International Neurosurgical Children’s Association

INCA (http://www.incachildren.org/) was founded with the primary goal of educating, equipping, and empowering neurosurgeons in developing regions of the world to provide lasting and sustainable neurosurgical interventions for impoverished children living in their cities. The organization offers assistance in the form of equipment, technical information, training, and surgical support to neurosurgical teams throughout the world. In practice, INCA’s neurosurgeons are deployed on targeted visits over several years to build or renovate international pediatric neurosurgical programs. Success in this endeavor is measured by 2 parameters: how rapidly the neurosurgical team becomes obsolete in the host country and the amount of donation dollars spent.

Establishment of an Acute Response Medical Team

To manage global response to disasters, the World Health Organization (WHO) created emergency medical teams—Acute Response Medical Teams (ARMT)—comprised of groups of medical personnel with documented qualifications that are officially registered with the WHO. These teams are then deployed after a disaster in official coordination with the government of the country in question.

We established an equivalent version of an ARMT comprised of select personnel from ENG and INCA. Interaction of the leadership of the Division of Pediatric Neurosurgery at UCSD–RCHSD (also in leadership positions in INCA) and ENG was coordinated by the primary author (D.M.L.). Specifically, the primary author was concurrently a member of ENG (with prior experience in Nepal) and the UCSD-RCHSD Neurosurgery Service. The UCSD-RCHSD Neurosurgery Service is the primary sponsor of INCA. The relationship between the 2 organizations was negotiated for this single mission. These efforts were not coordinated with any other teams from either the WHO or United Nations (UN) in Nepal.

Inclusion on our team was foremost determined by availability of continuous contact with ENG team members living in the Gorkha earthquake disaster region; team members were selected for their local knowledge and familiarity with the region. Given the acuity of the intervention in a complex landscape, an additional consideration for inclusion was having the capacity to work in that region. Final considerations included medical and psychological expertise with trauma response. The medical team thus consisted of a naval military corpsman (surgical assistant and hospital administrator from UCSD), a trauma nurse from UCSD, a trauma psychologist, a local hospitality worker responsible for the labeling and distribution of packages of antibiotics and other medications, 2 nurses who had been scholarship recipients of ENG, 2 translators, a primary Nepali guide who also served as a logistics supervisor, and 6 local porters who carried medical supplies, tents, and survival equipment that were distributed along the way. Almost all the equipment and supplies had been donated by various organizations and physicians in the United States.

Barriers to a Successful Natural Disaster Medical Response

Achieving successful public health interventions or effective medical responses to natural disasters invariably requires identifying and overcoming barriers to medical delivery or implementation, some of which may be generalizable to a variety of settings and natural disasters ^{Reference Guha-Sapir and Scales9} but others of which are context-specific. The observations described here further elaborate previous efforts that have been made to identify several of the barriers that specifically impeded the Gorkha earthquake response. ^{Reference Cook, Shrestha and Bo Htet5,Reference Lee10,Reference Hall, Lee and Cartwright11}

Geography

The goal of the natural disaster medical response group from ENG and INCA (Figure 1) was to travel to rural areas in Nepal (Figure 2, top left) that had previously been considered inaccessible to both national and international medical teams. These regions, in addition to their poor accessibility, were simultaneously expected to be among the most devastated. ^{Reference Adhikari, Bhandari and Neupane12–Reference Aryal, Acharya and Shrestha14} The most direct access to these areas was provided by helicopter, creating a logistical transport challenge for the medical relief effort. ^{Reference Bilham3,Reference Cook, Shrestha and Bo Htet5,Reference Platt, Gautam and Rupakhety8} This challenge worsened further on Tuesday, May 12, 2015, when a United States UH-1Y Huey helicopter involved in the relief efforts crashed near Charikot, Nepal, killing all onboard. ¹⁵ Helicopter support for the relief efforts ceased 2 wk later, ¹⁶ further diminishing capability to travel to desolate locations by air. ^{Reference Cook, Shrestha and Bo Htet5,Reference Gulland13} Many remote locations affected by the earthquake were subsequently either inaccessible or accessible principally on foot with the guidance of knowledgeable locals, the approach used by the ENG/INCA team, described below.

Figure 1.

The 2015 Gorkha earthquake medical response team from ENG and INCA. Left, some members of the team arranged with supplies. Right, members of the group interacting with a Nepali girl (top) and preparing to welcome patients to an ENG/INCA health camp (bottom).

Figure 2.

Distributing medical aid in Nepal in the aftermath of the Gorkha earthquake. Top left, poorly accessible rural areas of Nepal were expected to be among the most severely affected by the earthquake. Top right, coordinating with Nepali nurses to distribute medical supplies. Bottom, some devastated areas of the city of Kathmandu (left) resulted in displaced residents setting up encampments (right).

Language

Although the language barrier presented multiple difficulties, the assistance of 2 Nepali Sherpas and a Nepali nurse, included among the ENG members, was sufficient to not only triage patients but also to package the various drugs and antibiotics into individual pediatric and adult doses for distribution (Figure 2, top right) in addition to providing verbal and written instructions in Nepali regarding their correct usage. Partnership with ENG, an organization deeply integrated in the local community, was ultimately critical to successful delivery of medical care.

Series of Acute Interventions, Supplies, and Chronic Issues and Future Engagement

Series of Acute Interventions

On May 11, 2015, the group arrived in Kathmandu (a summary of the timeline and location-specific impact are provided in Table 1) with supplies, which included antibiotics and other assorted medications (Table 2), intravenous fluids, dressings, bandages, splints, sutures, stethoscopes, blood pressure cuffs, oxygen-saturation finger probes, headlamps, and additional medical supplies to combat a myriad of other conceivable contingencies. The following day, couriers from ENG brought additional supplies into Kathmandu, including more pharmaceuticals, antibiotics, and medical supplies.

Table 1.

Itinerary, Treatment, and Resources

Table 2.

Supplies for Chronic Illness

On May 12, 2015, the group traveled by bus to the ENG school in Kathmandu. Significant devastation was evident throughout the city with some people, having abandoned buildings and homes, living in makeshift tent cities (Figure 2, bottom left and right). The response team began treating children at the school but were forced to take a brief hiatus due to a 7.3 M_w aftershock, which originated east of the city in the Everest region. ^{Reference Avouac, Meng and Wei23}

On May 13, 2015, the team traveled throughout the most economically compromised neighborhoods in Kathmandu and set up a treatment center in a school room (Figure 3, top). The treatment center consisted of 2 clinics, 1 medical and the other for psychological trauma, a system the group subsequently replicated at each location.

Figure 3.

Schools often served as makeshift clinics to provide medical care to local residents. Top, caring for patients in a temporary health camp set up in a school. Bottom left, less acute medical ailments such as earache become more common than trauma in the subacute to chronic aftermath of earthquakes. Bottom center and right, treatment for many children included counseling.

Earthquakes are often associated with a particular pattern of medical complications in which a preponderance of traumatic injuries in the acute aftermath of the disaster is subsequently followed by a subacute to chronic period of medical abnormalities resulting from impaired access to medical care. ^{Reference Adhikari, Bhandari and Neupane12,Reference Aryal, Acharya and Shrestha14,Reference Bartels and Vanrooyen24} In accordance with this pattern, the primary medical issues the ENG/INCA team encountered included upper respiratory and gastrointestinal infections, sprains and fractures, intestinal parasites, foreign objects in ears, congestive heart failure, allergies, and psychosomatic issues including insomnia and panic (Figure 3, bottom left). Indeed, mental health issues were the most pronounced. Nearly everyone was experiencing symptoms of posttraumatic stress disorder, and depression and suicidal ideation were frequent. Behavioral regression was evident in the younger children, and the group ultimately provided psychological counseling to over 50 children throughout the duration of its deployment (Figure 3, bottom center and right).

On May 14, 2015, the group traveled to the Tenzing Hillary airport in Lukla, close to the origination of the major aftershock 2 d prior. From Lukla the group traversed through Phakding and onward to Monjo by means of the Himalaya trail. Along the Himalaya trail, given the overall lack of acute response, individuals were left to survive on their own, as no physicians or health professionals could be found. Damage from the aftershock was evident, as all of the structures between Phakding and Monjo were destroyed. Indeed, the persistence of intermittent major aftershocks (∼5-10 per d) discouraged sheltering in any infrastructure that remained, forcing the group to sleep outside despite the beginning of monsoon rains. Other than locals, the trail all the way to Monjo was empty of travelers (Figure 4, top left), and the trail itself was full of slides and fissures. Nearer the epicenter of the aftershock, many of the trails had been destroyed by landslides, requiring the group to find alternate routes. Lodging the next evening was provided by 1 of the accompanying Sherpas, with travel continuing the next day toward Namche Bazar, where another treatment clinic was hosted.

Figure 4.

Only locals were encountered in isolated rural areas. Top left, the rugged terrain of the trail meant it was devoid of any travelers other than locals. Top center, patients were treated at makeshift health camps along the trail between villages. Bottom, map of Nepal; red circle identifies Kathmandu, and red box portrays inset region at right, near the focal origin of the 7.3 M_w aftershock on May 12. Right, inset region summarizing ENG/INCA group’s travel and treatment provided between May 14 and 17. Map used courtesy of © OpenStreetMap contributors (https://www.openstreetmap.org/copyright) under the Open Database License (https://opendatacommons.org/).

On May 15, 2015, the group traveled to Namche Bazar and set up a medical clinic in a small wooden school that was still structurally intact; the 1 clinic in the Everest region near the epicenter had been reduced to rubble. Numerous patients were treated, including a group of Nepali military medics who had been injured helicoptering into the valley, having been unwilling to traverse the path the group had used to get into the city. Similarly, the ENG/INCA group provided additional medical supplies to a Nepali military medic team that had reportedly exhausted their supplies 10 d prior.

On May 16, 2015, the group reverse-trekked its path back down into the valley, stopping at each village work or tent encampment to offer medical care to patients (Figure 4, top center).

On May 17, 2015, travel continued to Lukla, where 40 patients were treated in an abandoned German Red Cross tent. Furthermore, additional medical equipment was provided to a Swedish physician who was stationed at the medical clinic in Lukla (travel and treatment provided May 14-17 summarized in Figure 4, bottom and right), who said the ENG/INCA medical response team was the first he had seen to provide Western medical care in this region since the initial earthquake. No other nongovernmental organization (NGO) or health organization, government assistance, or foreign aid were present or available during the first mo after the earthquakes in any of the villages along the Himalaya trail with which we were familiar.

On May 18, 2015, the group returned to Kathmandu from Lukla and traveled to the Rising Ray School in Kathmandu to provide medical care.

On May 19, 2015, the group traveled to the 8th century city of Bhaktapur, a neighboring city of Kathmandu and the old capital of Nepal, to provide additional medical care. In total, during its week-long deployment, the medical response team from ENG and INCA was able to successfully provide care to 834 patients.

Supplies

The medical supplies that were brought along included 35-50 boxes (20 × 20 × 15” in size) filled with syringes, needles, dressings, alcohol preparations, saline vials, saline flushes, lactated ringers, scissors, forceps, and more (Table 3). A priority of the medications that would likely be most useful was determined by undertaking a prospective review of the United States Center for Disease Control’s Refugee Health Profile for Nepal and Bhutan. ²⁵ In addition to medical care, psychological treatment was offered to care for trauma. Trauma was treated by group support sessions, individual consultations, and information packets distributed explaining the nature and process of traumatic stress.

Table 3.

Other equipment and supplies

Chronic Issues and Future Engagement

Based upon the temporally dynamic pattern of medical issues associated with earthquakes and reports from medical personnel in Kathmandu immediately following the earthquake, ^{Reference Aryal, Acharya and Shrestha14,Reference Bartels and Vanrooyen24} it was anticipated that the most frequently encountered injuries would not be acute in nature. This enabled the establishment of a secondary source of supplies and diagnostic equipment that would be directed toward injuries of a more chronic nature. ^{Reference Bartels and Vanrooyen24} Many patients, for example, reported experiencing chronic or acute headaches precipitated by deteriorating eyesight. Likewise, the prominence of poor dental care was demonstrated by how frequently patients exhibited infected teeth and gums which, left untreated, can precipitate even more severe systemic issues. Most prominently noticeable was the need of treatment for mental illness, for which the availability of care is starkly absent.

To sustainably ameliorate these more chronic maladies, however, it will be necessary to marshal further effort and resources beyond acute disaster relief. ^{Reference Aryal, Acharya and Shrestha14,Reference Bartels and Vanrooyen24} Although the treatment and trauma centers we established along our route were temporary, all of the medical and surgical supplies we brought into Nepal were given to locals before our departure. Given the acuity of the present mission, no formal follow-up was scheduled or envisioned. However, the ENG presence is so consistent—the ENG organization returns to this region every 6 to 12 mo—that follow-up encounters were inevitable in some cases. Nevertheless, the dearth of resources or health-care in the region in which we operated persists.

Limitations

The conclusions we can recommend from this hybrid approach to natural disaster response are necessarily subject to limitations. One limitation is that this, our Gorkha earthquake response, is our first application of this model to a natural disaster, and it is conceivable that this approach may be less effective in other contexts. Because this approach relies on the joint application of organizations’ inherent capabilities, we expect it will be readily generalizable to other emergent medical responses. Indeed, our approach is fundamentally rooted in the public health model of community-based intervention, which has demonstrated efficacy in a variety of contexts and health conditions. ^{Reference McLeroy, Norton and Kegler35–Reference Roussos and Fawcett37} Nevertheless, further evaluation will be necessary to validate the efficacy of this model in responding to other types of disasters. A second limitation is the timing of the response. Although the subacute response timing described herein bolstered the ability of these organizations to respond impactfully (eg, predictive tailoring of medical supplies, side-stepping prohibitive regulations, etc.), future disasters may demand responses in which timing is more restrictive. Future evaluation of this hybrid approach in settings requiring more acute or more delayed medical response timing is an important next step. A third limitation of our approach is that individual organizations risk duplicating efforts and inefficiently using local resources if inter-organizational communication is inadequate during preparation of a natural disaster response. The future impact of this limitation could be reduced by means of the aforementioned establishment by the UN/WHO of a resource site listing willing organizations and their potential contributions. Such a site would promote strategic inter-organizational communication and reduce redundant efforts, thereby bolstering disaster response efficiency.