Abstract
The frequency of natural disasters appears to be mounting at an alarming rate, and the degree to which people are surviving such traumatic events also is increasing. Postdisaster survival often triggers increases in population and individual disability-related outcomes in the form of impairments, activity limitations, and participation restrictions, all of which have an important impact on the individual, his or her family, and their community. The increase in postdisaster disability-related outcomes has provided a rationale for the increased role of the disability and rehabilitation sector's involvement in emergency response, including physical therapists. A recent major earthquake that has drawn the world's attention occurred in the spring of 2015 in Nepal. The response of the local and international communities was large and significant, and although the collection of complex health and disability issues have yet to be fully resolved, there has been a series of important lessons learned from the 2015 Nepal earthquake(s). This perspective article outlines lessons learned from Nepal that can be applied to future disasters to reduce overall disability-related outcomes and more fully integrate rehabilitation in preparation and planning. First, information is presented on disasters in general, and then information is presented that focuses on the earthquake(s) in Nepal. Next, field experience in Nepal before, during, and after the earthquake is described, and actions that can and should be adopted prior to disasters as part of disability preparedness planning are examined. Then, the emerging roles of rehabilitation providers such as physical therapists during the immediate and postdisaster recovery phases are discussed. Finally, approaches are suggested that can be adopted to “build back better” for, and with, people with disabilities in postdisaster settings such as Nepal.
The relative number and overall financial costs of global natural disasters appear to be rising at an alarming rate. Leaning and Guha-Sapir1 reported that there was a 3-fold increase in disasters globally between 2000 and 2009, as compared with 1980 and 1989, and Aliyu2 reported that the cost of humanitarian responses to disasters approached $17 billion (US currency) in 2005. In recent years, there has been a series of major earthquakes in several different countries, including, but not limited to, Haiti (2010), Japan (2011), Philippines (2012), Pakistan (2013), and China (2014), that have garnered much public attention, not only because of the scope of the calamities, but also because of the scale of the global community's humanitarian response.3–8 A recent major earthquake that garnered the world's attention occurred in a small, landlocked, and low-income country nestled between 2 of the world's largest populations and growing economies. Nepal is bordered by China to the north and by India to the south, east, and west and has a population of almost 28 million people. To provide perspective, Nepal's population is similar to that of Texas within the surface area roughly equivalent to the state of Illinois. However, unlike Texas or Illinois, about 80% of Nepal's population lives in rural areas and depends mostly on subsistence farming for their livelihood. Nepal is considered one the poorest countries in Asia, and ranks 145th out of 187 countries on the United Nations Development Programme's Human Development Index, placing it in the bottom quartile in terms of international development standings.9
The same robust geologic forces that give rise to Nepal's majestic Himalayas also create one of the most active earthquake regions on Earth. Scientists have predicted for decades that the escalating tectonic and geological pressures located miles beneath Nepal's surface would, at some point, reach a breaking point and result in a major earthquake10,11; these predictions were tragically realized in the spring of 2015. On April 25, 2015, in the Gorkha district, and then again on May 12, 2015, in the Sindhulpalchok district, earthquakes registering 7.8 and 7.6, respectively, unleashed tremendous physical damage and human carnage.
The epicenter of both earthquakes occurred at the periphery of the capital city of Kathmandu (Fig. 1) in what is known as the Kathmandu Valley. The structural damage was tremendous, as buildings, bridges, roads, and other components of Nepal's infrastructure crumbled during the tremors and the aftershocks. Although infrastructure can often be replaced or rebuilt, the same may not be true from a humanistic and humanitarian perspective.
Relationship between location of Kathmandu and the series of earthquake(s) and aftershocks. Reprinted with permission.
The United Nations estimated that close to 9,000 casualties and 20,000 injuries resulted from the earthquakes.12 The majority of the injured and affected communities were located in rural and remote parts of the country, which made recovery efforts exceptionally challenging immediately following the earthquake and during the torrential monsoon rain season that closely followed the disaster. In the spring and summer of that year, the cascade of disaster-related structural and architectural damage, alongside political turmoil related to a new constitution and nationwide demonstrations, created significant logistical complications. These complications included deploying humanitarian aid, transporting building materials and equipment, and mobilizing people to and from the affected areas. Even at the time of writing this perspective article, a 4-month fuel crisis had just ended, but had seriously obstructed the winter preparedness in shelters where the displaced and affected people resided in the mountains. This meant that many families endured the harsh Himalayan winter under tarpaulins and other makeshift structures (Fig. 2).
Winter in the Kathmandu Valley (courtesy of Sundip Gurung, Institute of Medicine).
Changing Profile of Earthquake Survivors
The often gruesome images of survivors and disaster landscapes frequently hide the reality that survival rates after disasters are improving.13 Technical advances in field medicine have meant that greater lifesaving interventions can be achieved in the field, and relatively easy access to antibiotics has meant that postinjury infections can often be controlled. However, “survival” rarely translates to a return to pre-earthquake health status for many survivors due to the development of impairments and lifelong disabilities. The mechanisms of injury subsequent to earthquakes are fairly predictable and include being crushed by collapsing buildings and debris and falling from buildings and structures; as a result, the vast majority of acute injuries after an earthquake tend to be orthopedic and neurological in nature.14–17 Rathore and Gosney18 suggested that a decade after the 2005 Pakistan earthquake, trauma resulting in spinal cord injuries, traumatic brain injury, and peripheral nerve injuries figured highly among the causes of long-term disabilities among survivors. Beyond the musculoskeletal and neurological context, there is increasing evidence to suggest that mental and psychosocial aspects are an additional challenge in terms of long-term recovery and integration.19–22
Disasters Amplify Predisaster Disability Rates and Rehabilitation Challenges
The absolute and relative numbers of people living with disabilities are increasing internationally. People with disabilities, especially those living in rural or lower resource communities, often experience important challenges in accessing services. When the rural and lower resources community experienced natural disasters, the number of individuals with newly acquired disabilities is added to the existing number, and the net overall effect is a spike in disability rates. Thus, it can be speculated that disasters amplify predisaster disability-related rates and create a concomitant increase in the need for services. This ultimately widens the gap between need for services and the availability of financial and human resources to meet that need.8 The unfortunate irony is that natural disasters tend to occur in some of the poorest communities and countries where there is little infrastructure, governance, or regulation to effectively manage the surge in rehabilitation demand or efficiently deploy scarce resources to address injuries and disability-related outcomes of disasters. Hence, the spike in postdisaster disability rates, alongside the fairly weak rehabilitative infrastructure, creates an important gap in demand and supply for services with detrimental population and public health outcomes. It is this “gap” between the demand and supply for health and rehabilitation services that emerges in the aftermath of a disaster that sets the stages for the global community, and a constellation of local and international nongovernmental organizations (NGOs), to enter the scene to balance the supply-demand disequilibrium, all with the goal of reducing disaster-related disability in the short term and long term.
Lessons Learned in Nepal That Can Improve Disability and Rehabilitation Outcomes in Future Disasters
The rising number of disaster survivors with impairments, activity limitations, and participation restrictions has set the foundation for a progressively increasing recognition of the importance and utility of rehabilitation intervention early in the emergency response.23 Evidence is emerging to suggest that earlier inclusion of rehabilitation in disaster settings can create positive outcomes, including (but not limited to) fewer acute and long-term complications, decreased length of acute hospital stay, improved functional outcomes, and better community reintegration of survivors.24,25 Although full integration of rehabilitation concepts and providers at the forefront of emergency response is yet to occur, a pathway forward has been demonstrated by a recent World Health Organization (WHO) initiative to establish a set of standard guidelines for foreign medical teams regarding the integration of rehabilitation as part of their activities.26
Given our collective experience in the disaster response in Nepal, we suggest that there are clear and specific actions that can be taken by the rehabilitation sector in the area of disaster preparedness and disaster response to minimize the impact of natural disasters on short-term and long-term disability. In this perspective article, we articulate some of the humanitarian actions that were taken by the disability and rehabilitation sector in preparation for a natural disaster in Nepal, which we have articulated under the heading “Before: How Disaster Preparedness Can Minimize the Impact on Disability-Related Outcomes.” We also discuss actions that were taken in the immediate aftermath of the earthquake under the heading “During: How the Rehabilitation Sector Can Mitigate Disability in the Immediate Emergency Response to Disasters.” We then outline actions that were taken in the months after the earthquake to address rehabilitation needs, under the heading “After: Use the ‘Building Back Better’ Principles to Create a Better, Safer, and More Accessible Environment for People With Disabilities.” We end by proposing a way forward to building a better, safer, and more accessible community for people with disabilities in postdisaster settings such as Nepal.
Before: How Disaster Preparedness Can Minimize the Impact on Disability-Related Outcomes
Prevention and preparation are key to minimizing the health and disability outcomes in a disaster zone. In this section, we outline a series of disaster preparedness steps that were taken and yielded positive outcomes and areas where further preparedness would have been useful in minimizing disability-related outcomes.
Develop and implement standardized disaster preparedness planning and response protocols.
Mass casualty management plans (MCMPs) are disaster planning, preparedness, and response protocols developed in the event of a disaster or other forms of mass casualty scenarios. The chaotic moments immediately after a natural disaster are clearly not an effective time in which to begin to prepare and plan for a coordinated and effective emergency response; nonetheless, until only recently this has been the rehabilitation sector's general approach in postdisaster settings. Many of the MCMPs in Nepal were focused on the urban sprawl of Kathmandu, when in reality the epicenter of the 2015 earthquakes were in very rural and remote villages where the country's infrastructure and population were most vulnerable. Many of the declared 14 highly affected regions were virtually unreachable; some villages were accessible only by foot or by helicopter following the earthquake.
Given that Nepal was at high risk of an earthquake, the national government and some NGOs developed MCMPs in the event of a disaster or other events with mass casualties. However, much of the rehabilitation-related planning was developed somewhat in isolation from the larger mainstream disaster preparedness and planning. Although it is difficult to demonstrate empirically, it appears that disability disaster preparedness and planning, regardless of how uncoordinated or disjointed they may have seemed at the time, minimized the earthquake's impact from a disability perspective. The framework of disability disaster preparedness planning is rather complex to fully describe here; however, the overall strategy was to provide training to rehabilitation staff and responders regarding emergency rehabilitation response, create a triage network to inform and deploy rehabilitation staff in the event of a disaster, and stockpile an ambulatory aid and devices equipment cache ready for distribution.
This disability disaster preparedness planning was enacted immediately following the Nepal earthquake to ensure that injured individuals would receive not only acute medical care but also rehabilitative care to minimize disability. The strategy of stockpiling rehabilitation equipment and assistive devices for such an event was one of the success stories that emerged from the tragedy. According to Pokhrel,27 prior to the earthquake, a stockpile of mobility aids, orthoses, and prostheses was held in reserve, and when the disaster struck, NGOs were able to distribute the devices quickly to those in need. However, he notes that in the distribution of devices, it was absolutely critical to have previously agreed-on protocols and pathways to ensure that the most needy individuals receive the devices in priority sequence. Although Pokhrel27 does not discuss in any detail the moral or ethical tension of how and where mobility aids were distributed in the aftermath, it is likely that the distribution of mobility aids may have been proportionately higher in urban versus rural settings (where most of the needs were located following the earthquake) because of the relative difficulty in distribution. This likelihood raises the notion of ethical or decisional frameworks used in aid distribution. Although there are ways in which to prioritize high-need individuals, areas, and locations, the reality is that distribution is more of a “patchwork quilt.” This random distribution is due to the scarcity of resources, and the absolute geographic ruggedness and isolation of Nepal often contributed to the randomness of the distribution. Thus, the extent to which a balance between mobility aid supply and demand was reached remains relatively unknown. In either case, the preparedness planning was effective, as Auerbach28 recently reflected that it was Nepal's preparedness that partially explained the differences in causality rates in Nepal compared with the 2010 earthquake in Haiti.
Map rehabilitation providers and services.
Prior to the disaster in Nepal, the Ministry of Health and Population, the WHO, and the NGO community, mostly independent of each other, had engaged in national mapping of rehabilitation providers and services. At the time of the earthquake, there were no comprehensive lists of rehabilitation providers and services because the registration of settings and individual professional practice legislation are relatively weak in low resource settings such as Nepal. Moreover, there is no national structured registry for volunteers who may be in the country at any given time. However, an informal understanding and “common knowledge” of care settings existed across the country. For instance, there is essentially only one major spinal cord rehabilitation center in the country located just at the periphery of Kathmandu, but services also are available for spinal cord rehabilitation at a facility outside the Kathmandu Valley. In the days following the earthquake, the capacity of these 2 facilities was reached, and although capacity existed in other institutions, this excess capacity was not well known to many of the NGOs or institutions who were triaging patients being discharged from acute care facilities. This lack of complete and up-to-date provider and service information created a partially avoidable challenge during the triage and discharge planning process. A comprehensive map of providers and services available immediately after a natural disaster would be essential to coordinate rehabilitation programs, encourage timely and efficient access to care, and promote available services in the community.
In Nepal, the early establishment of an Injury and Rehabilitation Sub-Cluster (IRSC), whose structure will be more fully described later in this perspective article, was instrumental in rapid mapping of injury “need” and rehabilitation services, both new and existing, and circulating them widely to response actors.* The IRSC filled the information gap by quickly establishing contact details and availability of beds in the days after the disaster. All information was circulated in weekly, then biweekly, meetings and online reports, allowing for easy referral of patients who needed care. As with the strategies mentioned previously, a real-time registry of existing health care and rehabilitation services, as well as rapid update methods should, be organized in the planning phase. This information was paramount to efficiently address rehabilitative needs within, and across, the highly affected areas.
Training and capacity development in emergency response.
Given the strong predictions of an imminent earthquake, health human resource workforce training, otherwise referred to as “capacity development” in global development circles, had been prioritized well before April 2015. Mass casualty plans were implemented, and knowledge was disseminated for years. However, many of these plans and capacity development initiatives were designed around predicting an earthquake in urban areas of Nepal. The epicenter of the earthquakes of the spring of 2015 occurred in rural settings where disaster planning and dissemination of information was lacking, and thus the extent to which such preparation planning was effective is unknown. Ultimately, and even though training sessions were provided to clinicians and community-based staff before the earthquake, there were limits in the saturation or coverage of this training based on scarce resources (both within and outside of Kathmandu) and how capacity-building sessions were interwoven within disaster response and surge capacity. A particularly important nuance in disaster response, articulated by Pokhrel,27 was that the injured individuals were rushed to both public government and private hospitals; therefore, it is important to include health care professionals from both sectors in the predisaster training.
Because more people are surviving natural disasters, disaster preparedness should contain greater emphasis on survival and on follow-up care for the survivors (somewhat of a “mass survival plan” rather than the usual “mass casualty plan”). It would seem reasonable to begin by assessing the knowledge and competency among the community of emergency responders and emergency response infrastructure prior to natural disasters and then incorporate effective training of a new concept of “emergency rehabilitation” into emergency preparedness planning and deployment. This preparedness would include developing and having ready culturally appropriate training materials. These materials should address issues that might arise in small- to large-scale emergencies and identify individuals or organizations willing to provide emergency training. Practical training on topics such as proper handling and transfer techniques should be provided in collaboration with emergency teams, military, and hospital staff to prevent further injury while transporting victims. Topics related to clinical and resource decision making in emergencies, how triage can and should work, and aspects of effective communication management also should be incorporated.
Training in the immediate aftermath of disaster also is beneficial, as it can be tailored to the injuries and individual complexities of each disaster. A strategy used in Nepal was to identify training needs of rehabilitation professionals and complete on-site sessions to quickly enhance skills in certain areas such as acute spinal cord injuries, complex fractures, and amputations. It may be important to note that many of the injured people in remote areas were airlifted or carried overland by the Nepalese military, making them key actors in patient transport and initial triage. Overall, preparedness plans are fundamental in planning and coordinating an effective response; however, in reality, not all disasters can be fully predicted, nor can all of the outcomes be fully mitigated. Similarly, each disaster is unique and offers individual complexities and challenges depending on the country, landscape, and political environment. As we will discuss next, while the planning assists in developing structure and coordination, the disability response must focus on decreasing the long-term effects of disability and quickly implementing sustainable solutions and policy.
During: How the Rehabilitation Sector Can Mitigate Disability in the Immediate Emergency Response to Disasters
Despite the best preparedness plans, people and communities will sustain injuries in a disaster, and some of those who sustain injury will survive and will continue to live with lifelong disabilities. The number of new people with disabilities is added to the community of people with disabilities from before the disaster. As mentioned previously, many disasters occur in low-resource settings that struggle to meet the health and social needs of people with disabilities before disaster, and the reality of quickly adding a large cluster of people with disabilities is often overwhelming at the community and national levels. Providing direct rehabilitation services during the disasters offers an opportunity to minimize the extent of disability.
It may be important to note that, similar to the fairly vague distinctions between the definitions of “acute” and “postacute” clinical care, the distinctions among the acute, immediate, and long-term postdisaster phases are vague and ambiguous. In emergency disaster response, the “during” phases are generally described as the phases in which the United Nation's cluster system, again which will be described more fully later in this section, is implemented and remains active. The “after” phases would be demarcated at the moment when the cluster system is dissolved. Based on our experience, there are important actions that physical therapists can, and should, take during the immediate, acute response.
Direct treatment of injuries.
Although physicians and nurses often attend to life-threatening injuries, physical therapists and rehabilitation providers are generally working as part of the health care team to address function and mobility and to quickly scale up quality of life of the injured individuals. In the initial days after the earthquake in Nepal, rehabilitation professionals performed and taught early mobilization, transfers, and safe patient handling techniques to improve function and prevent long-term effects of disability. Rapid discharge from acute medical facilities among the survivors is critical in order to allow the maximum number of people with injuries to receive lifesaving interventions. The flow of survivors who are medically stable needs to be rapid in order to decompress the beds for other survivors. In disaster scenarios, the luxury of planned or functionally based discharge is rare, given the surge in demand. The ultimate goal of rehabilitation interventions in the initial stages was to allow individuals to return to their communities and families with an optimal level of function and participation. Improving function for people with disabilities is especially important in countries such as Nepal where accessible infrastructure is virtually nonexistent, even in the capital city of Kathmandu. Given that the majority of the damage occurred in the rural, mountainous regions, individuals will need a very high level of function to return to their communities and previous employment. Disability and poverty are intrinsically linked. Individuals living in poverty have a higher risk of acquiring diseases and impairments, and people with disabilities usually become poorer because of reduced opportunities, stigma, and costs of care. Addressing the “disability-related” reduction of function and participation after a disaster can be paramount for the country to manage the financial burden involved in postdisaster relief.
The WHO supports and promotes the application of community-based rehabilitation (CBR) as a strategy to meet the rehabilitation needs of people with disabilities in an appropriate and sustainable fashion. Community-based rehabilitation is grounded within human rights and community development frameworks that ultimately emphasize equalization of opportunities and social inclusion for people with disabilities. Although it is not the purpose of this article to describe the complexities of CBR, it is important to state that CBR is a viable disaster rehabilitation approach to support people with disabilities based on health, education, livelihood, social, and empowerment strategies.† When links between CBR programs and specialized or hospital-based health and rehabilitation intervention are strengthened, the mechanisms for identification of people in need in the community, referrals, and long-term follow-up become more effective.
Facilitate early discharge and ensure effective discharge planning from hospital.
During the acute response phase, medical relief agencies and key treatment facilities begin to examine longer-term care and support options for survivors. This examination inevitably leads to integrating patients into the existing health system that, in most cases, will have sustained considerable damage to its infrastructure and human resource base. In the case of Nepal, a total of 462 public and private health facilities were completely destroyed, and 765 facilities were partially damaged.12 Although it is not fully clear, it seems that very few of the destroyed or existing facilities provided long-term rehabilitation, as this was not a strong component of care delivery prior to the quake. The limited capacity at the district level to provide long-term rehabilitation care also meant that follow-up rarely occurred once survivors returned home, which posed a number of challenges in attempts to limit or even prevent lifelong disabilities due to injury.
During a disaster, a limiting factor for timely discharge is the extent to which an individual has a secure shelter to return to and an understanding of whether he or she can function safely. Rehabilitation providers and health staff in general hospitals are extremely important in facilitating safe discharge to decompress the overflow of patients. By completing discharge assessments, providing mobility aids, and teaching safe mobility and function to those who are able, hospital staff can focus on more severe cases and new injuries. In Nepal, this role became increasingly important when planning safe discharge among people with significant impairments, such as spinal cord injury and traumatic brain injury.
Discharge planning serves 2 important outcomes: (1) it provides a better trajectory of care for those who are medically stable and in need of intense rehabilitation not available in acute settings, and (2) it improves overall efficiency of trauma centers because individuals can be discharged more quickly, opening up much-needed acute care beds for the influx of new patients.
An unprecedented increase in injuries after a natural disaster seems to necessitate the provision of rehabilitation services in areas where services were previously weak or nonexistent. In the case of Nepal, 5 short-term rehabilitation units were established within the first month of the earthquake. Each unit provided basic physical therapy care and linkages to social welfare services. Although it is unknown how long these units will be supported in the future, the provision of such services is expected to increase access for those in need and will raise awareness of injury and rehabilitation services among health care workers and the community. In addition, the International Organization for Migration and other emergency response partners transported patients between facilities and home, ensuring that patient discharge and referral ran smoothly over the weeks and months after the earthquake. This is important because in many low-resource settings, ambulatory services can be limited. The number of causalities and distances that must be traveled by injured people in the initial days makes patient transportation a major challenge after disaster. Engaging local health officials is essential in establishing such services; however, they are often overwhelmed in re-establishing pre-existing capacity and responding to emerging health priorities, including disease surveillance and outbreak response.
Advocate within the “cluster” for the needs of people with disabilities.
The overall “cluster approach” is a mechanism aimed at improving the effectiveness of humanitarian response by ensuring greater predictability and accountability while strengthening partnerships and collaboration among the existing government, the United Nations, NGOs, and other international organizations.29 The notion that underpins the United Nation's cluster system is the assumption that in a disaster, the demands far exceed the local government's ability to cope with and effectively manage the unfamiliar complexity of emergency response in terms of coordination, management of multilateral humanitarian aid agencies, and the surge of foreign medical teams. The cluster approach begins with a central coordination committee, established with membership from the national government, alongside the United Nations, and designed to coordinate all of the clusters. From this central committee are a series of standardized units, or clusters, each with its own specific functional areas of expertise to contribute to the response. One of the 11 clusters is “health,” which is coordinated by the WHO and the national government's ministry of health.
In the case of Nepal, the WHO and the Ministry of Health and Population co-lead the health cluster. Given the nature of the response and needs, the health cluster created 4 subclusters: maternal health (MH), tuberculosis (TB), reproductive health (RH), and injury rehabilitation (otherwise known as the IRSC). Prior to the 2015 earthquake, injury and rehabilitation were not considered as part of the health cluster; however, following a number of disasters, including the response in Haiti and the ongoing conflict in Palestine, a working group for disability and injury was established and increasingly became mainstreamed into the cluster system. Due to the mainstreaming of disability in humanitarian response over the years, a new subcluster, the IRSC, was formed in the immediate aftermath of the earthquake in Nepal (Fig. 3).
Cluster system with Injury and Rehabilitation Sub-Cluster (otherwise known as “Injury Rehabilitation”) included. NEOC=National Emergency Operation Center, NMT=national medical team, FMT=foreign medical team, RH=Reproductive Health, MH=Maternal Health, TB=Tuberculosis, HR=Human Resource.
Rehabilitation professionals had an important role in coordinating the IRSC during the earthquake, which was responsible for establishing broad partnership bases that engage in 3 main areas: (1) setting standards and protocols, meaning that the IRSC sets the standards of delivery of care and setting policy; (2) building emergency rehabilitation response capacity within the members of the IRSC, as well as within the greater community of responders, including foreign medical teams; and (3) providing advocacy and operational support to the overall health cluster and to the Ministry of Health and Population. The subcluster requires leadership and input from rehabilitation professionals to identify gaps in humanitarian response for people with disabilities, develop effective policy on disability and rehabilitation, and advocate for the needs of people with disabilities.
After: Use the “Building Back Better” Principles to Create a Better, Safer, and More Accessible Environment for People With Disabilities
More than a decade ago, in late 2004, a megathrust 9.3 earthquake occurred along the ocean floor just off the coast of Indonesia, resulting in a massive 30-m (100-ft) tsunami that spread across the Indian Ocean and devastated the physical landscape and the lives of millions. The humanitarian response from the global community was swift as aid agencies quickly responded across the affected zones, and the constellation of international donors pledged close to $14 billion (US currency) for aid and reconstruction. According to the UK Collaboration on Development Sciences, the 2004 tsunami collective response strongly emphasized saving and restoring lives, but also placed a significant focus on using financial and human resources in order to leave disaster struck communities safer and stronger than before the disaster.30 Since then, this catchphrase of “build back better” (BBB), or its more recent incarnation, “building back safer,” is now commonplace during the recovery phase in disaster or emergency responses.
In general, the BBB concept means to plan, implement, and monitor strategies to advance the infrastructure of a devastated community so as to ensure that it emerges as better, safer, and more resilient than before the events. The BBB concept can be grouped into 3 main categories: risk reduction, community recovery, and coordinated implementation of policy. In our opinion, the BBB approach can, and should, serve as stimulus for advocacy efforts to improving the quality of life for people with disabilities following a disaster. Risk reduction aims to improve a community's physical resilience and reduce the community's vulnerability to natural hazards.31,32 For instance, following an earthquake, improved structural designs and construction standards improve a building's resistance to natural disasters. In terms of disability, risk reduction involves supporting early interventions to minimize long-term disability, developing inclusive and accessible health infrastructure, and ensuring specialized health services are available for people with disabilities. Although it is beyond the scope of this article, other determinants of disability, including, but not limited to, access to education and livelihood, should be considered as part of the emergency response. Using the BBB concept, the following are a series of suggestions to create a better, safer, and more accessible environment for people with disabilities.
Establish a patient registry that can support postdisaster planning and infrastructure.
In the case of Nepal, although there was an increase in the number of facilities and medical relief agencies attending to the injured people, records of patients who were treated remained internal to organizations or districts. The national health management information system, which routinely captures patient and treatment data from government and private hospitals, lacked the detail required to understand the patterns of injury types. As such, one of the lessons learned was that the use of standard data collection protocols regarding injury for medical teams responding to disasters could be implemented at relatively low cost under the usual emergency response health coordination mechanism with a dedicated information management team for injury and rehabilitation. The most useful data elements to consider for collection would include: patient demographic data, type of injury/diagnosis category, primary treatment received, complication and expected length of recovery as dictated by health care professionals, follow-up plans, habitual residence, contact details, and contact details of family or next of kin. These elements can allow for better planning and policy development for rehabilitation. Where possible, geo-coordinates of treating facilities and habitual residence should be collected. These data provide evidence about the scale of the disaster, assist targeted emergency and recovery efforts, and support long-term follow-up of patients once they are discharged from the hospital.
Leverage the postearthquake situation to improve the lives of people with disabilities.
In times of crisis, so-called vulnerable populations, such as those living with an existing or newly acquired disability, are most affected and often overlooked. Postdisaster reconstruction provides a unique opportunity to decrease the vulnerability of people living with a disability and advance the scope of rehabilitation.
One of the components of the BBB concept involves improving the long-term sustainability of communities by taking into account social and economic factors. To aid in community recovery, interventions should focus on initiatives such as educational support for people with disabilities, with an emphasis on children with disabilities who have limited opportunities for physical labor jobs, which are common for people from rural areas. Providing educational opportunities and support can enable people with disabilities to contribute to society—financially, socially, and politically.33 Another strategy to consider for community recovery involves developing long-term financial and psychosocial support systems for individuals injured in an earthquake. These strategies are implemented to help patients receive needed medical and psychosocial support and to navigate the health care system. The overall success requires effective implementation of policy, which involves stakeholders, legislation and regulations, community consultation, monitoring and evaluation, and inclusive policy. Given the WHO's strong emphasis on the CBR approach as part of an effective development strategy, elements of CBR also could be part of the BBB when the target beneficiaries are people with disabilities.
The third component suggests the important role of policy implementation. Health policy that includes disability and rehabilitation for people living in rural and urban centers is imperative to facilitate the implementation of meaningful and effective strategies that meet the needs of people with disabilities. Policy must be inclusive to all people and focus on: developing accessible health care infrastructure, supporting early interventions, ensuring access to specialized health services, providing education opportunities, and creating funding mechanisms for long-term financial support for people with a disability. Nepal applied the BBB principles following the earthquake to improve the landscape of the country. Developing inclusive and participatory policy ensures that the needs of people with disabilities are met to build a better, safer, and more accessible and resilient environment in the future.
Share lessons learned.
With the shift from high mortality to increased morbidity, along with the lessons learned from previous disasters (such as the 2010 earthquake in Haiti), the groundwork has been laid for mainstreaming rehabilitation in humanitarian relief and increasing the awareness of the necessity for inclusive policy on disability and rehabilitation. International stakeholders now understand and value the role of rehabilitation in postdisaster relief and recovery. It is now imperative to develop capacity among rehabilitation professionals globally and advance competencies for the role of rehabilitation in the planning, immediate response, and recovery following a disaster. This could lead to the development and implementation of well-accepted international policy.
The collection of injury data immediately after a disaster, effective discharge planning, providing interdisciplinary care in the community, and ensuring that CBR programs are integrated into response and development strategies arise as key lessons learned for the next response.
Conclusions
The lessons learned from Nepal must be used to “build back better” for that nation, to share knowledge and experience about what worked well so as to more effectively implement future strategies aimed at reducing the effect of natural disasters on the existing population of people with disabilities, and to be more prepared and effective in minimizing the effects on long-term disabilities. The number of natural disasters globally is forecasted to increase; therefore, it is our collective responsibility as global health practitioners, emergency responders, and physical therapists to be better prepared to minimize the risk and to act with speed, precision, and in coordination with other relief actors once disasters strike to minimize the disability-related outcomes of such tragedies. The alternative of “doing nothing” as physical therapists in disaster management and response is no longer a viable position from a moral, ethical, and professional perspective. Those of us who were on the ground in Nepal during these recent events and experienced firsthand the terrible carnage of the earthquake have an obligation to tell this story and to advance the role of the disability and rehabilitation sectors' role in emergency disaster response. In many ways, we must seek to honor the lives of those who perished alongside those who survived in Nepal by sharing the lessons learned from this disaster and making future disaster response more robust, more effective, and more inclusive of emergency rehabilitation interventions.
Footnotes
Dr Landry, Mr Sheppard, Dr Salvador, and Dr Raman provided concept/idea/project design. Dr Landry, Mr Sheppard, Ms Leung, and Dr Raman provided writing. Dr Landry and Dr Raman provided data collection. Dr Raman provided data analysis. Dr Landry provided project management. All authors provided consultation (including review of manuscript before submission).
↵* The term “actors” is part of the lexicon and jargon used in global health and development circles to refer to people, institutions, and organization that are participants in a response or initiative.
↵† For further reading on CBR, see information available at: http://www.who.int/disabilities/cbr/en/.
- Received December 17, 2015.
- Accepted May 1, 2016.
- © 2016 American Physical Therapy Association
References
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