TAR VILLAGE, Sidhupalchowk District, Nepal — The entire field clinic for a team of Israeli and Nepali doctors setting up temporary facilities in remote mountain villages across Nepal fits into 10 large orange backpacks and three duffel bags. After porters carry these bags to the top of a mountain, it takes less than half an hour to arrange the bags on the floor of a school and start treating patients.
The medical team from IsraAID, Israel’s humanitarian response nonprofit organization, works in 29 countries and has responded to disasters in Haiti, Japan, and the Philippines, and to the Sierra Leone’s Ebola crisis, among others.
After the devastating earthquake on April 25 in Nepal that killed at least 7,000 people, 10 doctors, nurses, and midwives left their jobs in Israel for two weeks to volunteer in Nepal. Their first mission was to a group of mountain villages known as Thangpaldkap, in the district of Sidhulpalchowk, one of the hardest-hit regions of Nepal.
In those orange backpacks is a wide range of medical items useful for whatever the doctors encounter: painkillers, anesthesia, IV drips, syringes, eye drops, blood pressure cuffs, bandages, stitches, plaster for casts. Even in the crumbling structure of a primary school, they can do small operations with local or full anesthesia.
IsraAID’s medical team set out for Sidhulpalchowk immediately upon arriving in Nepal on May 2, along with a team of Nepali doctors and nurses from Kathmandu. The idea was to provide medical help in rural areas still cut off from assistance. A seven-hour drive from Kathmandu and then a three-hour walk brought the IsraAID volunteers to the village where they set up the mobile clinic.
Earthquakes are usually the most devastating in urban areas, where the population density and unsound structures often lead to horrific loss of life. But Kathmandu, miraculously, was mostly unscathed. The National Society for Earthquake Technology-Nepal estimated that about 80 percent of the buildings in the capital, home to 1.7 million people, escaped unharmed.
The real tragedy lies in Nepal’s far-flung villages, sprinkled over mountains that rise higher and higher until they reach the Himalayan peaks. These small villages are difficult to access at the best of times. But the quake caused many rockslides, making the narrow muddy tracks used as roads even more impassable.
Many of these villages have yet to see any assistance since the earthquake.
“We got here five days too late,” said Yotam Polizer, IsraAID’s regional director in Asia who lived in Nepal for four years while working for other organizations. Polizer, who speaks Nepali, had just returned from crisscrossing the village paths to tell people that a team of doctors had set up a clinic at the Golmesory Primary School in the village of Tar.
There are 3,800 people in the Thangpaldkap collection of villages, perched among terraces of wheat and rice. In the earthquake, 105 people died. The destruction is nearly 100 percent — every home is flattened partially or completely. Families are sleeping with all of their belongings under plastic sheeting, and there is little food.
A week after the earthquake, their needs were overwhelming.
“The most critical cases have been evacuated,” Polizer said, referring to four people who were brought for treatment to Kathmandu. “Here, there are a lot of back pains, people just in a lot of pain [from falling rocks]. And there’s also an incredible amount of post-traumatic stress,” he said, shaking his head. “That walk through the villages, that was so hard. They are so traumatized.”
As word spread of the mobile clinic, crowds began to arrive at the clinic. People came with injuries wrapped in dirty rags, limbs frozen at strange angles, infections that had festered beyond recognition. Elderly people hobbled in with makeshift crutches fashioned from sticks.
“A lot of these injuries are secondary injuries,” explained Micky Noam Alon, an IsraAID project coordinator based in Israel who has worked in a variety of disaster zones. “They are caused by lack of sanitation, especially now that they’re not even living in houses, but they’re living in tents.”
Waiting patiently in pain
The first patient of the day is a 70-year-old woman named Purna Devi Shresta. When the earthquake hit, a rock fell on her arm. Since then, her hand has been frozen in a limp position. It’s not broken, but she has no control over it.
It takes just a few minutes for Dr. Amir Korngreen, head of the Orthopedic Trauma Unit at Soroka University Medical Center in Beersheba, to diagnose her with nerve paralysis due to a blow to the radial nerve.
“Tell her she’ll get full movement back if she does simple exercises, but it will take three to four months,” Korngreen told Nepali nurse Asthita Nakarmi, who was fulfilling double duty as translator and nurse.
Shresta’s eyes lit up at the news and she smiled to hear that the damage was not permanent. After receiving a plaster splint to stabilize her wrist in a neutral position to allow the nerve to heal quicker, Shresta got a packet of painkillers and went on her way.
The day continued like that with 150 more patients: a consultation with Nepali nurse Saru Lawot, who wrote out their symptoms on a scrap of paper and triaged them to the appropriate doctor based on their symptoms. The patient took that paper to the doctor, where they underwent examination. After receiving a diagnosis, they moved along to get prescription, treatment, or a plaster cast.
Babies wailed in terror as doctors probed sensitive areas injured in the earthquake, children with deep cuts stood stoically as they were cleaned. The crowd waited patiently, explaining pains and aches and symptoms when it was their time to talk to Lawot.
But the most heartbreaking case of the day came around noon, when a man showed up carrying his son on his back, in a straw basket usually reserved for animal feed. Eight-year-old Jourson broke his femur in the earthquake, doctors quickly deduced. As he got ready for the anesthesia so doctors could try to reset the leg and stabilize it in plaster, the rest of his story came tumbling out. Jourson’s mother and sisters were killed in the earthquake. He and his father were the only survivors in their family.
Despite all of the terrible injuries, that story made the entire medical staff pause for a moment, imagining the pain and suffering of an untreated broken leg on top of grieving for his whole family.
After recovering from the anesthesia, Jourson sucked down a juice box as his neighbors gathered around to examine his new cast. His father was quiet as he hoisted Jourson, still in the basket, onto his back again, to begin the trek back to their village. The doctors recommended Jourson’s father take him to Kathmandu for X-rays to check if the leg was set properly and get a more supportive cast, though they know that it was unlikely that the father and son would make the journey. As they turned the corner, Jourson looked back at the clinic from his basket and smiled briefly. The road to recovery was still long, but at least every jolt of his father’s step no longer caused him shooting pain.
Creativity and levity in the mountains
Working in such harsh conditions requires a lot of creativity as doctors come up against logistical and cultural challenges. The placement of the clinic was constantly changing to keep the medicines out of the sun, frustrating attempts to keep everything organized.
Early in the morning, the doctors realized that many of the villagers were illiterate, so writing out instructions for how to take medicine was useless. Nepali numbers are also different from Roman numerals. To solve this problem, doctors gave out pictorial prescriptions, a line with circles to illustrate how many times the pill should be taken each day.
The five Nepali staff assisted with translation and cultural understanding. One woman arrived with an injured foot that was completely black. The Israeli doctors were puzzled, until a Nepali nurse recognized that it was charcoal, used in traditional medicine for healing.
And there were also moments of levity among the staff, some of whom are veterans of past missions to the Philippines or Haiti and bring with them a vast knowledge of operating field hospitals in difficult conditions. They also understand the importance of letting off steam as the staff treats a never-ending stream of patients with heartbreaking stories.
Camping out the night before the mission, a three-hour hike from the village of Tar because rockslides had blocked the roads, the staff gathered for a briefing in their tent. “They never had so many doctors in this area, and they may not ever again,” Polizer said. Just then, we felt a small tremor through the tent floor, one of the many small aftershocks.
“That was an aftershock?!” one of the doctors asked in disbelief. “I thought Dudi farted!”
How do you say ‘efficient’ in Nepali?
When major disasters strike around the world, aid organizations rush to help. But the panic and disorganization surrounding a disaster can often lead to ill-prepared teams doing more harm than good.
International aid is a complicated puzzle, trying to match a patchwork of organizations with different abilities and resources to remote areas. Everyone means well; everyone wants to help. But without local knowledge and experience, the help is ineffective and ultimately harmful, because resources are tied up so the people that need the help most do not get it.
IsraAID tries to increase its effectiveness by utilizing extensive local contacts as well as quickly adapting to the changing situation. In Nepal, three IsraAID staff members had significant experience in Nepal, which helped with the local connections.
“We’re a nongovernmental organization, so we have much more flexibility than a government or really large organization. We can be fluid,” explained Alon, the project coordinator in Israel. “There are things that we can do, and things that we can’t. We find things that are relative to our size and the way we can be the most efficient. This is the best thing we can do with our ability.”
IsraAID could not create a field hospital with the level of complexity that the Israeli army did, noted Alon. But the IDF also does not have the mobility and flexibility to go to serve people in these remote villages.
Figuring out how to assign different organizations non-overlapping tasks is the biggest priority of organizations like the United Nation’s Office for the Coordination of Humanitarian Affairs. OCHA runs a booth at the airport to greet incoming groups and tries to organize them into a cohesive response to reach many different villages, with varying levels of success.
In the quake’s aftermath, IsraAID also operated a 15-member search and rescue team in Nepal. That team was involved in rescuing 24-year-old Krishna Devi Khadka who was trapped for five days beneath the rubble, one of only four successful rescues by search and rescue teams.
Polizar said IsraAID plans to be in the country for at least a year, and has already started rolling out its trauma therapy field model, which will employ therapists using art, drama, and other methods to help children deal with the emotional side of this disaster.
On to the next mountain
The medical team stayed in Tar for a day and a half before heading back to Kathmandu to regroup and leave for another village, this time in the Gorkha region. During the 36 hours of the clinic’s operation, bulldozers cleared many of the rockslides, meaning a jeep could reach all the way to Tar Village, so they could send the backpacks and duffel bags down the mountain by car rather than porter.
Road clearing efforts also cut down the drive time back to Kathmandu and other major highways. Getting to Gorkha will now take a few hours rather than a day or more in the early days after the earthquake.
The opening of the roads has meant that aid groups are starting to reach these far-flung corners. Hiking down from Tar Village, we came across a group of Nepali doctors living in Bangladesh who had set up a similar mobile clinic, a few villages over. On the way back to Kathmandu, we saw half a dozen food trucks delivering desperately needed food to rural areas. We passed many jeeps festooned with international aid logos.
Though accessibility is improving, the main concern now is the approaching monsoon season, which will start in two to three weeks. Though the line of patients in Tar eventually trickled to a stop, there are so many needy villages in the same situation, waiting for a line of orange backpacks to come up the mountain.
“I’m glad I came,” said Muza Shrestha, an orthopedic surgeon from Kathmandu. “It’s difficult, but the destruction is worse and it’s more remote than I could have imagined.”
“We see things here that we’ve never seen before,” said Dr. Michael Alkan, an infectious disease internist who teaches in the School for International Health at Ben Gurion University. “We see [bone] breaks that are eight days old, old infections that no one has looked at before. You’d never see that in Israel. But what we see the most is post-trauma. There was one 70-year old woman who buried her daughter. We were trying to treat her and she was just sobbing over and over, ‘What do I have to live for?’ The pain, it’s nothing. But the sorrow is overwhelming.”