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Preparedness explains some differences between Haiti and Nepal’s response to earthquake

BMJ 2015; 350 doi: (Published 05 June 2015) Cite this as: BMJ 2015;350:h3059

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  1. Paul S Auerbach, Redlich family professor of surgery, Division of Emergency Medicine, Stanford University School of Medicine, USA
  1. auerbach{at}

Paul S Auerbach responded to recent disasters in both countries and reflects on why Nepal saw so many fewer deaths and injuries

On 12 January 2010, a magnitude 7 earthquake struck Haiti 25 km from the capital, Port-au-Prince. Between 160 000 and 200 000 people are estimated to have died and more than 300 000 were injured.

Five years later, on 25 April 2015 a 7.8 magnitude earthquake struck Nepal, its epicentre 77 km from Kathmandu. This was followed on 12 May by a 7.3 magnitude earthquake equidistant from Kathmandu but on the opposite side. So far 8604 people are reported to have died and 16 808 have been injured.1

In both countries, buildings collapsed and enormous numbers of people were displaced and relocated to improvised shelters. The risk of communicable diarrhoeal disease loomed because of crowding and rain. Restricted airport capacity delayed relief workers and supplies.

The many differences between the two countries help explain why Haiti was far more vulnerable than Nepal to a similar sized earthquake. Both countries are poor, but Haiti is significantly poorer than Nepal. Haiti is considered politically a fragile, if not failed, state. It was more densely populated in the immediate region of the earthquake. The overall result was that Nepal was better prepared than Haiti to respond to such a major disaster. Nepal’s comparatively low death toll shows how much preparedness, both by governments and the international community, can make a difference.

Haiti had less medical and civil infrastructure

Haiti had a very weak medical system infrastructure and shortages of staff and equipment even for routine care, let alone for mass treatment of patients with trauma. Large parts of the university hospital in Port-au-Prince collapsed structurally and functionally. Haiti had no effective emergency medical services system or network of community healthcare workers, and crushed neighbourhoods had had no preparation for dealing with an earthquake. Civil disobedience and marginally effective law enforcement ensued. Global responders effectively had to create a healthcare system rather than support one.

By contrast, Nepal’s robust healthcare system remained largely intact. Most of the many hospital and clinic buildings remained usable. They were staffed by highly qualified doctors and nurses, rose to the occasion, and functioned well. For example, Patan Hospital had been retrofitted to withstand an earthquake and the orthopaedic surgeons had working operating theatres.2 The recently created Nepal Ambulance Service, whose staff Stanford University Medicine International helped to train,3 worked overtime to transport injured patients while operating its dispatch centre from inside a tent.4 The business community, including the Federation of Nepalese Chambers of Commerce and Industry, organised volunteers who provided essential non-medical services. The military and local law enforcement helped transport patients and maintained law and order in public areas, which were rapidly occupied by displaced people.

Kathmandu was ready

I arrived as an emergency medical provider for International Medical Corps within a few days of the earthquake in Haiti and the first earthquake in Nepal. The first days of the response in Haiti were chaotic and there were tensions between the Haitian government and international organisations. The first days of the response in Nepal saw more prompt structured collaboration internally and coordination between national and international response organisations. Many Nepalese organisations had expected an earthquake and had prepared to some degree with drills.

We can learn lessons from what transpires in Nepal and from preceding earthquakes.5 To minimise loss of life and property, and maximise early recovery, preparedness is essential. Geophysicists can predict where and when earthquakes might occur.6 We must design for the possibility of earthquakes. The earthquakes in Nepal again highlight the perils of non earthquake-proof construction and isolation. Communities need to enforce building codes and construction standards, with incentives, funding, and the mandate to improve. The initial medical focus is on people seriously injured by falling debris and collapsing buildings. Poor living conditions following an earthquake mean that conditions such as diarrhoea, respiratory infections, and skin infections should be anticipated.7

All citizens should be taught personal protective behaviours, such as “drop, cover, and hold on,” and these should be practised in drills.8 9 National and international relief teams may take days to arrive, so communities need to identify local emergency response teams in expectation of a disaster, and the general population should be taught safe sheltering, water disinfection, and basic medical first aid. Every municipality should try to have, or know where to obtain quickly, heavy lifting equipment to clear rubble to allow movement through affected areas. Shelter, food, and water are essential for displaced people and responders. Sanitation and hygiene need to be priorities. Injuries and medical problems caused by earthquakes are predictable, and medical professionals need thorough and validated training. Emergency response systems should be created and prepared. Supply chain management, communication, and transportation needs can be anticipated. Interoperability of communication systems, particularly when multiple languages are spoken, should not be assumed without preparation. Events as large as the Nepal earthquake will almost always need a global response. Regional teams that can be rapidly mobilised could be set up.

Comprehensive global approach

Undoubtedly, discussions, reports, and action plans will follow the Nepal earthquake. Every aspect of rescue, medical care, and recovery will be analysed, with criticisms and suggestions. Whatever the conclusions, we should call for an integrated global approach to preparedness, and we should prepare and practise self help and mutual aid until we are confident that we can respond as effectively as possible.


Cite this as: BMJ 2015;350:h3059


  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.


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