Published On August 5, 2015
WHEN THE 7.8 EARTHQUAKE HIT NEPAL LAST APRIL, it killed nearly 9,000 people and left hundreds of thousands injured, homeless or lacking basic services. The global medical community quickly arrived in the Himalayan country, a force that included many from Massachusetts General Hospital, some of whom published accounts of their experiences (see, for example, accounts from Renee Salas and Annekathryn Goodman).
Two members of the MGH Center for Global Health—Miriam Aschkenasy, a physician and deputy director of global disaster response, and Jacqueline Nally, a nurse practitioner and disaster response manager—were part of that effort. They offer their thoughts on the global response, based on more than 35 years of combined experience in disaster zones around the world.
Q: What’s the hardest part of delivering care at a disaster site in the developing world?
Miriam Aschkenasy: You have to keep reminding yourself that our standards are not their standards. The goal is not to export western care. So part of doing humanitarian work abroad is understanding that you cannot take the same approach you would at home.
Jacqueline Nally: For instance, in the United States we tend to treat pneumonia with very expensive broad-spectrum antibiotics. But because there are limited resources available in Nepal and other emergency relief areas, and a large population in need, we treat pneumonia with a very low-cost antibiotic. But because the Nepali people do not have the same resistance to drugs as we do, these simpler measures often have a greater effect.
Many of us find that switch emotionally challenging. Luckily, Médecins Sans Frontières [Doctors Without Borders] publishes a document that outlines clinical guidelines for diagnosis and treatment in disaster relief, which is supported by the World Health Organization. That helps medical providers feel more comfortable making decisions they may find ethically difficult.
Q: When you arrived at the villages, what types of medical issues did you see?
Aschkenasy: The first couple weeks we were still seeing earthquake victims—crush injuries and broken bones that hadn’t been attended to. Rebuilding efforts in the ruins also caused a number of injuries. As we got to the end of the third week we saw more of the emotional impact—people not being able to sleep at night, stress due to the coming rainy season, as well as depression and frustration related to the struggles of how to rebuild.
Nally: A significant proportion of our work also focused on primary care. This is a population with limited access to routine health care. We also monitored diarrhea and other gastrointestinal diseases that can occur after an incident like this because of hygiene issues and water contamination.
Q: Do you find different attitudes toward medicine?
Aschkenasy: In any type of disaster where relief comes from outside, there will be differences between those who deliver care and those who receive it. Part of your job is building trust with the community.
Nally: We had an incident where there was a motorcycle accident, and the local health care worker gave medications that we felt were not the best treatment. But we had to support the worker’s decision, because if we had imposed our standard of western medicine, he would have lost the respect of his village. You cannot step over that line. These are his patients; this is his home. They are the authority that we fall under.
Aschkenasy: You have to remind yourself that we are not there to do what we think is best. We are there to provide a service that they need and have asked us to do.
Nally: That also can mean working with practitioners of traditional medicine. A few patients came in with a wound prep provided by their local healer. To his credit, this remedy worked wonderfully as far as covering the wound and stopping the bleeding. And after a week or two when it was removed there was no infection. The plants and herbs that he used actually have coagulation benefits in them.
Q: What do you bring back home after an experience like this?
Nally: This work is really rewarding. I have amazing respect for my fellow team members and have formed bonds that will last a lifetime. And I find it helps me in my clinical practice. When I work in the emergency room, my assessment skills are stronger, I am less dependent on technology, and I am less frustrated when someone comes in expecting more than we can provide.
Aschkenasy: You learn a lot about what a care team is. When you arrive on one of these scenes, it’s hard for physicians and nurses to understand that clinical knowledge is actually secondary to the ability to be patient, flexible and team oriented. You often have to perform any function that the team needs—from dressing wounds to cooking dinner. In the end having clinical skills is great, but what I’ve found I admire most is someone who can pitch in.
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- When Disaster Strikes
The best intentions don’t always add up to a fast, effective medical response. A multidisciplinary approach could help.