The challenge to save the survivors of Nepal

The death toll in Nepal’s earthquake is now more than 7,000, but thousands more face paralysis and long-term care. Aid agencies warn that the country needs more spinal injury resources to prevent further tragedy.

A Nepalese staff member of Handicap International (L) speaks to Dinesh Tamang, 10, as he sits on his bed at the National Trauma Centre hospital in the capital Kathmandu on April 30, 2015, following a 7.8 magnitude earthquake which struck the Himalayan nation on April 25. The UN launched an appeal for Nepalese quake survivors in dire need of shelter, food and medical care April 30 as anger boiled at the government’s inability to cope with a disaster that has killed more than 5,000 people. Nicolas Asfouri / AFP
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The death toll in Nepal's earthquake is now more than 7,000, but thousands more face paralysis and long-term care. Aid agencies warn that the country needs more spinal injury resources to prevent further tragedy.

When the 7.8-magnitude earthquake hit Nepal on April 25, Gopal Thami, 5, was alone in his family home.

His father Nanda, 42, made it inside just in time to pull the boy out before the building collapsed as the aftershocks continued.

Nanda, who lives with his family in a small village in the Dolakha district, was not as lucky as his son and was crushed as the building collapsed.

He is now in a bed in the Bir Trauma Centre in the country’s capital, Kathmandu, paralysed from the shoulders down.

His nephew Kumar said people in the village took him to Charikot, the district headquarters, where he was given a ride by local police to Kathmandu.

While much of the media attention is on the dead, there are thousands of people like Nanda who, although alive, now require complex and long-term care and rehabilitation.

This week the World Health Organisation said the priority for the country was spinal injury rehabilitation.

Time is of the essence and if left untreated, some of these injuries could cause permanent paralysis.

“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,” says Dr Ganesh Gurung, of the Bir Trauma Centre.

The WHO has called for all donor agencies and emergency relief partners to prioritise the long-term needs of the population and not just focus efforts and resources in search and rescue, and immediate medical relief. “If the people are not properly cared for, spinal cord injuries could lead to paralysis,” says Damodar Adhikari, programme manager at the WHO Nepal earthquake response.

Most of the damage and loss of life during and after an earthquake comes from collapsing buildings and falling debris.

Hyo-Jeong Kim, the WHO emergency operations manager in Nepal, says the emergency preparedness work in the country was largely focused on “earthquake-specific” injuries caused by structural damage.

“Right now there is a call going out for additional support with rehab issues,” says Ms Kim.

“In an earthquake most people that need immediate medical care are those that have been injured by falling debris.

“They have a broken bone or a spinal cord injury and these have serious consequences, like being paralysed or needing longer-term rehabilitation care for them to lead a normal life.”

Nepal was on the “better prepared side of things”, she says, thanks to much of the work in preparing the country to deal with such a large-scale disaster.

“The health system in Nepal is relatively weak and has been weak for a long time,” says Ms Kim.

“The country itself acknowledges the need for additional support from international partners in this area.”

The confirmed death toll stands at more than 7,300, but it is probable that not all deaths have been reported to the authorities yet, especially those in very remote areas.

Dr Wesley Pryor, of aid organisation Handicap International, says it could be closer to 10,000.

A Handicap International survey of injuries in four major hospitals in the Kathmandu Valley reveals that 65 per cent of cases related to bone fractures and 12 per cent have a spinal cord injury.

It says limb amputations have increased and the “frequency seems to be accelerating”.

The organisation, which has been working in Nepal since 2000, is one of a handful coordinating with the WHO to assess and manage the care available to the injured.

It has already drafted in an additional emergency team to boost the 50 workers in Nepal, and more help is on its way.

It is also shipping in specialist equipment such as orthotic braces, used to align bones while they heal, and rehabilitation kits.

Wheelchairs are being distributed across the country. They are provided by groups such as Motivation, a UK company that helps to deliver specialist and low-cost wheelchairs in developing countries, especially adapted for the difficult conditions.

Another of Handicap International’s important roles is helping to manage the flow of patients.

There is a risk in disaster situations that patients who require long-term care but not immediate help can fall through the net.

“When a lot of people have been injured in an earthquake, each individual needs to be case-managed as quickly as possible, and provided with follow-up care once they leave the hospital,” says Helene Robin, head of Handicap International’s emergency response in Nepal.

“Our experience in natural disasters, particularly in Haiti after the earthquake in 2010, has taught us that it’s important to stay in touch with the injured after they return home, and to continue providing them with care so that they don’t develop permanent disabilities.”

To ensure the injured get the help they need, the group registers patients, takes contact details and information on types of injuries, and helps to refer them to existing rehabilitation centres.

The types of injuries sustained in earthquakes are “complex and multiple”, says Dr Pryor, a regional adviser in rehabilitation with the disability charity.

“The patterns of injuries are very different from anything else, there’s nothing like it other than industrial types of accidents and they are usually only one at a time,” he says, speaking from Nepal.

“The number of deaths is approaching 10,000 and injuries way above that. The scale is always going to stress a health system.”

The displacement and lack of adequate shelter solutions also contribute to “second waves” of ill health and requirements for surgeries that get more complex as time goes on.

Infections can also set in because of the mechanism of injury and the way they are managed in temporary camps. On top of this, there is a huge social impact on people with new or existing disabilities.

“The social effect, the strain and stress of not knowing where to go, or not having anywhere to go, or being afraid to go inside even if the house is moderately damaged or not damaged at all. These are the layers of complexity, there’s nothing like it,” he says.

As part of the country’s emergency preparedness, Handicap International laid plans to bring in physiotherapists and other rehabilitation staff to help in the worst-hit areas.

The idea is that the sooner the patients receive the right care, the less likely they are to need invasive operations or amputations, or even suffer paralysis.

Lessons were learnt, says Dr Pryor, in the 2010 Haiti earthquake that measured 7.0 on the Richter scale.

Reported death tolls ranged from 100,000 up to 300,000. Medecins Sans Frontieres reported a huge number of amputations because of the structural damage in the country.

“The awareness and vigilance is better now,” says Dr Pryor.

“We learnt from Haiti about some of the worst-case scenarios. There was a huge number of amputations – 4,000 were reported but I don’t know how accurate that was. I hope we don’t get anywhere near that here.”

The group has now drafted in extra physiotherapists and rehabilitation staff from across the country. This was put into action as soon as the earthquake hit.

Dr Pryor says he expects the numbers of these specialists to triple in coming days.

As a long-term priority, the group works with authorities looking at rules governing disabilities in the workplace.

“Sometimes it works, sometimes is doesn’t,” he says.

“Generally speaking, the priority is to get them back to work. That might mean us working with industries, their employer, or offering micro grants or skills training, or building a shop that is accessible.”

Many of those affected by the quake will have no choice but to find new ways of working and living.

“It’s really, really different and really, really hard,” says Dr Pryor.

“Just on the most superficial level of accessibility; moving in and out of buildings that are not designed for people with mobility limitations.

“Livelihood strategies and finding alternative means of work for individuals or families is a large part of what we do.”