Interested in #globalhealth & disaster relief? Attend Dartmouth’s #NepalEarthquakeSummit Feb 18-20. See schedule: https://t.co/sARW1fodnp

— Dickey @ Dartmouth (@DartmouthDickey) February 10, 2016

Abstract

On February Nineteenth, 2016, students, professors, anthropologists, and representatives of Nepal convened at Dartmouth College for the Public Health Responses to the Earthquake Panel within the Nepal Earthquake Summit. Nepal’s Public Health sector was well-represented, as representatives practiced and acquired a mastery of public health response from prestigious hospitals, medical schools, undergraduate institutions, and/or hands-on experience in Nepal. In their presentations, the panelists described core issues pertaining to the public health response after the Nepal Earthquake in 2015, issues including the lack of transportation-based and health-based infrastructure as well as the deficit of affordability and accountability of public health aid in Nepal. The goal of the panel was to not only inform the audience of the form & function of the public health response to the 2015 earthquake in Nepal, but also to facilitate an open discussion for analysis, inquiries, and insights to assist in the formation of future protocol.

Background and Historical Context

There are two general categories of health care practices in Nepal – modern medical care and traditional, folk medical care which relies on shamans. In many cases, the ill seek a combination of both forms of aid. Modern medical services in Nepal are centralized to large cities. Many families will go to modern medical facilities if available and accessible to them, however there is an absence of modern medical care and social services in rural areas. This can be attributed to the fact that geographical limitations play a large role in Nepal’s social and economic situation. In the aftermath of the Nepal earthquakes, this became a salient issue widely discussed and debated by public health organizations as they worked to formulate a long-term sustainable plan for public health care in Nepal.

Ethnography

Ian Speers, Earthquake Preparedness in Nepal

Ian Speers, a student studying anthropology at Dartmouth College and a member of the Dartmouth Coalition for Global Health, presented on the Earthquake Preparedness in Nepal. Speers discusses the limitations of infrastructure practices in Nepal, communications and coordination protocol, health care infrastructure, mental health, and education and training of earthquake preparedness in Nepal schools and institutions.

From the beginning of his presentation, Speers acknowledges how geographical determinism is the driving factor behind weak and unstable earthquake preparedness of Nepal. Scientifically, Nepal sits atop a highly vulnerable region of the earth where the Indian plate constantly pushes against the Eurasian plate, thus resulting in an 11th place ranking of seismic vulnerability throughout the world. Like a domino effect, the geographical vulnerability of Nepal manifests itself in vulnerable infrastructure, and vulnerable infrastructure leads to poor communication and enforcement of government law and emergency protocol extending to rural areas (for example, the communication of seismological warning via radio and the enforcement of building codes). Indeed, a more effective model of transportational infrastructure must be implemented to facilitate an effective route of communication and coordination between the large number of public health officials in Kathmandu and the rural regions of Nepal.

Speer’s urge for the development of University level disaster management classes illuminates a structure versus agency framework. In order to improve the efficacy of aid at the local level, Nepal must have local first-responders who are adept in the practice of disaster management and emergency response, and in order to develop proficient local first-responders, University students of Nepal must be willing to stay in Nepal rather than relocate elsewhere in search of new opportunities.

Among the challenges in regard to communication and coordination that Speers mentions, the unequal distribution of foreign aid is perhaps the most vital to address. Rural areas in the Kathmandu Valley are most vulnerable to earthquake disasters, yet health care services are primarily funnelled into larger communities, such as the city of Kathmandu. The lack of infrastructure in these marginalized areas and damage to roads that were already in poor conditions prior to the earthquake subsequently mean central communities receive medical aid before the peripheral do.

S.P. Kalaunee

S.P. Kalaunee, from Achham Healthcare, spoke on plans for long-term sustainability of medical services and healthcare in Nepal. He stressed that such a plan necessitates both affordability and accountability, and further discussed what his organization had provided insofar and what has yet to be implemented along those terms including medical practitioner training, a supply chain supported by the Nepal government, and reconstruction of health posts.

Achham Healthcare’s massive expansion of employees and healthcare infrastructure exposes the structure versus agency framework among aspiring Nepali healthcare professionals. A repetitive trend in Nepal is for Nepali medical practitioners to migrate elsewhere in search of occupational opportunity. However, Accham Healthcare’s installment of over 130 full time public sector employee positions and Care Delivery system among thirteen clinics and 165 health-care workers invites Nepali medical practitioners to stay in Nepal and serve their native country. Indeed, in order for Accham Healthcare’s Initiative to operate efficiently and effectively, Nepali medical practitioners must cease their migrational trend and stay within Nepal’s borders.

Bijay Acharya

Bijay Acharya from the Massachusetts General Hospital discussed the realities of the immediate foreign aid responses to the earthquake in Nepal. Having assisted on one of the two public health teams representing Mass General Hospital’s Global Health sector in Nepal, Acharya spoke on the lack of coordination of NGOs (non-governmental organizations), imbalanced distribution of foreign aid resources, improper healthcare regulations, and the overall chaos during efforts to provide medical aid and services to communities in Nepal.

Geographical determinism is a critical component behind the imbalanced distribution of foreign aid resources in Nepal. Indeed, geographical determinants stymied Acharya’s team from providing essential aid to rural areas located at the earthquake’s epicenter. As the earthquake wiped out the already limited number of routes leading to these rural villages, Acharya and his team were unable to travel on the naturally tumultuous terrain. Due to geographical obstacles augmented by the earthquake, Acharya’s team had to rely on monetary donations to acquire a helicopter to reach the rural village of Ghorka. Chaos ensued in Kathmandu as an overwhelming amount of incoming public health aid was geographically barricaded within the city’s borders.

Bijay Acharya provides another reason behind the unequal health care distribution (an issue Ian Speers priorly mentioned) in Nepal. He remarks that although there was a proliferation of foreign aid in Nepal after the earthquakes, there was also a lack of harmonious convergence and proper planning, leaving local and foreign health care services in disarray when they arrived. Many organizations were so focused on providing immediate medical aid that they failed to provide forethought towards the logistics of sending over health care workers and resources. When they arrived, some realized that they were unable to actually provide medical aid because they did not speak the Nepali language or, for those who only sent over only medics and emergency response personnel, there was a lack of proper medication. Most of what was available were either narcotics or expired medication. Improper management of health care services lead to confusion. Medics and other emergency response workers would fly out to rural communities only to find that there were already other organizations in the area. Sadly, due to the ensuing chaos, many rural communities received no foreign aid.

Acharya remarks that improper healthcare regulations took the form of posts on social media of Nepali patients without a doctor’s consent. Analysis within a structure versus agency framework raises the question of whether public health aid arrived in Nepal for the correct reasons: are public health officials posting pictures of victims of the earthquake in an attempt to boost their self-worth, or are they in Nepal to genuinely provide crucial medical assistance to victims of the earthquake? In other words, does a need to validate self-worth via social media cloud the ability to provide effective, positive aid?

Bijay Acharya mentioned that traditional healers are now in high demand as a result of the earthquake. This is likely due to an overall lack knowledge of western techniques of medicine among the masses, coupled with a strong sense of spirituality amongst Tibetans along with their strong sense of ethnic identity. This is interesting because it shows that there is traditional infrastructure in place which has functioned for many years, yet the western world would consider these methods inferior to western medicine. This both shows the large scale of devastation of the earthquake and the beliefs of the Tibetan people in this time of need. Traditional medicine thrives where modern medicine fails both due to a lack of knowledge and supplies of western medicine and and a strong sense of ethnic identity which leads people to look to healers since they are both Tibetan and available, two factors which most aid workers lacked following the earthquake, yet two important factors considering Tibetan identity and their choice to lean on traditional ways both because they need to and they want to as both an opposition and precaution to western medicine.

Shreya Shrestha and Daniel Albert, Dartmouth Response

The final presentation was given by Shreya Shrestha from Dartmouth’s Geisel School of Medicine and Dr. Daniel Albert from Dartmouth Hitchcock Medical Center who spoke as representatives of Aasha for Nepal. They discussed health and humanitarian relief and Aasha for Nepal’s approach to relief in Nepal which was centered around health, shelter, and supplies. Additionally, they both gave personal recounts of their time spent in Nepal after the earthquake. Shreya Shrestha worked on giving on-ground needs assessments, and both worked with a mobile clinic.

Much of the panel was focused on international aid to Tibet, specifically Dartmouth through Aasha for Nepal. The presentation by Aasha for Nepal brings to question the relationship between Tibet and the western world. Throughout western history Tibet has been viewed by the west as mystical, peaceful and romanticized. This has been a perpetuation of Shangri-la and peace. These stereotypes of the peaceful land of Tibet, however true they are was suggested to influence the aid provided to Nepal by the western world when Dan Albert mentioned the effect of his influences in Tibet shaped his desire to help the land which he had a strong emotional connection to. Concerning western perceptions of the eastern world, including Tibet, we look to orientalism. Orientalist theory might suggest that this perception of Tibet as a Shangri-la or a peaceful place where westerners desire to be and be like is a perpetuation of stereotypes which I would suggest are neither completely positive or negative. This can be seen as Tibet received so much foreign aid from NGO’s and other countries due to the good relationship between Tibet and the rest of the world.

Panel Discussion

When the panel opened up for discussion, commentary was made on issues of resource constraints and lack of staff in Nepal after the earthquake. A Dartmouth group, Dartmouth for Nepal, questioned the panelists, asking for advice on what smaller organizations such as theirs could do now to help and what they believed to be viable long-term solutions.

Significance

This panel was particularly important in understanding the complex relations between the people, the government, western aid, Tibetan interpersonal relationships and infrastructure which all came to light in the wake of the earthquake. This panel was important in understanding the earthquake because following the earthquake, the infrastructure of Nepal was strained and pushed to its limits in many facets. This shows the relationship between the people and the government and brings to question what shapes this relationship since when disaster strikes people expect direct action by the government and the structural systems which are meant to serve the people in a time of need. Understanding the difficulties providing aid and public health due to geography and lack of optimal infrastructure is important in understanding just why it is so crucial that there is a conversation about how to minimize damages and losses when the next big earthquake hits the earthquake prone country. The public health panel also was very important for understanding the relationships between people when disaster strikes. This speaks to the cultural traits of Tibet which both influenced how the people reacted to the disaster and how westerners reacted as well. The main reason why this panel was important was because it spoke to what can be done to help more people in the future through highlighting shortcomings, highlights, structural systems and limiting factors in the minimization of damages and losses anticipating the next big earthquake.

Core Issues

The core issues established during the Public Health Response Panel of the Nepal Earthquake Summit encompass geographical, infrastructural, and socioeconomic factors. Geographically, Nepal is extremely susceptible to earthquakes, for underneath the arid soil of Western Nepal the Indian plate constantly pushes against the Eurasian plate. Due to the inevitability of another earthquake occurrence in Nepal, improvement of public health response must be implemented in order to safeguard Nepal against the inescapable forces of nature. Furthermore, the essentiality of the improvement of disaster relief efforts in rural, marginalized areas of Nepal was a common theme addressed during the panel presentations. Indeed, this issue includes the improvement of both transportational and healthcare infrastructure, the implementation of disaster preparedness programs in communities and universities, improved modes of communication outstretched to marginal villages, and facilitated communication among NGO’s. Finally, Public Health Aid in Nepal must discover a way to keep resources and health-care workers in Nepal; in order to maximize the affordability and accountability of public health aid, officials, workers, and volunteers must foster a healthy and efficient collaboration with the local government of Nepal. Furthermore, the strengthening and expansion of health care facilities and opportunities within Nepal must take place in order for Nepali students to stay in Nepal and not migrate elsewhere.

Discussion Questions

How can smaller non-profit organizations or individuals do to help provide medical aid and reconstruct healthcare services in Nepal?
Concerning the Interplay between infrastructure and public health response, clearly a massive renovation of Nepal infrastructure must take place in order for public health aid to reach rural areas in an effective, timely manner: will this cause the further spread of industrialization to Nepal?
Is there a way to preserve the cultural-identity of rural Nepal while simultaneously introducing transportation-based infrastructure?
Considering the fact that another earthquake is guaranteed “the big one”, what must happen to minimize the damages and costs following the next earthquake? Would this require a forfeiting of ethnic identity and tradition, or could this be achieved while simultaneously conserving Tibetan culture?