Paul Auerbach on the public health needs in Nepal

I am on my way back to the US now, and getting information from people who are in Nepal. Because I am inundated with requests to provide information from people who have read my previous posts, I will keep writing, but only if there is something useful to report. Please let me emphasize that this is no longer firsthand, but rather, based on communications from persons in Nepal whom I very much trust. They are working really hard, so it is “above and beyond” (and very much appreciated) that they find time to keep us all informed.

Surrounding Kathmandu and seen from the air, there are many remote villages that have been devastated, with all or nearly all dwellings demolished by the earthquake. These buildings had mostly been constructed of bricks mortared with mud. They crumbled during the shaking and may have been struck by rockslides. Anyone caught within the buildings could have been mortally wounded or severely injured.

Many villages are situated one or more days’ walk from the nearest vehicle (4-wheel drive truck or SUV)-accessible roadway, so rapid access will need to be by helicopter if there is a suitable landing site or the ability to carry out long-line rescues (this requires the appropriate equipment and operators with technical expertise, both on the ground and in the helicopter). Helicopters are in short supply relative to the need, so that is a rate-limiting part of the operation. The helicopters will be needed both to get teams in and to get patients out. The first step will be to provide on-site triage in order to prioritize where to deploy medical and other resources. Patients will be assessed in order to determine whom to transport and in what order. Treatment will be initiated when possible. The possibility of trekking into villages will be dictated by the condition of the paths normally used for foot travel. The paths are often narrow, rocky, and steep. It is likely that there have been rock-and-dirt slides that will render traversing some of these paths extremely difficult or impossible. If the paths are passable, that may be how some of these villages will eventually be reached, and people and supplies delivered. The delays will be overcome by cooperation and perseverance.

Medical teams from around the globe have come into Kathmandu and are assisting or prepared to assist. They will be responsive to the Nepal government, global health agencies such as the World Health Organization (WHO), and non-governmental organizations (NGOs) such as International Medical Corps. The search and rescue (SAR) component intended to find victims trapped in rubble will expect from this point forward to find only a few miraculous survivors of the initial event, so the role of SAR to extricate buried people will diminish. From this point forward, it will be about getting to the injured and sustaining them until they can be extracted to a higher level of medical care, if this is what they need. Reaching all the affected villages and injured persons may take weeks. To assist displaced (e.g., no longer have a home) persons, there is need to provide food, sheltering materials, and water disinfection supplies.

The public health mission, in particular trying to prevent the spread of potentially epidemic infectious disease (particularly diarrheal disease) is hugely important. This is essential now and particularly as the monsoon season approaches. This includes human waste management, providing safe drinking water, possibly providing immunizations, and surveillance that promotes early detection of disease.

Many people wish to respond. People who wish to participate in person are advised to do so with an agency that is approved to be in Nepal and working in coordination with the official response agencies and the government. People who do not come to Nepal should support in-person responders by assisting them with requests and staying in touch, but expect that there will be lapses in communication and understand that normal systems for delivery of items are overloaded. Supply chain management is being addressed at many levels. Monetary donations to organizations working “on the ground” are incredibly important, because the donations sustain rescue and relief efforts.  Recovery and reconstruction are complicated and expensive, and will take time, so your donations really help.

In summary, the situation in the city of Kathmandu proper appears to be slowly and steadily improving from the perspective of acute injury treatment. Support is being mobilized to assist for the surgeries that will be necessary to manage the patients who were stabilized, but now require definitive procedures. The hospitals in Kathmandu may face a substantial wave of additional patients needing definitive procedures or other care as the remote villages are reached. Sanitation, hygiene, and public health efforts to prevent, identify, and control communicable diseases are essential in all affected areas. The basic needs of living (e.g., shelter, food, and water) need to be provided for displaced persons. There are many unknowns – how many people remain in villages and the specifics of their medical needs, the condition of paths to the villages and if they are blocked how long it will take to clear them, and so forth. The people of Nepal are amazing, and as was the situation in Haiti, effective coordination and teamwork will hopefully help the greatest number of people possible.

Paul Auerbach is a professor of Surgery, Emergency Medicine at Stanford University Medical Center.