Nepal was brought tumbling down through a series of disasters beyond its control. The collapse of buildings may have ceased -- for now -- but the lives of Nepal's residents remain at risk with the deluge of health consequences now facing them.
"The first priority is immediate medical services for trauma care, surgeries and wounds [such as] broken bones, spinal injuries and head injuries," says Jesse Hartness, director of Emergency Health and Nutrition
at Save the Children, whose Nepal-based staff were at the scene the day after the earthquake hit on April 25.
But this crucial starting point was made difficult by teams finding 90% of remote health facilities destroyed. "[Risk of] mortality increases within the first 24 hours if people aren't treated immediately," says Hartness.
But as aid agencies rushed to those caught in the rubble, their attention was needed simultaneously by others now finding themselves homeless, in need of shelter, and at risk of a multitude of health consequences -- including malnutrition and infection.
"In Nepal, you already have more than 50% of children malnourished, this was already a nutritional emergency," says Hartness. The response provided by Save the Children therefore made sure to encompass access to good food and breastfeeding practices to prevent the enhanced risk of infection that comes with malnourishment.
"Typhoid and cholera are [also] endemic," he says, meaning these diseases were already present in the country and pose a risk to aid efforts. Health teams must be prepared for the arrival -- and spread -- of cholera whilst also preventing its onset by ensuring that people have access to clean water.
The numbers of people reporting diarrhea has already risen in affected areas. According to Nepal's Ministry of Health and Population (MOHP), 445 cases -- averaging 64 per day -- were reported between May 2 to May 8 2015.
But the risk of new infections doesn't stop there.
"You now have a concentration of people in one place, so you can expect infections," says Karl Blanchet, head of the Public Health in Humanitarian Crisis Group
at the London School of Hygiene and Tropical Medicine, referring to the millions now finding themselves crowded into in temporary shelters.
Overcrowding in an undernourished population can be a lethal combination.
"We need to manage the transmission between people ... [that's] why we talk about vaccinating measles right away," he says.
Measles is among the most contagious of all infections. Someone infected with measles can transmit the virus to between 12 to 18 people susceptible to the infection, making vaccinations crucial both routinely and in an emergency.
In 2013, 88% of the country's population had been vaccinated against measles, which is lower than the desired herd immunity threshold of 95% -- the level at which infections are expected to no longer be transmissible within a population. But this reasonably high coverage rate meant the delivery of measles vaccines could be held back slightly -- but not too far back.
"Nepal is high already but without routine services the coverage will fall," says Hartness. "[It] will have to be a priority in a few weeks," he says. Vaccination campaigns have already begun in some regions and are given to everyone, whether they've had the vaccine already or not.
Nepal's mountainous terrain means mosquitoes -- and therefore the infections they carry, such as malaria -- are less of a concern, unlike disasters such as typhoon Haiyan. After the Philippines disaster, large levels of standing water and greater numbers of people sleeping outside meant a high risk of malaria transmission.
Pneumonia rates have risen in Nepal, with 817 cases of acute respiratory infections reported between 2 to 8 May in the 14 most affected districts -- due in part to high numbers now sleeping outdoors.
Need for water
The need for water is evident and emergency aid organizations, such as Medecins Sans Frontieres
(MSF), have rules in place to ensure everyone is covered.
"In the first days we have a minimum of five liters per day per person, which is very low," says Eric Pujo, emergency coordinator for MSF. Pujo recently returned from deploying teams to the city of Arughat, home to 10,000 people and a city serving more than 50,000 people in surrounding regions with health services, according to Pujo.
"Our objective very quickly is to reach 20 liters per day per person to ensure people have proper access to safe water in terms of quality and quantity," says Pujo. The use of latrines is also set at a maximum of 20 people per latrine to ensure certain levels of sanitation
The extent to which access to clean water improves the health of people now displaced from their homes is vast, moving beyond simple hydration, sanitation and endemic infections such as cholera.
"Not enough water can also generate skin diseases for people," says Pujo. One key example is scabies, which can lead to blindness, and treatment is therefore provided in standard health kits issued by organizations such as Save the Children.
The demand also varies greatly across Nepal. With the majority of the country's population living in rural mountain regions, access to freshwater alleviated the need for water supplies. "Freshwater supplies are not likely to be affected," says Hartness. But once you move into cities -- such as Kathmandu -- the picture is very different. "If you're dependent on a hand pump, they will be broken," he says.
Once the demand for immediate supplies such as food, water and surgical interventions falls, Nepal will face a new landscape of health issues that the country's primary healthcare and rehabilitation services will need to manage -- once they're restored.
The World Health Organization has mobilized funds to aid the treatment of spinal cord injuries, which account for approximately one third of injuries, according to Hartness, and which health services lack the resources to handle themselves. But one often overlooked consequence is mental health issues, such as anxiety, particularly after the occurrence of a second earthquake.
"It reminds everybody the risk is still there," says Blanchet. "People are now scared to return to their houses." This fear will see an increase in the numbers of displaced people, putting pressure on health systems as a result.
"The psychological trauma of continuously feeling unsafe can have a big impact," adds Hartness. Organizations on the ground, including UNICEF, are now prioritizing psychological support -- alongside water, sanitation and medical supplies -- through counselors, child-friendly spaces, art therapy classes and learning centers to get children back into a learning environment and more crucially, a sense of routine.