With her broad smile and habit of ending sentences with a burst of body-shaking laughter, Ganga Shakya is, for the most part, as intimidating as a warm ‘namaste’ and a cup of dudh chia.
But when the 45-year-old mother of two is training Nepal’s health workers in post-earthquake injury and trauma management, a change is evident. The finer points of tending to head injuries or amputee wound care are delivered in rapid-fire staccato, as students scramble for their notebooks and fumble with smartphones. Despite her diminutive stature, Shakya’s message is delivered with a clarity and force that ensures it will have maximum impact.
“Our aim is to impart our skill and knowledge so that local health workers are able to address the ongoing injury management problems of earthquake victims,” Shakya says after delivering a lecture to health workers in Makwanpur District.
The physiotherapist of 24 years’ experience explains that the three-day program, which is being rolled out across quake-affected districts by Nepal’s Ministry of Health and Population, and which is supported by WHO, Handicap International, CBM and the UK’s Department for International Development, will enhance access to basic physiotherapy services for the 22 309 people injured in the country’s 25 April and 12 May earthquakes. She says this is critical to preventing a range of secondary problems that inadequate injury management can cause.
“People may have deformities and a shortening of the muscles around their joints as a result of their injuries, which will make it difficult for them to carry out their daily activities. To prevent these difficulties they need to be rehabilitated at the community level,” she says.
According to Shakya, the trainings will also increase knowledge of pre-existing referral systems. “Many lower-level health workers do not know when and where to refer cases. From this training they will have greater knowledge and can refer cases more effectively.”
The 36 health workers attending the program in Makwanpur, which will be reproduced in each of the 14 most affected districts, traverse the full spectrum of the country’s occupational and institutional heirachy – from health assistants to doctors, and from the sub-health post level to the district hospital level.
According to Dr Mike Landry, a WHO expert in post-disaster injury management, the training modules – which cover head injuries, spinal cord injuries, poly-trauma injuries, psychosocial first-aid and community-based rehabilitation – were designed to facilitate peer-to-peer learning, thereby increasing their efficiency and reach.
“When putting together the training materials, great efforts were taken to ensure that the best evidence-based approaches to injury and rehabilitation were used as a baseline, including WHO’s technical guidelines around community based rehabilitation and provision of manual wheelchairs,” he says. “Modules on teaching pedagogy were also used to ensure that the trainers not only knew the clinical information, but also how to effectively teach other health workers at their facilities. By carrying out these trainings we have the opportunity to strengthen the health system greatly, and need to take full advantage of that opportunity.”
Tulsi Prasad Dahal, Section Officer at the MoHP’s Curative Division, which is tasked with disaster and emergency management, attended the Makwanpur training to monitor and evaluate its effectiveness. He echoes Dr Landry’s sentiment, and says that from what he’s witnessed the program will prove immensely valuable.
“If anyone from any health facility comes here they will simultaneously train their colleagues. They will share their experiences, and that is important,” he says.
Though Dr. Landry stresses the long-term significance of the trainings in terms of overall health system strengthening, he says their utility as a stand-alone disaster response initiative must not be diminished. Nepal’s implementation of the trainings, he argues, is key to normalizing post-disaster rehabilitation and injury management programs worldwide.
“Over the past 20 years or so, the ratio of those killed and injured as a result of natural disasters and conflicts has changed dramatically. Now, we find that relatively more people survive these tragic events, however there is a corresponding rise in the number of injuries that must be managed in their aftermath,” he says. “As health professionals we have demonstrated our ability to save life, but we now have to become equally effective at saving the quality of life of those who now have a disability. Part of that is changing the way disaster response works and ensuring robust injury management programs are implemented.”
Suniti Amatya, a physiotherapist who has worked with Handicap International’s (HI) disaster preparedness and response unit for the past four years, says that the trainings’ community-based rehabilitation module is critical to creating localized solutions in a country in which injury and disability care is difficult due to its natural topography.
“We have introduced a module on community-based rehabilitation and disability which is important in terms of linking health and rehabilitation,” she says, explaining that when a person is discharged from a hospital and returns to their home they may struggle to access health facilities on a daily basis for a range of reasons.
At the same time as supporting the training of health workers at the community level, Amatya describes how HI has devised materials that health workers can provide patients and their families in remote areas to help them self-care.
“We have developed a booklet for use at the household level that addresses the main trauma topics and the complications that can arise,” she says, adding, “They are very user friendly and easy to follow.” According to Amatya, the best way to ensure adequate care is provided is to diffuse knowledge widely.
Back in Makwanpur, Ganga Shakya agrees. Standing in the sunshine in a bright pink kurta, she motions toward the building in which her students are practicing their new skills and explains that despite the students’ range of expertise they are working together well. According to Shakya, apart from their eagerness to learn, their progress is a function of her teaching style.
“I forget everything – who is the doctor, who is not. They are all learners. They are all equal to me, and they listen to me,” she says seriously, before breaking into a smile and letting out a signature round of deep, infectious laughter. “They’re learning things, it’s good.”