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‘You’ve saved a life, now what?’ A field report from Nepal on the critical role of rehabilitation

Wesley Pryor is an Australian Adviser in Rehabilitation in Global Health for Handicap International, currently working in Nepal in the midst of the post-earthquake disaster where the organisation is responding to the chronic needs of thousands of injured people with massive, long term effects.

The teams anticipate hundreds of amputations, up to a thousand required secondary surgeries, and discharge care for people with no home. He says their big question, to emergency and health services – ‘you’ve saved a life, now what?’ – is just not on the agenda, and is critical.

Pryor reports below on the issues that are emerging and gives five reasons why rehabilitation is a critical part of emergency response and good health policy.

Thanks to Handicap International also for the photos: see at the bottom of the post for photo credits, and also news of a local Canberra fundraiser for Nepal students living in Australia.

***

Wesley Pryor  writes:

Seven days after the earthquake in Nepal, the official death estimate is 5,582. Media reports suggest the death toll will reach 10,000. As of today (Saturday) 2 May, there are 11,175 reported injured. We’ve traced 1,000 injured people, of which 400 will require follow up and long-term care. That number will increase as we link with more people.

Just 24 hours after the quake, I was in a rented car heading to the  Gorkha district to check  how people with injuries would access medical care, and to start a response to ensure they have basic rehabilitation. In the most heavily affected regions, there are only basic surgical facilities – people are moved across broken roads, to Kathmandu’s overflowing hospitals. BIR hospital, a major centre for trauma response, has 1 out of 5 theatres in operation – the rest were damaged in the quake. There is no rehab at all.  This emergency is symptomatic of what is happening in global health: rehabilitation is simply not part of many health systems.  Services have focused on preventing deaths, but as my colleague puts it: “you’ve saved a life, now what?

By the time I return to Kathmandu two days later – international surgical crews are deploying. They are all over the press. Fixators are being procured from India, pins from Frankfurt, sutures from anywhere they can be found. Donors are signed up. Commercial flights are cancelled to prioritise aid. A ventilator is in a 1 ton truck from Pokhara to Dhadin. This is it – we are in Life Saving Mode. By Wednesday, “saturated” is the term officials are using to describe it. Only one of these crews has rehabilitation in their plans.

This is what we do at Handicap International. We ask, “what happens next?” We’ve deployed therapists to hospitals, have released stockpile braces, mobility equipment, and are using our logistics platform to re-stock depleted orthopaedic surgery materials.

Five reasons rehabilitation is a critical part of emergency response and good health policy

  1. 1.       Secondary prevention is critical

Any public health wonk knows prevention is key. But, rehabilitation is prevention. To distinguish primary from secondary is to suggest prevention is only important if you’re not broken or sick in the first place. Therapies prevent contractures and deterioration in injuries. Proper assistive devices promote mobility and prevent wounds. For spinal cord injured patients, proper seating prevents life-threatening ulcers. These secondary preventative measures are crucial in mass casualty, where hospitals are stretched to breaking point dealing with primary injuries, and of course, to prevent unnecessary disease and disability in survivors.

  1. 2.       Rehabilitation is a catalyst for other essential services

What happens next, if you’re medically stable, but have no place to go? Injured people are often injured because their homes have been damaged or destroyed. Accessing early rehabilitation starts a link with the broader emergency response, ensuring people can access services like food distributions, shelter, sanitation, and are safe from physical harm as they heal and adjust.

  1. 3.       Rehabilitation is a critical part of a strong health system

In Nepal, we have been able to respond effectively because of a long investment in rehabilitation services, and because rehabilitation is part of earthquake preparedness protocols. Even then, we need backup from international services, because the national workforce is small, young, and lacks specialised training needed to treat complex injuries. Our logistics platform ensures assistive devices are available, since there are not sufficient stocks locally.

Elsewhere, communicable disease outbreaks have renewed focus on a need to strengthen health systems before emergencies occur. Large scale disasters are similar – ensuring strong rehabilitation services within the overall healthcare system is a critical part of preparedness for emergencies.

  1. 4.       Health is not universal unless it includes rehabilitation and includes people with disabilities

Universal health coverage (UHC) is an ambitious target, but a practical and useful framework for all health care policy makers to work in. The very definition of UHC includes rehabilitation, but in low and middle income countries, physical therapy and assistive technologies are scarce, under-supported, and not part of state health infrastructure.

Around the world people are living longer, but emerging health challenges mean we need to have systems that can not only prevent death, but help to support quality in life.

  1. 5.       Some emergencies are slow

Earthquakes are fast, but some emergencies appear over years or decades. Responding effectively to the massive increase in non-communicable diseases such as diabetes and cancer in coming decades, where almost three quarters of the effect is in low and middle income countries, requires strong rehabilitation services. But precisely where the need is greatest, the response is weakest.  WHO Director, Margaret Chan has called the emergence of NCDs “a slow motion disaster”.

Practical solutions

We have real solutions to train and support rehabilitation professionals and the systems in which they work.  In emergency response, we partner with the UK International Emergency Trauma Register to train and include rehabilitation in their medical response from day 1. Today, Nepalese therapists are leading Handicap International’s rehabilitation response teams. The World Health Assembly has called for greater emphasis of rehabilitation in health policy, and ensuring access to healthcare for disabled. Rehabilitation is only the start – people with long term disabilities can be excluded from recovery initiatives, may lose jobs, family, and have long-term needs. We have models and technique, and are building evidence to improve – these need financing and policy reform.

It’s up to health policy and global health leaders to decide – what happens next?

Wes Pryor, PhD, works in physical rehabilitation in low-income and conflict situations, with experience in emergencies across Asia. He was in Kathmandu last Saturday and has since visited the most heavily affected districts, met with authorities and coordinating agencies, and is deployed with Handicap International to contribute to the early response. Handicap International Federation, co-winner of the 1997 Nobel Prize, is an independent aid organisation working in situations of poverty and exclusion, conflict and disaster, working alongside disabled and vulnerable people in over 60 countries worldwide.

Photos:

1.  © ADH /Timm Schamberger

2. © Dominique Pichard/Handicap International

3. © Brice Blondel/Handicap International

Photo of Wesley Pryor: © Mike Landry/Handicap International

***

Croakey PS

Here’s a note from University of Canberra’s Dean of Students, Associate Professor Michele Fleming:

UC is saddened by the devastating impact of the recent earthquake in Nepal.

We currently has 99 students from Nepal. Sadly some students and their families at home in Nepal have been directly affected. Some students have advised that their family homes have been destroyed, and in some cases their family businesses.

In response, the University has established the UC Nepalese Earthquake Student Support Fund. Through the Fund, Nepalese students affected by the earthquake will be able to apply for financial support.

Donations to the fund are welcomed from staff and students. All gifts over $2 are tax deductible and 100% of your gift will go towards supporting UC students affected by the earthquake in Nepal.

Donations can be made online or by calling (02) 6201 2291.

 

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Closing the Credibility Gap 2013
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Racism and children/youth health symposium 2014
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Population Health Congress 2015
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