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Running head: RECOVERY OF NEPAL AFTER 2015 EARTHQUAKE 1

Recovery of Nepal After 2015 Earthquake

Katherine F. Sellards, RN

Western Washington University

NURS452 Global Health Inequities and Interventions

Hilary Schwandt, PhD MHS

August , 2017
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Recovery of Nepal after 2015 Earthquake

Nepal is a developing south Asian country landlocked by China from the north and India

to the south. The land is mostly mountainous with some peaks that range from sub-arctic to

arctic temperatures and about one-third of the country is low lands with sub-tropical to tropical

temperatures. Agriculture is abundant in the low lands and valleys, which drives the Nepalese

economy and holds the largest employment sector. Nepal possesses some of the highest

mountains, including Mt. Everest, and is a main attraction for mountaineers and trekkers.

The geographical location of Nepal makes it highly susceptible to earthquake activity and

has sustained several earthquakes, resulting in mass casualties and destruction in the past

century. On April 25, 2015, an earthquake measuring 7.9 hit the Kathmandu valley, killing

nearly 9000 people and injuring approximately 20,000. Densely populated areas in the valley

were greatly affected destroying homes, accessible roads, sanitation systems, clean water sources

and leveling historical architecture. Days and even weeks later, aftershocks continued causing

more deaths and devastation. The difficult terrain and the massive amount of debris made rescue

efforts grueling and somewhat dangerous.

The immediate threats to health and disease prevention, physical injuries, rehabilitation

efforts and the possible long-term psychological impacts of earthquake survivors will be further

reviewed in this paper.

Risks for Infection

Nepal has long endured the dilemma of cholera outbreaks across the region that adds to

morbidity and mortality rates. Cholera is an enteric infection caused by the ingestion of

contaminated food and water sources resulting in sudden onset of severe diarrhea leading to

dehydration and possibly death if not promptly treated. Although cholera and other water and
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food borne bacterial outbreaks have been a continuous health concern in Nepal, they are without

pertinent resources for laboratory testing and inspection strategies to locate the sources and route

of transmission of the outbreak (Dixit et al., 2014). Some regions of Nepal lack substantial clean

water sources and proper sanitation infrastructure and when natural disasters occur it can result

in devastating structural damages which can kill and displace thousands of people, making the

spread of disease a greater health concern.

In an article discussing the risk of infection after earthquakes, Bagcchi references a

World Health Organization report that states that because this earthquake stricken area is already

at risk for disease, and when compounded with the loss of clean water sources, adequate toileting

facilities and remains of bodies not being immediately removed, the risk for the spread of disease

exponentially increases (2015). Bagcchi corroborates those findings in an interview with

Mariana Palavra, UNICEF spokesperson, which also states that when access to clean water is not

available, people will seek out other sources of water, such as rivers or streams, to drink from

that may have been polluted with sewage or other contaminants possibly from damaged

sanitation systems and the delayed removal of human and animal remains thus, increasing the

risk for disease (2015). Palavra also stated that the upcoming monsoon will further aggravate

the situation, especially for vector-borne diseases such as malaria, dengue chikungunya, and

Japanese encephalitis since Nepal and the earthquake-affected districts are already at risk for

these diseases (2015, p. 770). In a personal communication between Dr. Anup Bastola, STIDH,

and Prativa Pandey, Pandey explained in a correspondence letter, dated three months after the

earthquake, that in three districts, twenty-nine cases of Cholera have been documented and are

being attributed to the consumption of polluted water, poor sanitation and living in heavily

populated areas where infections can quickly spread (2015).


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In the hard hit, remote districts where travel was already difficult, the destruction from

the earthquake paralyzed communities, making travel even more difficult and seeking out of

much needed medical treatment nearly impossible to obtain. Not only were emergent healthcare

services delayed, but also preventative care, placing more vulnerable populations such as

expectant mothers, children and the elderly at higher risk for communicable diseases. Another

disease outbreak that is cause for concern among the most vulnerable populations is Hepatitis E,

which is also common in Nepal. It was estimated by a group of infection disease experts that up

to 500 pregnant women could succumb to a Hepatitis E infection (Basnyat et al., 2015).

Trauma

The Kathmandu Valley is a densely-populated area of approximately one million people,

rich in history and ancient architecture. Unfortunately, this district was the one of the hardest hit

earthquake stricken areas, which resulted in collapsing buildings and destroying historical

landmarks. Because of toppling buildings and flying debris, many people in these areas have

sustained major bodily injuries. From research conducted on previous earthquake destruction, it

is predicted that most injuries will result in fractures, burns, soft tissue injuries, traumatic brain

injuries and spinal cord injuries (Zhang et al., 2014). A WHO report (as cited by Sheppard &

Landry, 2015) states that In total, approximately 18,5000 people were injured in both major

tremors, of them approximately 6% suffered spinal cord injuries (SCI), 2% had amputations, 4%

sustained traumatic brain injuries (TBI) and the mass majority (approximately 70%) of the

injuries were fractured. Data collected regarding spinal cord injuries revealed that of the one

hundred and fifteen patients presenting to one spinal cord injury rehabilitation hospital, most

spinal cord injuries occurred in women compared to men and that the most frequent type of

injury recorded was incomplete paraplegia (Groves, Poudel, Thapa, & Baniya, 2016).
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In addition to neurologic and musculoskeletal injuries, several earthquake victims sought

treatment for ocular traumas at the Tilganga Institute of Ophthalmology (TIO) in Kathmandu.

Initially, there were approximately sixty patients that presented to the TIO, which had suffered

ocular injuries, presumably from falling earthquake debris. Of those cases, chief ocular

findings at the time of presentation were blurring of vision (35 cases), red eye (15 cases), cut

injury (5 cases), diplopia (3 cases) and a foreign body (1 case) (Pradhan et al., 2017, p. 2).

Additionally, closed globe, open globe, and corneal ulcerations were injuries that were found to

be the most common among ocular injury victims, some of them having to undergo surgery to

save the eye itself and the vision. However, none of the victims were stricken with bilateral

vision loss (Pradhan et al., 2017).

Psychological Impact

For the victims of the Nepal earthquake, after the realization of the destruction of their

homes, communities, markets and cultural monuments begin to set in, overwhelming emotions

can begin to emerge. Although, there is not much research that has been done regarding the

psychological aspects of the Nepal earthquake, an evaluation of sources related to post-traumatic

stress disorder and depression from past earthquakes in other regions will be reviewed.

Studies conducted after a major earthquake in China, the Wenchaun earthquake of 2008,

evaluated the prevalence of post-traumatic stress disorder in adolescents. In one such study,

research concluded that the severity level of PTSD and depression symptoms among adolescents

is dependent upon the level of damage to homes, injuries to self and family members or being a

direct witness to earthquake destruction (Zhang et al., 2011). Goenjian et al., further

corroborates these findings by stating that the youths that were exposed to more graphic images

of the earthquake destruction experienced more PTSD symptoms than those who did not have
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direct exposure (2011). Other factors that were found in predicting the level of PTSD and

depression symptoms were being female and belonging to a multi-child home. Reasons found

for this are that females presumably have different coping mechanisms for managing emotions

and are of a lower socioeconomic class (Zhang et al., 2011). Furthermore, it was also concluded

that females have experienced reminders of the earthquake more frequently than males causing

more symptoms of PTSD (Goenjian et al., 2011). It was stated, that the possible reasons that

children with siblings were found to be experiencing more symptoms were due to the parents

being less attentive in comforting all the children as opposed to just one (Zhang et al., 2011).

Additional studies evaluating PTSD and depression in adults and the elderly show similar

results to the effects on adolescents. In the adult and elderly population, females were found to

have a higher prevalence of PTSD and depression symptoms, level of symptoms were dependent

upon whether there was a direct or indirect exposure to earthquake destruction, injury to self or

to family members and socioeconomic class (Zhang, Shi, Wang, & Liu, 2011; Guo, He, Qu,

Wang & Liu, 2017). It was suggested that the elderly may be more at risk for a higher

prevalence of psychological disorders due to decreased sensory and motor function, poor

physical health and low socioeconomic status may further decrease the ability of the elderly to

cope with disaster and to resume a normal life (Zhang, Shi, Wang & Liu, 2011, p. 62).

Preparing for Recovery

Many sources were reviewed regarding recovery, rehabilitation and emergency

preparedness to learn more about the suggestions put forth that would help emergency workers to

prepare for future natural disasters. In saying that, there are some situations that could remain

problematic, such as the rural districts of Nepal that even under normal circumstances are

difficult to get to and in the event of landslides makes rescue work more unmanageable. In
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response to the risk for spread of infections, particularly from water borne sources and/or oral-

fecal routes, one should steer clear of drinking from water sources that may be at risk for being

contaminated. Pandey (2015) suggests that water should be boiled or treated to prevent an

outbreak of a bacterial infection and that bottled water would be a better choice if available.

However, since access to bottled water can be somewhat difficult to obtain, the addition of

certain agents to water, such as chlorine and potassium permanganate tablets, could be used to

disinfect water (Gulland, 2015). Bagcchi (2015) also endorses the use of these agents for water-

purification as well as the simple preventative measure of hand washing. Observing the basic

practice of hand washing would reduce the spread of infections, especially in cases where

displaced citizens are living communally in temporary shelters because of the loss or instability

of their homes. Additionally, the establishment of rapid response teams for early detection of

potential outbreaks and alerting those in high-risk areas would decrease and control the spread of

pathogens (Bagcchi, 2015). Furthermore, the use of vaccines, notably for cholera and Hepatitis

E are highly recommended for early prevention when outbreaks have been detected.

The destruction of homes and overcrowding of shelters then leads to lack of adequate

toileting facilities to serve the mass population. It was suggested that to reduce the threat of

transmission, the emergency relief workers must ensure proper sanitation by placing adequate

number of mobile toilets, digging trench and pit latrines for safe excreta disposal (Gulland,

2015, p. 2).

Immediate responses to natural disasters are demanding on emergency service workers,

hospitals, health care workers and essential medical resources needed to care for the victims in

need of emergent care and the number of injured far outweigh the resources that are available.

This is true, not only in the immediate aftermath of the disaster, but also in the long-term care of
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people that have sustained lasting disabilities from their injuries. In the aftermath of the Nepal

earthquake, researchers are endorsing the importance of rehabilitation services for those

recovering from physical injuries sustained in the earthquake. Landry, Salvador, Sheppard and

Raman (2016) examine how initiating rehabilitation in the early stages of recuperation can

support a better management of patient flow through hospitals from the time of admittance to

discharge, decreases the chances of secondary complications and facilitates patients adjusting to

a new disability. However, Landry et al. (2016) does point out that Nepals infrastructure was

difficult for people with disabilities to maneuver before the earthquake and for the rehabilitation

process to be effective, the rebuilding of the environment must be supportive of the newly

disabled.

Rebuilding and repairing infrastructure and physical rehabilitation of injured patients are

critical for the future of Nepal, however the psychological aspects cannot be overlooked. It is

important to note that with any healthcare treatments, incorporating the patients cultural,

spiritual and religious beliefs within the plan of care is a beneficial aspect of healing. For

instance, someone with a strong cultural, spiritual or religious background may have more of a

support system, or overall faith, that will offer comfort and will guide them through their

emotional recovery. Researchers conclude that post-disaster psychological assistance should

respect cultural and religious belief. Because religion is a central part of Nepalese culture,

integrating consideration of religious beliefs into the psychological assistance for survivors may

facilitate the relief work (Hu & Su, 2015, p. 353). Zhang et al. (2012) continues this idea by

proclaiming that not only is culture-specific interventions necessary for emotional healing, but

that early introduction of the interventions is necessary to decrease the symptoms of depression

and PTSD. As stated earlier, there is limited research focused on the psychological impact from
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the Nepal earthquake. Nevertheless, researchers from prior studies agree that continued research

regarding long-term effects of mental health after natural disasters should be conducted to assess

and expedite the emotional healing process of the survivors and as a nation (Guo et al., 2017;

Zhang et al., 2012; Goenjian et al., 2011).

Conclusion

The amount of devastation in the wake of the earthquake reaches far beyond what could

be covered in this informative paper, which highlighted only a few health risks, physical injuries

and possible psychological impacts endured by the survivors of the earthquake. To review, early

detection of infectious diseases and educating people on avoiding questionable drinking sources

would greatly reduce spread of pathogens. Impressing upon the importance of how early entry

into rehabilitation services would facilitate recovery from physical injuries and integration of

newly disabled people back into the community. Lastly, increasing the awareness of the

psychological impacts on survivors, how PTSD symptoms can be delayed up to a year after the

event and the need for continued research on long-term effects.


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Basnyat, B., Dalton, H. R., Kamar, N., Rein, D. B., Labrique, A., Farrar, J., & Piot, P. (2015).

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Groves, C. C., Poudel, M. K., Thapa, B. P., & Baniya, M. M. (2016). Spinal cord injuries related

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