Dollars to Disasters: The Gamble of Emergency Relief

Inside a camp set up by an Israeli medical team in Nepal after the April, 2015, earthquake. Inside a camp set up by an Israeli medical team in Nepal after the April, 2015, earthquake. Credit Photograph by Mushfiqul Alam / NurPhoto via AP

In the Himalayas, many houses are built of fieldstone: shale and slate, pried from the earth, stacked in the mountain air, and mortared with mud and hay. This was the type of home that crashed down on Aimoj Tamang, an eighty-six-year-old Nepalese woman, on April 25th, the day when, in twenty seconds, an earthquake measuring 7.8 on the Richter scale destroyed much of what was man-made in Nepal and killed more than eighty-five hundred people. For three hours, Tamang lay trapped beneath the rubble, thinking about her children and grandchildren. She had been born in a house not three miles distant, which had also been destroyed by a natural disaster—a landslide that struck when she was a child. As an adult, she’d farmed millet on the same green terraces as her parents, in Paticho, a close-knit Christian village of three hundred people, only rarely leaving the valley where she was born.

Tamang’s son-in-law eventually arrived and freed her from the rubble, then carried her home. The next day, some men from the Nepali Army arrived and asked her to consent to evacuation by helicopter, which was the only way in or out of Paticho aside from steep stone paths. Her feet were crushed, the bones revealed. She swatted the men away with a stick. Eventually, they left her.

Nine evenings later, Ryan Paterson, a thirty-six-year-old E.R. doctor and experienced mountaineer from Denver, arrived at Tamang’s house and made the same request. Her wounds were now infected, and Paterson believed that she would die if she didn’t receive treatment. By iPhone and headlamp light, he and Jake Dutton, a New York City paramedic and firefighter, carried Tamang from her wooden shack into the family’s muddy yard, where a hobbled water buffalo backed away as they lay her down. Paterson began the long and sometimes painful process of cleaning, anesthetization, debridement, stitching, splinting, and dressing. As he worked, Tamang tsked him, questioned him, and clutched a pack of Khukuri cigarettes beneath her sari. She continued to refuse evacuation.

For the next week, Paterson visited her every morning, discovering each time that she had removed the splints he’d applied the day before. Even so, by day two she was referring to him teasingly as “my son.” He, in turn, called her “grandmother.” She was his most serious case, and he talked about her often that week. She was tough, he said, but she might not make it, no matter what he did. Which was a lot.

If they’d been in Denver, members of his team estimated, the care they were providing Tamang alone would have cost perhaps a hundred thousand dollars. As it was, NYC Medics, the Harlem-based charity that organized the trip, had spent more than twenty-three thousand dollars to equip and transport Paterson and the others to Nepal, and they’d brought with them thousands of dollars’ worth of donated medicines and supplies—enough to treat approximately four thousand patients.

During previous two-week deployments, in places like the Philippines, Pakistan, and Haiti, NYC Medics teams had treated thousands of people, hundreds of whom were suffering from disaster-related traumas. But during the trip to Nepal, Tamang was one of only a handful of urgent cases that Paterson’s team saw. The mission instead proved to be a lesson in real versus imagined needs in a disaster zone, and called into question the value of emergency medical intervention by foreign teams.

“I try to reconcile in my head,” Paterson said toward week’s end, “is it worth coming?”

Tamang, for her part, often commented that “everything happened with the blessings of Christ.” Paterson was the first doctor she’d ever seen.

NYC Medics has a concise mission: the rapid provision of medical care to remote locations that have been hit by disasters. Founded by a handful of Hell’s Kitchen-based paramedics in 2005, in response to an earthquake in Pakistani Kashmir, the organization has now conducted seven relief missions, drawing on a roster of volunteer medical professionals who are prepared to deploy anywhere in the world.

The government of Nepal issued a request for international assistance almost immediately following the quake on April 25th. By the evening of the 27th, when NYC Medics announced that it was mobilizing, Nepal was reporting that some eight million people had been affected, with more than forty-three hundred dead and nearly twice as many injured. “What we were hearing from the field indicated that mobile medical teams would be helpful,” Tim Tan, the medical director of NYC Medics, told me. Mountainous Nepal seemed like a particularly good fit for the group, whose members pride themselves on mobility in difficult conditions. Several among the twelve-person team formed for the mission had responded to earthquakes in Pakistan and Haiti. Two were U.S.-special-forces veterans. One of the nurses had worked as a photojournalist in Iraq, and another had been in Liberia the year before, treating Ebola patients. Paterson had been an expedition doctor on Mt. Everest. NYC Medics agreed to let me join their trip to report on what I saw. (I paid for my own travel to Nepal, though, once in the mountains, I shared food and transport with the team.)

The team was delayed leaving New York because of a ticket mix-up, and plans soon went further awry. The morning after we arrived in Kathmandu, everyone met with Anil Parajuli, the founder of Himalayan Healthcare, a local charity that NYC Medics was partnering with for the mission. The original idea, per Nepal’s Ministry of Health, the United Nations, and the World Health Organization, which were coördinating relief missions, had been to go to Barpak, a village of about twelve hundred homes near the quake’s epicenter, in the Ghorkha district, approximately a hundred miles from Kathmandu. But as it happened, a doctor friend of Parajuli’s was already in Barpak, and he said that the area was well served by the Indian Army. Fearing redundancy, Kathy Bequary, the director of NYC Medics, agreed that the team might be more effective in a different district.

Parajuli suggested Jharlang, where H.H.C. traditionally worked and where his contacts described widespread destruction and an absence of aid. “There is chaos going on,” he told the team. Though Jharlang was only eighty miles or so from Kathmandu, as the crow flies, it was a two-day trek from the nearest road, and many of the trails were compromised. Some five thousand people were potentially in need of care, and no one, to Parajuli’s knowledge, had delivered any aid to them since the quake. Bequary cleared a new plan with the health ministry: the team would drive three hours west, to Dhading Besi, the district capital, then take a half-hour helicopter ride into the mountains.

Arriving in Dhading Besi toward midday, we saw some severe destruction. The U.N. was estimating that as many as eighty per cent of the houses in the affected districts were damaged or demolished, and it had requested four hundred and twenty-three million dollars for urgent response. Only a small portion of that amount—itself a fraction of the five to ten billion dollars the country will require to rebuild—had been donated. (As of now, four months after the quake, more than three billion dollars has been pledged by donor governments.) There were, however, at least eighty foreign medical teams registered in the country. The influx of humanitarian workers was large enough to be causing delays at Kathmandu’s airport, not to mention coördination issues countrywide. The office of Nepal’s U.N. Resident Coördinator issued a warning: “Since several agencies are fielding needs assessment teams, a need for better coordination is necessary to avoid overlap and misunderstanding.”

Most of the misunderstandings seemed to revolve around helicopters, which were in high demand. Parajuli had told the team that transportation to Jharlang would ultimately be up to the district health officer, who was coördinating with the Indian and Nepalese armies. Bequary stopped in at the local health office, where she soon learned that official priority had shifted from medical care to the provision of food and shelter. While they waited for two helicopters to become available, the team camped on the edge of Dhading Besi’s town green, increasingly frustrated. Their immediate neighbors, from India’s 60th Parachute Field Hospital, didn’t understand the hurry. “These people are going eight days late,” Sergeant G. H. Marathe said, as he lounged in the shade of a bandstand opposite Paterson’s tent. “All the people they want to save will be dead.”

The team had been concerned about this, too. Most earthquake fatalities occur in the first seventy-two hours, and it was now nearly nine days later. They briefly considered setting up in Dhading Besi, but the Indian Army seemed to be meeting the town’s needs. Bequary began calling charter services, and learned that a private flight to Paticho would cost twelve thousand dollars. “You could build and staff a clinic for a year with that. It’s fucked up,” Dave Young, an emergency-medicine doctor from Denver, remarked.

The next day, the team finally caught a free ride on a pair of Indian Army helicopters that were making supply drops. At touchdown, Paticho greeted the team in force. Perhaps half of the houses dotting the green terraces above and below the drop zone had been torn open to the elements or collapsed. Accompanied by a large crowd of villagers, who insisted on carrying the gear, the team soon set up their clinic amid the ruins of the local school. Patients began arriving immediately. Health services in rural Nepal—where the per-capita G.D.P., of six hundred and ninety-eight dollars, is the second-lowest in Asia, not far above Afghanistan’s—are rare and rudimentary. Lightly trained government health workers occasionally pass through Paticho, but the nearest doctors are usually in Dhading Besi.

In the first twenty-four hours, the team treated two hundred and forty-two people from the village and surrounding area. They soon learned that scores of people had already been evacuated from the area by either the Indian or Nepalese army. This was the first indication the team received that any other support had been there before them. The trauma victims, it seemed, were already dead or gone.

Aimoj Tamang, who is eighty-six years old, was trapped under rubble when her house collapsed in the earthquake. Aimoj Tamang, who is eighty-six years old, was trapped under rubble when her house collapsed in the earthquake. Photograph by Nick McDonell

That night, though, they found Aimoj Tamang a little way down the mountain. And they were making a difference to Paticho residents; all of the people I spoke with were glad that the doctors had come, even if, as they mentioned, shelter had become a more pressing concern. Monsoon season was approaching, and they needed tarps, and sheets of corrugated iron, to rebuild their roofs. The Nepalese Ministry of Health had, by then, requested that no more foreign medical teams fly in. “We do not need any more foreign personnel, but we definitely need the commodities,” a senior official told a reporter.

The team was in good spirits for a while, but on their second full day, the patient count slowed dramatically and they began operating far below capacity. In conversation with Parajuli in Kathmandu, they decided to start sending mobile groups out each morning, trekking to villages where they might find others in need of care, especially any remaining trauma patients.

On the fifth day, I joined one of the treks. Our guide, Yuan Tamang (no relation to Aimoj; Tamang, a minority ethnicity and language, is the surname of almost everyone in Paticho), was employed part-time by H.H.C.; he led us from house to house, along the valley’s narrow paths. The patients on the trek, like those at the clinic, had only rarely suffered injuries in the quake. Up and down the valley, Paterson dispensed albuterol for respiratory problems, Tylenol for arthritis, and all of the anti-fungal and anti-worm medication that he had. Though he was evidently frustrated with the team’s placement, he remained upbeat, listening to everyone’s stories and joking with the children. One woman who complained of insomnia had, Paterson discovered, lost her daughter to a falling boulder. He sat with her for a while in the makeshift refugee camp that was now her home, attempting to comfort her. “We talk about the resources being used,” he remarked to me afterward, “but we don’t talk about the value of just being here.”

When we returned to camp, we learned that some doctors from Médecins Sans Frontières had passed through Paticho. They were camped on the other side of a nearby landslide, perhaps two hours’ walk away. Apparently, they had arrived two days after the earthquake and were registered with the U.N. and the Ministry of Health. They weren’t on any list that Bequary had seen.

Faced with this news, the team began to consider alternate plans, including trekking out to Dhading Besi and treating people along the way, or flying back early to Kathmandu and handling patients there. Bequary tried to arrange an early relocation, but couldn’t, so the team stayed to treat what patients remained. Around the village, some modest rebuilding began, stone by fallen stone.

Four days before NYC Medics was scheduled to leave the country, an aftershock hit. The team had already packed up the clinic and were waiting for a helicopter when the vibration began. Across the valley, plumes of dust rose behind new landslides. The noise was tremendous. The shock, at its most intense, was dreamlike—difficult to recall, except for the deep, adrenalized unease that it evoked. The quake, which reached 7.3 on the Richter scale, constituted a major seismic event. Across the country, more than a hundred people were killed. No one in Paticho required care though, so, following Paterson’s lead, everyone worked on clearing the many piles of rubble instead.

By the time the team left that week, Nepal’s Ministry of Home Affairs was reporting that, countrywide, nearly five hundred thousand houses had been destroyed, nearly seventeen thousand people had been injured, and more than eight and a half thousand had died in the quake and the aftershock. During its mission, NYC Medics had treated six hundred and thirteen people, and only twelve for trauma injuries. But Aimoj Tamang would not be counted among the dead.

Several people mentioned to me, over the course of the trip, the pleasure they derived from disaster relief, despite the frustrations and the knowledge that it might not be the most effective use of resources. “I enjoy the work. It’s satisfying,” Micaela Theisen, the nurse practitioner who had recently treated Ebola patients in Liberia, said, adding, “but I think primary health work is better for the community.” NYC Medics has conducted a teaching mission in Kenya in the past, and Bequary told me that she’s interested in having the organization do more work developing health-care systems abroad. Theisen works in both areas, as does Paterson, who is planning to return to Nepal in November to teach. Another team member, the physician assistant Eric Holden, has returned annually to Haiti since his deployment with NYC Medics there in 2010. “It takes an earthquake to get people to care about primary care,” he told me.

This is a fundamental dilemma of disaster relief: preparedness is more effective than response, but it is also more difficult to staff and fund. “Across the relief effort, money could have been better used,” Buddha Basnyat, the medical director of the Nepal International Clinic, told me back in Kathmandu. He singled out the need for systemic investments such as health surveillance and vaccination. NYC Medics’ expedition budget could have bought a lot of vaccines, it’s true, but it’s difficult to say whether the decision to undertake an emergency expedition was, in some sense, wasteful. Finding an answer to that question would entail the fraught calculation of a “cost-effective” amount of money to spend on prolonging the lives of people affected by a disaster. Even though the Nepal mission was inefficient compared to NYC Medics’ past forays (and, probably, compared to the operations of some N.G.O.s that arrived earlier), the organization saved at least one life and helped many other people. It was at an average cost per patient that was higher than the cost of preventive treatment alone, yes, but one far below what comparable care would have cost in the U.S.

Not long after I returned from Nepal, I met again with Tim Tan, the organization’s volunteer medical director, at a café near New York’s Presbyterian-Columbia hospital, where he was then working as an E.R. physician. Tan, who also researches medical cost-efficiency and has a degree in public health, told me that he rates the efficiency of international disaster relief, generally, as a two on a scale of ten. “Full of inefficiencies, questionable agendas, misaligned motivations, and politicking,” he wrote later, in an e-mail. Even so, he believed that the Nepal mission had been worthwhile. “I can’t deny that fewer logistical delays or higher patient volumes would have been welcomed by everyone on the team,” he concluded, “but when we can undeniably save some lives, even if only a handful per deployment, while also easing suffering and providing hope for many others, I feel that the cost is justified.”

Tan was about to work an overnight shift, and when we finished up I walked with him to the hospital. Outside the E.R., he described the myriad non-life-threatening complaints he encountered during a typical shift, compared to the number of trauma cases. Working in a disaster zone changed that ratio, he said, but didn’t reverse it. It was the irony of all emergency medicine, he observed: “Most of the time, we don’t deal with emergencies.”

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