HKJCDPRI E-NEWSLETTER (ISSUE 3)

“Dear friends in Nepal, We are sorry to learn the sad news of your country being struck by the catastrophic earthquake and the dire loss your people suffer. We hope you and your family are alright. Do feel free to tell us if there is any information we can provide as a little contribution to the relief efforts you or your colleagues are striving for. When the emergent situations got settled a bit, we would be eager to learn what you and your family, friends and colleagues have done in response to this disaster, so that we can see if there is anything we can do. Our thoughts are with you, your family and your people during this difficult time. Prof. Emily Chan, Sida and CCOUC colleagues”

Ms Gloria KW CHAN MSSc, BSSc Centre Manager, Collaborating Centre for Oxford University and CUHK for Disaster and Medical Humanitarian Response (CCOUC)

The above email undersigned by Professor Emily YY CHAN, Director of CCOUC and Associate Director of the JC School of Public Health and Primary Care of CUHK, Mr Kevin Sida LIU, Tutor of CCOUC online course “Public Health Principles in Disaster and Medical Humanitarian Response” supported by the University, and CCOUC colleagues to their Nepalese students of the online course soon after the earthquake struck Nepal on 25 April 2015, was an important bridge to connect online education with concrete humanitarian actions.

CCOUC reached to its students from Nepal after the quake trying to understand what was going on in the community with first-hand information, in parallel with news that flooded in with striking images of the devastation. After establishing some points of contact with local community groups, and with request from the NGO community, CCOUC conducted its first-ever technical training in Kathmandu on “Key Issues to Design and Implement Post-disaster Public Health and Medical Interventions for Asia in 21st Century”. Representatives from local and international NGOs, hospital management, and academia attended the training. It is found that only 30% of this group reported having access to at least one relevant technical support channel, and only 10% were aware/or had heard of international relief standards and guidelines.

Besides clarifying some myths and realities in disaster and medical humanitarian response, topics like public health principles and how to measure and document human health impact of disaster were touched on, and standards of disaster response programmes, especially the SPHERE Project – an internationally recognized minimum standard in humanitarian response, for which CCOUC is appointed as the Country Focal Point for China, was introduced and explained to the participants.

The CCOUC team also ventured into different communities to engage in needs assessment. Assessments were done in urban setting and in a sub-urban community. Sankhu, on the outskirts of Kathmandu was destroyed by the earthquake; the locals were busy clearing collapsed roofs and rubbles on the streets. Sanu Bajracharya, a 35-year-old Nepalese, having his house completely destroyed, shared with the team in his makeshift shelter made by tarpaulins and tin sheets, "Water pours in when it rains. But I don't know when we can leave this shelter. We have no money to rebuild the house. I can only stay strong."

High up in the mountain, in rural villages in Gorkha near the epicenter, CCOUC conducted focus groups and did some basic survey with the local community to understand their needs.

The health situation of survivors of a disaster is usually compounded with pre-disaster health issues. CCOUC witnessed the nutritional situation of a number of children under five in a nutrition centre, and learnt about the risk of Hepatitis E outbreak that the Oxford University Clinical Research Unit of Nepal (OUCRU-Nepal) was seriously looking into.

To minimise the risk of disaster, the vulnerability of people exposed to hazards must be reduced; at the same time their capacities to anticipate, cope, resist, and recover from hazard impacts have to be strengthened. In partnership with HKJCDPRI and other collaborators, CCOUC wishes to contribute through knowledge transfer, education, evidence-based research, and case studies to fill in the gap of needs by building resilience via a bottom-up approach, in line with the international consensus recently made through the Sendai framework for disaster risk reduction 2015-2030 to promote the incorporation of disaster risk reduction efforts in the health sector.

Prof BURD is currently the Centenary Professor of Regenerative Medicine and Translational Science at the School of Tropical Medicine in Kolkata. From 1999 to 2013, he was Chief of Plastic and Reconstructive Surgery and Director of the Burns Service at the Princes of Wales Hospital, in Shatin, Hong Kong. He has travelled widely lecturing on Burns Reconstruction and has over 200 publications in the field of Burns and Wound Healing. His ongoing laboratory research is focused on the cellular mechanisms of repair and regeneration and the clinical modulation of burns and wounds with stem cell applications.

Prof Andrew BURD

As the death toll from the tragic Taiwan Water Park disaster rises, it is a salutary reminder that disasters can happen anywhere, at any time. Preparation is essential and this is a good opportunity to review the situation in Hong Kong. A disaster is present when the needs exceed the resources. We can and must make plans but we must realise the purpose of the plan is not to prevent a disaster, but to prevent a disaster from becoming a catastrophe. Before proceeding, I recall full well the sage advice of the godfather of my eldest daughter, he was a fireman, Peter Kisby. I have the greatest respect for these primary responders who daily risk their lives and in so doing witness some of the horrors that fire can create. Pete told me that when staying in a hotel, going to a cinema, a club, a theatre, getting on a bus, train, or plane his first thought is always ESCAPE. Where are the exit signs? Spot checks by fire prevention staff are essential because some of the worst fire related disasters have occurred in places where there are exits but they are blocked or locked. It is horrific to think of teenagers in clubs trampling over each other to try and escape from a fire and then all succumbing to the effects of smoke inhalation. But returning to planning; disasters can occur in one site when the infrastructure for response is intact as was the situation in Taiwan or they can occur as multiple incidents when the infrastructure is also destroyed as may occur in an earthquake and other natural disasters. (Fig 1)

There are certain principles of planning which are well established: the plans need to be simple, scalable, flexible and preferably written by and for the end users (Fig 2). Armchair planners are generally a waste of time and space. The priority of all responders should be to save as many lives as possible and this requires Triage. The reality of triage requires the absolute epitome of professionalism. This is not the time for emotions to affect judgement. If the causalities are geographically together then the process involves an initial walk through and a predetermined tagging process. One that is commonly used is the Red, Yellow, Green or Black tag (Fig 3).

Triage is a process, not a procedure, and needs constant re-evaluation and this comes back to the primary and very pragmatic goal: this is a disaster, resources are overwhelmed, not every life can be saved but the outcome should be to save as many as possible. When disasters occur in urban locations, casualties may make their own way to a number of hospitals which makes the process of overall triage more difficult which underlines the need for a central command and control unit for response co-ordination (Fig 4).

It is essential in the planning to consider the handling of the dead. I am minded of the wonderful rendition by Kevin Branagh of Col. Tim Collins’ inspirational pre-battle speech https://www.youtube.com/watch?v=UpdeNcH1H8A watch it and you will forever remember to treat the dead with respect and dignity but also “... there is no time for sorrow, we will grieve for them later...” The wide reaching psychological impact of disasters cannot be understated as is the need for news. Both must be factored into any plan.

Returning to disasters when the primary injuries are thermal burns the recurring dilemma is whether to transport patients away from the disaster to other burns centres or to transport burn care professionals into the disaster area.

In Hong Kong, we did elaborate a distribution process for dealing with a Major incident involving Burns. Note, I use the word incident, not disaster. This distribution is based on the historical context of equality between Queen Mary Hospital (QMH) and Prince of Wales Hospital (PWH) but the reality is different. When asked to provide a concept plan for the burns centre in the new clinical block in PWH I insisted that the burns centre should be adjacent to the ICU and the theatres. That is where it is and that gives PWH the unique physical infrastructure for dealing with a large number of major burns (Fig 5,6) . But consider the human and other material resources. In preparation for the World Trade Organization (WTO) ministerial meeting in 2005 I developed, together with my wonderful ward manager Sherry Ng, an overview of dealing with just 15 patients with 50% Burn Surface Area full thickness burns (Fig 7). The number was derived from “the worst case scenario of an arson attack in crowded Victoria Park with 80 burn victims with 30 being severe.

Hong Kong has some excellent clinical facilities and many wonderful and dedicated healthcare workers. The incidence of major burns cases is however limited. On the positive side this is a reflection of the excellent prevention strategies in place but on the negative side it means that the local experience and expertise to deal with a large number of cases is limited. This is where politics must be set aside and a greater integration with the Mainland is essential particularly in the training of the nurses and doctors who are involved in Burns Care. I feel I have earned the right to say this as I have no vested interest apart from wanting the best for Hong Kong.

One final note is that I am now working in the new and exciting field of Regenerative Medicine which is predicated on the use of pregnancy specific biological substances (PSBS). These have proven benefit in burns care and also radiation injury. My colleague Lin Huang, who is in charge of the Skin Bank at PWH, authored a book chapter with me in which we reflect on the massive global waste of this invaluable resource¹. Briefly, each year the human race produces 50 million kg of placenta, 15 million square metres of amniotic membrane, 60 million litres of amniotic fluid, 61, 000 km of human umbilical cord and over 8 million litres of cord blood. 99.9% of this invaluable resource is thrown away! The birth rate in Hong Kong is one of the lowest in the world but do seriously consider storing fully screened PSBS. This would be a demonstration to the world that Hong Kong does have a vision for the future which includes the health and welfare of all its people, rich and poor alike.

1. Burd A and Huang L. A Massive Wastage of the Global Resources. In : Bhattacharya, N and Stubblefield P. Eds. Regenerative Medicine using Pregnancy-Specific Biological Substances. London, Springer 2011 p 3-8.