Healthcare Disaster Preparedness in Nepal

Dr. Calvello Hynes is currently teaching in the Colorado School of Public Health. She offers her students the opportunity to create blog posts to highlight current policies in global health.

This entry is by Alexa Hansen MPH candidate, submitted July 22, 2019

Photo credits: https://www.dw.com/en/scores-dead-as-monsoons-hit-india-nepal-bangladesh/a-49577881

Monsoon Conditions Impacting South Asia

Monsoon conditions starting on July 11th, 2019 have resulted in massive flooding and landslides, impacting areas of South Asia including India, Bangladesh, and Nepal. In Nepal alone, the most recent estimates include 90 deaths, 29 missing, and nearly 12,000 households displaced due to massive flooding and landslides. The most current report on the situation can be found here. The total impact on the Nepalese population is still to be determined, as these natural hazards continue to impact the country.

Most commonly reported are the immediate impacts and consequences, such as he death toll and damages. Less commonly reported are the long-term impacts that affect people’s livelihoods and wellbeing. It has been reported that the government of Nepal has deployed response teams to the region, but comprehensive assessments of the damages and losses are not yet known.

Historical Context

In 2015, 7.8 earthquake devastated regions of Nepal, killing around 9,000, injuring over 22,000 and displacing about 2 million, not to mention the total damages to infrastructure and people’s long-term livelihoods. The majority of health facilities in the affected areas were completely destroyed or partially damaged. The destruction of regular healthcare facilities resulted in thousands going without primary care required to treat chronic conditions such as diabetes, cardiovascular disorders, tuberculosis, respiratory infections, or even mental health conditions. It was not until 2016 that facilities were operating at a normal capacity. Steps have been taken towards improving disaster preparedness since the aftermath of the 2015 earthquake, including healthcare infrastructure, community engagement and health education.

Lessons Learned from 2015                                                                               

The World Health Organization (WHO) published a report on the post-earthquake health-service support in Nepal. Gaps in health services were identified following the earthquake, including the critical challenge of meeting the population’s regular health needs when the facilities had been damaged or were nonoperational and the amount of time it took before the facilities reached pre-disaster operational capacities. It had also been realized that health officials had to budget or means to repair facilities following disasters, or even a way to replenish supplies, including medication. The Nepal Center for Disaster Management (NCDM) aims to improve community awareness, capacity building strategies, resource availability, interagency coordination between government, agencies and stakeholders to more adequately address risk reduction and response during disasters. The NCDM acknowledges challenges with poor governance and public awareness, especially in a region prone to multiple natural hazards. According to the Nepal Disaster Management Reference Handbook (August 2017), the Nepalese government has been working to improve resiliency and preparedness through policy change and program development, such as the Natural Calamity Relief Act and the Central Natural Disaster Relief Committee. Within this handbook, challenges within the national healthcare structure are addressed, highlighting the various aspects of public health that are threatened during natural disasters.

Looking Forward & Questions to Consider

Nepal faces various challenges in improving emergency response and preparedness, including that in their national healthcare system. Many rural communities are difficult to reach and may be a considerable distance from the closest healthcare facility. If that facility is damage and unable to function, it leaves populations without needed medical care. Humanitarian aid and United Nations agencies have worked with Nepal in relief, recovery and rehabilitation efforts, but ultimately the responsibility of implementing adequate disaster preparedness in Nepal’s healthcare system lies with the government. In a country that is economically struggling, what can be done to substantially and rapidly improve in an area so prone to disaster cycles interrupting infrastructure development? Furthermore, how can an adequate health response and preparedness plan be developed and implemented in all regions including communities that are geographically isolated? This is a complex issue that requires examination, collaboration and discussion across multiple disciplines. While healthcare facilities have been rebuilt after the 2015 earthquake, the constant risk of natural hazards threaten an already fragile infrastructure. For Nepal to “build back better,” is outside aid an international cooperation required?

With the destruction ongoing the full impact of the monsoon on Nepal’s heath system has yet to be revealed. While there seems to be a significant effort in discovering the wide array of health threats and gaps in treatment during disasters, implementing policy change and preparedness plans are another step that require dedication, time, and resources, and examples of these successes are more difficult to come by. One can only hope that even amidst unavoidable damage during disasters, the lessons learned from previous disasters and identified gaps in services will prove to be making some progress.

Health Systems & Disaster Management

Dr. Calvello Hynes is currently teaching in the Colorado School of Public Health. She offers her students the opportunity to create blog posts to highlight current policies in global health.

This entry is by Leslie Walker, MPH candidate, submitted July 22, 2019

Photo credits: Getty Images

Health Systems Strengthening as an Approach to Disaster Management

While reading the qualitative analysis of the WHO Toolkit for assessing health system capacity for crisis management, I couldn’t help but think about certain natural disasters that have taken place in the United States and how the government has responded to them.  The World Health Organization (WHO) held its sixty-fourth World Health Assembly in May of 2011.  There, after identifying many publications and analyzing them, it was concluded that health system strengthening should contribute to disaster management. 

Natural disasters that have occurred around the globe were used as examples such as the 2010 earthquake in Haiti that left 1.5 million homeless and killed 149,095 people. It was stated that “Haiti lacked an effective health system prior to the earthquake and national authorities were not equipped to manage relief or recovery priorities when the disaster occurred” (Bayntun, 2012). This statement made me think about the lack of governance and how poorly the aftermath of Hurricane Katrina was handled by the government officials in New Orleans in 2005. The United States does have an effective health system in place, compared to places such as Haiti or other impoverished countries around the world and yet, Hurricane Katrina was not handled in the best way possible.  The hurricane caused flooding in New Orleans, where more than 1,800 people were killed, and property damage was estimated at $100 billion (Edwards, 2015). “Weather forecasters warned government officials about Katrina’s approach, so they should have been ready for it. But they were not, and Katrina exposed major failures in America’s disaster preparedness and response systems” (Edwards, 2015). Some major areas where the current administration of that time failed were: there was fraud and abuse, miscommunication and obstruction of private relief efforts. “Federal auditors estimated that $1 billion or more in aid payments for individuals were invalid. Other estimates put the waste at $2 billion” (Edwards, 2015). In other words, the actual amount of money lost through scams and schemes is not known for sure. Agencies could not communicate because of the equipment not working properly during this desperate need. And finally the Federal Emergency Management Agency (FEMA ) turned away doctors volunteering at the locations where medical attention was needed and blocked the delivery of emergency supplies that was ordered by the Methodist Hospital in New Orleans was blocked by FEMA on several occasions.

The WHO created a comprehensive Toolkit by studying lessons from natural disasters since 2000. The approach reiterates the WHO’s commitment to develop the health system approach to disaster management (Bayntun, 2012). In my novice level of Critical Polices and Global Health, I believe that while strengthening health systems can effectively increase the response to natural disasters around the globe, in certain wealthy countries like the United States, strengthening the health system that is already in place is not enough. There is already a health system in place in the U.S. and yet examples like that of Hurricane Katrina have taken place.  It is important to learn from previous mistakes, communicate and have well trained federal agencies along with being as well prepared as possible and having a plan in place when disasters such as hurricanes are forecasted to strike certain areas in the United States.  

References:

 Bayntun, C., Rockenschaub, G., & Murray, V. (2012, August 22). Developing a health system approach to disaster management: Aqualitative analysis of the core literature to complement the WHOToolkit for assessing health­system capacity for crisis management. PLOS Currents, doi:https://dx.doi.org/10.1371%2F5028b6037259a

Edwards, C. (2015, August 27). Hurricane Katrina: Remembering the Federal Failures. Cato Institute, Retrieved from https://www.cato.org/blog/hurricane-katrina-remembering-federal-failures

Crisis in Syria, the US Role and Policy

Dr. Calvello Hynes is currently teaching in the Colorado School of Public Health. She offers her students the opportunity to create blog posts to highlight current policies in global health.

This entry is by Dave Woods, MPH candidate, submitted June 23, 2019

Photo credit:https://news.sky.com/story/eight-things-to-read-to-help-understand-the-syria-crisis-10619641

The international community, with great assistance from the united states, has ended the humanitarian crisis in Syria

Unfortunately, this is not a real title. Despite the courageous, hard work of humanitarian organizations and individuals, the situation in Syria continues to worsen.

            The UN Office for the Coordination of Humanitarian Affairs (UNOCHA) has published five “Situation Reports” this year related to military hostility (towards civilians and non-combatants) and humanitarian needs in Syria. The latest report was dated June 14, 2019; it states “Violence in northwest Syria continued over the last ten days throughout Eid al Fitr, marking the end of Ramadan. Airstrikes and shelling in southern Idleb, northern Hama and western Aleppo governorates is putting civilians at risk and impeding the delivery of assistance” (UN, 2019). The report notes that humanitarian assistance is continuing despite impediments. While hundreds of thousands of people are receiving critical assistance, violence is still driving displacement. The report also states, “A further escalation of violence, triggering waves of displacement and complicating humanitarian access and provision of humanitarian assistance risks overwhelming an already stretched response” (UN, 2019). UNOCHA has estimated 330,000 people in Syria have been forced to flee their homes; most of them traveling north toward Turkey.

            The international humanitarian community has implemented plans that anticipated large-scale escalations of conflict and population displacement in northwest Syria. In Idleb and northern Hama, healthcare, shelter, food, and potable water have been the most needed and provided items. At least fifteen different international organizations have provided emergency response services to Syrian civilians recently displaced. Other services provided include: psychological first aid, psychosocial support, dignity kit distribution, and family tracing and reunification (UNHCR, 2019). While humanitarian organizations are responding to the needs of Syrian refugees their work has not been enough.

            The United States, as a world power, has seemingly not contributed to the Syrian crisis militarily or humanitarianly. Presidential messages to the State Department in 2018 suggest Trump intended to end the US’s obligation in Syria, short of military action against ISIS in the region. All future aid for Syria, including $200 million set aside for recovery efforts, was suspended by president Trump in 2018 (Laipson, 2018). Although  speculation about why the US has not contributed to Syrian relief centers around Trump, ‘finger-pointing’ or blame will not help the situation. A call to action is the morally imperative path to pursue at this time. Despite president Trump, the US should take humanitarian action in Syria immediately. A humanitarian operations plan should be implemented in accordance with The Core Humanitarian Standards (CHS) and Sphere. Sphere, formerly The Sphere Project, was created by the Red Cross, Red Crescent, and several NGOs. The mission of Sphere is to improve the quality of humanitarian organizations’ responses to disaster and conflict. The Sphere philosophy is based on two core beliefs:

1.     People affected by disaster or conflict have the right to life with dignity and, therefore, the right to assistance 

2.     All possible steps should be taken to alleviate human suffering arising out of disaster or conflict (Sphere, 2018).

 A US Humanitarian Operations Plan for Syria, 2019 would hold these beliefs as core values and mission statements. A plan with CHS and Sphere considerations would allow the US to assist the international community in ending the humanitarian crisis in Syria.

References

Laipson, E. (2018). Making Sense of Trump at War: Ramping Up in Afghanistan, Scaling Back in Syria. World Politics Review (Selective Content), 1–4

Sphere Association. (2018). The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response, fourth edition, Geneva, Switzerland, 2018.    www.spherestandards.org/handbook

UN Office for the Coordination of Humanitarian Affairs. (2019). Syria: Situation Report 5: Recent Developments in Northwestern Syria. June 14, 2019. www.unocha.org 

UN Office for the Coordination of Humanitarian Affairs. (2019).  Idlib, Syria:“We are faced with a humanitarian disaster unfolding before our eyes” – says UN Humanitarian Chief. June 18, 2019.

UN Office for the Coordination of Humanitarian Affairs.(2019). 2018 Syria Humanitarian Assistance Response Plan Achievements, January-December 2018.

UNHCR (2019). UNHCR Cross-Border Humanitarian Response Fact Sheet - Northwest Syria - May 2019 21 Jun 2019

Sustainable global health engagement - teaching ultrasound to change practice in Liberia

Dr. David Young
Earlier this year, I participated in a project to teach point-of-care ultrasound skills to residents studying in Liberia. This project, coordinated through Children's Hospital Boston and the Liberian College of Physicians and Surgeons, is essential in places like Liberia. There are few options for imaging diagnostics, especially at our main cite JFK Hospital in downtown Monrovia. While there is an X-ray machine, there is no official ultrasound department and no CT or MRI imaging available. While ultrasound requires training and practice, it is a very affordable, portable, and safe tool with hundreds of applications. 

The project was one year in duration and included several emergency medicine providers from American universities, including two providers from the University of Colorado. As the in-country Ultrasound Education Director, each provider worked with 12 residents across 5 specialties: Family Medicine, General Surgery, Internal Medicine, Obstetrics-Gynecology, and Pediatrics. 

Because there were 5 specialties, I devoted one day per week to one specialty. A typical day started with rounds, where I would attempt to interject ways in which ultrasound could have aided in the diagnosis or facilitated an intervention of one of the patients. After rounds, I would work with the residents to improve their ultrasound skills and increase their number of scans. Once a week, the Ultrasound Champions gathered for a lecture in the late afternoon to discuss a new application of ultrasound. In the month I was there, I focused on procedural skills such as US-guided IVs and central lines, paracentesis, and regional nerve blocks. 

The course was a resounding success. Even in the time I was there, I saw tremendous growth in all of the residents. I enjoyed sharing my ultrasound skills and learned quite a lot myself in the process. I am certain the Ultrasound Champions are working hard to share their knowledge to the next class of residents. 

Agents of Change: the word from Halima Adam - emergency medicine nurse, Uganda

Dr. Emilie J. Calvello Hynes

The Global Emergency Care Initiative contributed to sponsoring Halima Adam and Violet Mirembe to attend the 2018 African Conference on Emergency Medicine. As described in the November 13, 2018 post by Dr. Jen Bellows, Halima and Violet showed the world during their presentations how implementation of proven low cost solutions with local champions can create great change in emergency care outcomes.

Violet Mirembe presenting her data on before and after the  WHO Basic Emergency Care Course  was implemented in her hospital in 2016.

Violet Mirembe presenting her data on before and after the WHO Basic Emergency Care Course was implemented in her hospital in 2016.

We asked Halima, what were your top 3 contributors to success and ongoing challenges with changing emergency care in Uganda? She answered:
Contributors to success:

  1. Applying knowledge, skills and experience while on duty.

2. Positive attitude towards work.

3. Communicating expectations e.g,helping the team to stay focused and on track.

Challenges:

1. Negative attitude of some staffs towards work and change.

2. Inadequate resources in terms of human, equipments, drugs and sundries

3. Lack of enough skilled health personnel

HalimaPres (1).jpg

Halima Adam at AfCEM 2018

Agents of Change for Emergency Medicine in Africa: Nurses!

Dr. Jennifer Whitfield Bellows

This week found the GECI faculty in Kigali, Rwanda at the African Federation of Emergency Medicine Conference. Despite having been to several international EM conferences in the past, I never fail to be humbled and honored to meet the EM physicians that are on the leading edge of our specialty in Africa, who advocate for their patients to receive high quality acute care even as our specialty still struggles to receive recognition and resources.  

 This time, however, it was a different kind of champion that impressed and humbled me. Nurses. 

Developing and implementing emergency medicine systems - the package of advanced triage processes, provision of essential resources, and training of the staff working in emergency departments – does not happen overnight. A remarkable investment is needed for success: to not only implement the processes but to continue to teach and assess them, and to make sure that they remain in place even as staffing, patient volumes, and resources change. Success relies on months or even years of constant monitoring and re-training. Thus a unique kind of local champion is necessary: a person embedded in the community served by this emergency department, who works there every day and intimately understands the cultural and social nuances that effect patient care. 

You know who does that best?  Yep. Nurses. 

Health care human resource shortages are endemic to many low-resource hospitals; and oft-quoted statistic is the alarmingly low ratio of physicians to 100,000 people. Nurses are also in short supply but thankfully not in the same critically low levels as doctors. By necessity, they often step in to provide duties normally ascribed to doctors, a phenomenon known as “task – shifting”.  

As we saw this week, EM systems development is no exception. Nurses have been the leaders creating and maintaining functional, high quality emergency departments, with results that are nothing short of extraordinary. 

Halima Adam and Violet Mirembe are nurses in the Emergency Department at Mubende Regional Hospital in Kampala, Uganda. From 2016 to 2018, they implemented a comprehensive overhaul of the emergency ward including the following:

1.     Got providers trained in the WHO 5 day Basic Emergency Course.

2.     Defined clear roles for providers.

3.     Instituted a triage system.

4.     Ensured basic essential equipment and medications were available and staff was trained on their use. 

5.     Used pathways and checklists to standardize patient care and ensure safe handoffs. 

As a result, massive improvements were seen. From 2015 to 2018: 

1. Vitals were taken on emergency patients 80% of the time, from 30% in 2015.

2. Essential equipment and medicine stocked 70% of the time, up from 40% in 2015.

3. Mortality dropped in their surgical unit (where the ED is located) by an incredible 50%!

Success of this magnitude is extraordinary, and it is a testament to the dedication, resilience and leadership of these nurses to providing excellent care to their patients. I am in awe. 

Every medical resident has a story about how, at least once (or in my case, like once a week) a nurse saved their patient - by catching an error or recognizing when one is decompensating. If Violet and Halima are any indication, nurses that step in and lead their hospitals through emergency care system reform will save countless more.  

 

Implementation of Emergency Clinical Pathways to Improve Patient Outcomes in Zambia

In March 2018, a team of three emergency medicine residents (Kimberly Hill, Chelsea McCullough, and Jennifer Zhan) and one attending physician (Dr. Jennifer Bellows) traveled to Zambia to begin their journey in implementing clinical care pathways to advance emergency care. The team visited five hospitals and engaged in discussions with local staff as well as officials within the Zambian Ministry of Health with regards to feasibility and applicability of the emergency clinical care pathways that GECI has developed over the past few years.

The story began two years before, when the University of Colorado Global Emergency Care Initiative (GECI) launched a study to develop and implement clinical pathways that would provide a systematic approach to early resuscitation and stabilization of acutely ill patients. The GECI team constructed a list of empirically derived chief complaints from multiple African countries. From those lists, the most life-threatening complaints were extracted, and clinical pathways that were consistent with best practice emergency care guidelines - described in the African Federation for Emergency Medicine’s Handbook on Acute and Emergency Care - were developed. The pathways were organized with consideration of resource levels at multiple different types of hospitals common to low and middle-income countries. They were also made available to providers via a free application available on smartphones, allowing for rapid electronic access using the proven AgileMDä platform.

This trip to Zambia represented the initial fact-finding mission and a foundation for the pilot study to be performed in early 2019. The team visited five facilities and met with local health care providers at each site. These facilities represented a spectrum of facility tiers ranging from primary to tertiary levels of care and all completed the World Health Organization’s Basic Emergency Care Course, which provided an essential foundation of emergency care. The team presented overall project aims and five pertinent adult and paediatric clinical care pathways for review: asthma, sepsis, seizure, cough with fever, and blunt and penetrating trauma. A pre-

determined list of questions regarding the facility, the structure of the local emergency unit (EU), and available staff was then answered by the highest ranking provider available with the goal of informing future implementation strategies and site selection for the upcoming pilot study. Clinicians were also asked to provide feedback on the pathways with regards to applicability, feasibility and appropriateness of the selected pathways.

KasamaGeneralHospitalBlog.jpg

The team was met with tremendous enthusiasm. Zambian providers overwhelmingly agreed that the pathways would be useful in the emergency care setting and feasible to implement with current levels of training amongst emergency staff. The GECI team now prepares for a return trip in January 2019 to begin the pilot study, where they will select two hospital sites to pilot pathway implementation and data collection on process and clinical patient outcomes as well as pathway utilization by providers.

Additionally, the team facilitated the World Health Organization’s Basic Emergency Care (BEC) course at Chongwe District Hospital. The BEC course is clinical training aimed at frontline providers (doctors, nurses, clinical officers) who by necessity provide emergency care at their facilities, but have received little or no formal training in the field. Chongwe District Hospital is the only hospital in the town of Chongwe, serving a catchment area of 200,000 residents. This is the fifth facility in Zambia where the BEC Course has been taught. The course now spans three provinces and includes a total of 146 participants.

ZambiaHappyGroupBlog.jpg

This project was initiated and driven by GECI and the emergency medicine residents at Denver Health who are passionate about advancing emergency care on a global level. The clinical pathways are the culmination of two years of teamwork and collaboration between GECI, the African Federation for Emergency Medicine, AgileMDä, and GECI’s generous donors. As Dr. Jennifer Zhan describes, “This is the beginning of something great. Not only does this project have a tremendous personal impact, it has the capability to influence emergency care in Zambia and potentially the world. That keeps me ticking.”

2018 American Medical Association Global Health Challenge - Team CU SOM

The Khayelitsha township in South Africa lies just 31.6 kilometers from the cosmopolitan Cape Town, yet is profoundly distant in health outcomes, exampled by Khayelitsha’s 2006 under five infant mortality rate that was 342% higher than that of the country’s Southern Peninsula as a whole. Our experience working in the emergency department of Khayelitsha District Hospital powerfully underscored the importance of understanding the constellation of social determinants that define individual health and inform healthcare decision-making. The disproportionate poverty, violence, and disease burden of the townships are underpinned by historical prejudice that has endured as social inequality. This marginalization is not a tragic relic of a bygone era, but rather an artifact being actively preserved and restored in a new light.

Located on the fringe of Cape Town, these townships are an illustration of apartheid’s lasting mark on South Africa. By design, they are amongst the most densely populated places on Earth, resulting in overcrowding that amplifies disenfranchisement through inescapable economic hardship and disease burden. A majority of the trauma that presented to the emergency department was derived from gangs composed of boys with no direction, no other option within an opportunity-barren landscape beget by a lack of community bond, itself a product of the destruction of vibrant communities by apartheid policies. Unquestionably there has been tremendous progress in South Africa; however, 20 years later, there are still sizable inequities that are too blatant to be ignored.

Sitting on the rocks of Clifton beach #3 was a moment that captured the inescapable contradictions at work in South Africa- the setting sun projecting its color wheel over the ocean, splashing on the jettisons of Table Mountain, seemingly in sync with the rhythmic snap of the electric fence placed atop a layer of barbed wire, protecting the perimeter of the beachside mansion behind us. Structural inequality of this nature cannot be tucked away, out of sight in the Cape Flats, Brazilian Favelas, or Southside Chicago.

In Xhosa, the word Khayelitsha means ‘our new home.’ Indeed, outside of the stabbings, assaults, overdoses, and preventable deaths Khayelitsha is home to a community of over one million people, a majority of which just want better lives and greater opportunity for themselves and their loved ones. Healthcare, particularly global health, puts one at the receiving end of a large sieve that has filtered out the communities, relationships, and everything else that composes an individual and presented you- the physician, the nurse, the student, the technician- with someone at their most vulnerable. A transformation toward a more equitable society does not happen overnight; yet, as members of the global medical field, we can help galvanize it by mustering within ourselves the same self-preservation and fortitude exhibited by those who are marginalized.

Content source: https://amaghc.com/2018-finalists/cusom/

GECI in Panama: Introduction to Emergency Medicine course

In June 2017, Panamanian medical students participated in the “Introduction to Emergency Medicine: Tools for the Medical Frontline” course taught by Dr. Martin Musi, Dr. Julia Dixon and Joel Vaughan, EMT, all staff at the University of Colorado. The course was developed in collaboration with and sponsored by the Universidad de Panamá, Facultad de Medicina (School of Medicine). Medical training in Panama consists of 6 years of undergraduate medical school, followed by a required two years of clinical work. The first year is typically at one of the large hospitals on different rotations followed by one year in more rural communities. After this, they may pursue specialty training.  Currently, medical students have limited training in emergency medicine, yet most will spend one of their post grad years in a setting that requires they be adept at recognizing and treating emergency conditions.

Medical student participants in Introduction to Emergency Medicine course

Medical student participants in Introduction to Emergency Medicine course

The weeklong course emphasized a multidisciplinary team approach to management of emergencies. Students participated in lectures, workshops, procedures labs, and simulation-case scenarios that covered topics in trauma, medical, pediatric and obstetric emergencies.

Medical students practice essential trauma skills

Medical students practice essential trauma skills

Joel Vaughan, EMT instructs on IV placement on a low-fidelity model

Joel Vaughan, EMT instructs on IV placement on a low-fidelity model

The Facultad de Medicina has several high fidelity simulators where small groups of students practiced assessing and treating patients with a variety of conditions. Once acclimated, Dr. Dixon notes, the students thrived in this learning environment. The final simulation scenarios took place in the Emergency Department of the teaching hospital, and included residents from the EM Panamanian Residency to round out the realistic team-based approach.