Apart from opening two pre-primary schools, she has devoted time and resources to launching ‘Entry Point’, Thapa’s own pre-preschool program for disadvantaged children aged between one-and-a-half and three years old. Thapa, 70, now spends six days a week providing psychosocial support to the children of displaced families living in tents in Tundhikhel, a large open space in central Kathmandu. “Children need their emotions released, especially after the terror of the earthquake,” she says. “We give them chances to express themselves through many different activities.” At present, the mental health care needs of people of all age groups are acute. According to Rishav Koirala, WHO’s mental health specialist in Nepal, WHO and Nepal’s Ministry of Health and Population have been active in promoting access to culturally appropriate, evidence-based sources of care. “We have devised a screening tool for lower-level paramedics to identify patients with mental illness and we’ve shared a Nepalese version of WHO South-East Asia Regional Office’s Health Advice for Mental Illness,” he said. “We are organizing a ‘training of trainers’ program which will start next month to address mental health care gaps. This will help train doctors to provide a basic, primary level of care or make referrals as and where necessary.” As these initiatives highlight, ensuring that Nepal’s health system adapts to meet the post-quake needs of the country’s citizens is crucial. Addressing mental health needs in quake-hit Nepal WHO / M. Vuren van Es 51 NEPAL EARTHQUAKE RESPONSE: WHO SEAR Perched midway up a steep embankment in Nepal’s undulating Kavre district, the Spinal Injury Rehabilitation Centre (SIRC) is at first glance unassuming. Its front gates are barely marked and the turn-off easy to pass. Once inside, however, the capacity and scale of the non-profit facility becomes clear: Ramps with gentle gradients lead to expansive therapy and vocational training rooms, while a multi-terrain wheelchair course is visible through large, light-filled windows. A hydrotherapy pool planned before the quake to be open in May will now be fully functional once immediate patient needs are met. Since Nepal’s 25 April and 12 May earthquakes, SIRC has worked closely with the Ministry of Health and Population (MoHP) and WHO to provide critical care to those who sustained spinal cord injuries in the disasters. Along with Pokhara’s Green Pastures Hospital, SIRC has received referrals from health care centers throughout the 14 most affected districts, and has expanded its bed capacity from 51 to 200. As a result of SIRC’s impressive facilities and close coordination with health care partners, the center will form an integral part of the country’s ‘step down’ process designed to provide ongoing care and rehabilitation to those injured in the quakes. Along with accepting referrals of spinal cord patients, the center is working with the MoHP, WHO and other partners to ensure that the needs of those with multiple injuries and other complications are met. With Nepal’s emergency phase ended, the provision of ongoing care and reintegration services for the injured remain a priority. According to Administrative Director Dipesh Pradhan, when the magnitude 7.8 earthquake tore across the country on 25 April, the SIRC was rehabilitating 39 patients. In the days following the quake, the center’s staff supported spinal cord patients presenting at Kathmandu’s major hospitals, and worked closely with Nepal’s MoHP and other health partners to refer them on to SIRC to gain specialized care. In for the long-haul: Rehabilitation and Nepal’s ‘step down’ process WHO / J. Swan NEPAL EARTHQUAKE RESPONSE: WHO SEAR 52 In response to the post-quake influx of patients, SIRC has increased its capacity and now has the resources to provide the long-term care required. “We are planning to accommodate around 200 patients so we have sourced extra material and manpower. In addition to our regular staff we have hired four rehabilitation therapists and also two psychologists to provide psychosocial counselling,” said Pradhan. It costs donors and supporters approximately USD 3100 to support 3 months of a patient’s rehabilitation care, he said. Twelve years ago Sonika Dhakal was injured during Nepal’s annual Dashain festival. For the past decade she has been leading group counselling sessions at SIRC while demonstrating the possibility of living an independent, mobile life despite disability. In the post-quake context her services are more important than ever. “After the earthquake many of the patients have lost their family members and have accommodation problems. They have much more psychological pressure than they normally have. This drives me to give patients the best support we can,” she said. Keshab Prasad Sitaula manages SIRC’s occupational therapy department. After working at Kathmandu’s Bir Trauma Center for two weeks following the 25 April quake he returned to SIRC and now works to enhance his patients’ motor skills. He also coaches them in the use of assistive and adaptive devices. Despite his heavy workload, Sitaula says that he is ready and able to provide care to incoming patients. According to 23-year-old Shashi Shrestha, who runs SIRC’s physiotherapy department, the job of the team she commands is clear: “We try to make our patients as independent as possible,” she said. “When we are giving them the therapy we also make them realize what they can achieve.” Kshetra Gurung has worked at SIRC since the center first opened in 2002. In 2013, the one-time occupational therapy assistant moved over to the center’s workshop and began custom-fitting wheelchairs for the facility’s patients. Given the post-quake demand for his services, it’s a good thing Gurung’s technical expertise are well-honed. “I did basic and intermediate training for wheelchair assembly given by WHO in Pokhara last year and three months basic prosthetics and orthodics training in Thailand,” he said. “We assemble our wheelchairs according to the WHO guidelines on the provision of manual wheelchairs in less- resourced settings.” WHO / A. Bhatiasevi 53 NEPAL EARTHQUAKE RESPONSE: WHO SEAR During her second visit on 25 June 2015, Dr Poonam Kshetrapal Singh underscored the WHO committment to build back equitable and resilient health systems in Nepal. She said the health of people who survived the killer earthquakes could be at risk if regular services were not rebuilt and restored on a priority. All partners need to work together towards an early recovery and reconstruction of Nepal’s health systems. “We need to urgently restore regular health services for the millions of affected people – for the pregnant women, newborns, children, the aged, people with diseases such as TB, heart ailments, diabetes etc. Without critical services their health could be at serious risk”, Dr Poonam Khetrapal Singh, said at the International Conference on Nepal’s Reconstruction 2015. Dr Poonam Khetrapal Singh and Nepal’s Honorable Minster for Health Mr Khagaraj Adhikari visit a Medical Camp Kit set up outside the International Conference on Nepal’s Reconstruction in Kathmandu. Having lost their homes to the earthquake, displaced populations continue to live in temporary shelters with sub- optimal hygiene, sanitation and water conditions. They are vulnerable to diseases and health risks in the ongoing rainy season and the approaching winter. Many of the affected people - the injured, need long term care or rehabilitation. A large number of people need mental health care to cope with the trauma caused by the calamity. In addition to strengthening surveillance and disease prevention initiatives, one of WHO’s key interventions for the ongoing monsoon season is the medical camp kits (MCKs), a set of water proof tents. The MCKs are being strategically located in the most affected districts to serve as temporary patient consultation and treatment facilities and to ensure continuity of services. “The MCKs will provide the critical buffer during which the recovery of health system must proceed”, said Dr Khetrapal Singh. With 80% of health facilities in the 14 most affected districts damaged, the task of reconstruction is huge but equally important. The Regional Director said long-term development and the scaling up of risk reduction and preparedness will be key features of WHO’s contribution in the recovery and reconstruction phase. WHO affirmed support with capacity building of national and district health staff on emergency preparedness; expanding the number and quality of disaster-resilient health facilities in the districts; improved interventions for structural, non-structural and functional capacities; replenishment of buffer stocks of prepositioned medicines; and medical kits and supplies and rapid response team kits, among others. WHO has been supporting Nepal’s disaster risk reduction and emergency preparedness initiatives. Regional Director in Kathmandu: WHO commitment to early reconstruction NEPAL EARTHQUAKE RESPONSE: WHO SEAR 54 The World Health Organization has set up an advisory group to guide its support to earthquake-hit Nepal for rebuilding resilient health systems. Over 80% health facilities have been damaged in 14 districts worst hit by earthquakes that rocked Nepal on 25 April and 12 May this year. “Improving health system in Nepal as it goes through recovery, requires all of us to rethink and innovate. Long-term development and scaling up risk reduction and preparedness for the health sector are key features of WHO’s ongoing engagement in Nepal, ” Dr Poonam Khetrapal Singh, Regional Director, WHO South-East Asia, told the first meeting of the advisory group in New Delhi on July 31. The advisory group, comprising of academicians, policy makers, social scientists, economists, epidemiologists and other experts, will advise on WHO strategic approaches to ensure that the needs of the affected people are met through the process of transition from response to recovery and development. Dr Khetrapal Singh said, “the task ahead for recovery and reconstruction is huge. We must prepare ourselves so that we are ready with the right capacity in place to assist Nepal to move forward quickly in the effective and rapid implementation of recovery plans.” Set up for a year to cover the post-earthquake recovery and development phase in Nepal, the advisory group primarily recommended that the implementation of the recovery plan for health, should closely look at how health services are allocated. With the aim of a more resilient health system, MOHP, together with partners, should implement the recovery plan by prioritizing actions that will contribute to a quality health system – one that is accessible, especially to populations made vulnerable by the earthquake. WHO has been working closely with the Ministry of Health and Population (MOHP), Nepal, on the health sector response, which post-earthquake focused on trauma management and temporary reinstatement of the critical health services, and is now transitioning to early recovery and reconstruction. WHO sets up advisory group to guide post-quake recovery support in Nepal 55 NEPAL EARTHQUAKE RESPONSE: WHO SEAR NEPAL EARTHQUAKE South-East Asia Regional Health Emergency Funds (SEARHEF) Meeting immediate, critical funding needs SEARHEF approved for Nepal within 6 hours of earthquake SEARHEF helps to meet the needs in first few days of an emergency Up to US$ 350 000 made available for a single catastrophic event NEPAL EARTHQUAKE Providing critical medicines and medical supplies Four emergency health kits with medicines and medical supplies for 40 000 people for a period of 3 months provided within 24 hours of earthquake WHO continues to provide essential medicines, medical supplies and surgical kits Pre-positioning supplies to meet emergency needs NEPAL EARTHQUAKE RESPONSE: WHO SEAR 56 NEPAL EARTHQUAKE Preparedness pays off when disaster hits Trained by WHO in emergency triage, this doctor from Dhading district took charge of a medical tent Using colour-coded cloth, this woman segregated seriously injured patients from others WHO Mass Casualty Management Training saves lives NEPAL EARTHQUAKE Safe water and sanitation are critical needs Providing safe water, sanitation and hygiene to affected people WHO supports water quality monitoring Restoring water and sanitation in damaged health facilities Water and sanitation