Buddha Basnyat

When the earth shook violently at midday in Nepal on April 25, 2015, I was walking down my concrete staircase. As I was hurtled from side to side, I was certain I would die. Luckily, I didn’t. This was a pure privilege in the midst of so much death and destruction.

An earthquake in Nepal was a “no brainer”; something that seismologists had long predicted. Even so, the country was unprepared. And similar to the response to the Haiti earthquake, doctors from all over the world flocked to Nepal to help. Even as the commercial planes circled around Kathmandu’s busy Tribhuvan International Airport awaiting their turn to land, passengers looking out the windows could see that Kathmandu had not been razed to the ground, as expected with a 7.8 magnitude earthquake. Sadly, this was not true of the many remote mountain villages in this Himalayan country.

The scale of destruction in villages in the Gorkha district, the epicenter of the quake, was captured in aerial photographs that were published globally. I can only imagine the horrific sense of impending doom that many must have experienced as roofs and walls caved in and engulfed them in clouds of dust and falling debris.

Even in the midst of all this death and destruction, the resilience of the Nepalese people in villages was truly inspiring. While people were exhuming bodies from the rubble, other members of their families continued their work in the fields, just as they had done for centuries.  Clearly, there was deep sadness, but there was also a pervading sense of needing to meet the basic needs of survival, and to help others in the community do the same.  I witnessed a moving example of this. On the morning of the earthquake, a woman and her husband had been working in their field. During their lunch break, the husband rested in his bed while the wife stayed outside. When the earthquake struck, he was killed, but his wife and children who were playing outside all survived. Three days later, the husband’s body had still not been recovered, but the wife was back working in the same field. She said she needed to feed and educate the children, and if she did not have the land ready for plantation before the monsoon, the family would probably starve. Subsistence farmers throughout the country are surviving in the same way, through true grit and determination.

Nepali doctors from throughout the country responded immediately to the disaster. Within hours, Nepali orthopedic surgeons in various hospitals were reducing open fractures, and competently coping with the influx of quake victims. Despite Nepal’s low-income status, many army and civilian helicopters transported severely injured people from remote villages to Kathmandu hospitals on the same day as the quake.

Despite the overwhelming scale of destruction in areas such as Sindhupalchok, many severely injured people were successfully transported to Kathmandu by road or helicopter. Even in the worst-hit areas, the death toll was lower than expected—given the level of destruction) —because villagers were out working when the earthquake struck.

Although helicopter rescues were prompt in some areas, this was inconsistent.  There were some scenes of inequity. Foreigners trekking in the Langtang Valley used their satellite phones to call helicopters.  A landslide had buried hundreds of people in this valley. When the trekkers boarded the helicopter, the local villagers clung to its  landing skids and would not allow it to depart with uninjured foreigners ahead of badly injured Nepalis. This uncharacteristic behavior arose from the injustice of some helicopter companies not helping local people most in need. Although hospital care, including surgical care, was made free for Nepalese earthquake victims, the real barrier to care is access to hospitals—hence the desperation to get people on the helicopters.

When teams of doctors from local and international doctors hurried to villages to help with the earthquake response, many found that patients were seeking their help for chronic diseases like gastritis, prolapsed uterus, tuberculosis, and headaches—all of which predated the earthquake. This was both surprising and anticlimactic for many doctors who came with a focused, altruistic, and compassionate motive to help Nepal deal with its acute medical and surgical post-quake crisis. Even the Western doctors volunteering for the Himalayan Rescue Association (which has been helping climbers in the Himalayas for almost 40 years) were hard-pressed to find useful work. Indeed, there was a feeling of being “all dressed up with nowhere to go.” By the time the international doctors arrived, the surviving patients with severe injuries had been transferred to hospitals.  Many of these doctors ended up ferrying tents and food by helicopter to remote mountain districts, rather than providing medical services.

The influx of international doctors could have been avoided if there had been better coordination with local Nepali doctors and the local health system. The international doctors  continued to arrive for quite some time after the earthquake; I suppose many foreigners felt strongly that they needed to come and help. Many doctors may have been in what has been described as the “Haiti mindset,” where you just show up and try to work. Fortunately, the scale of the disaster in terms of the death toll was significantly less in Nepal than in Haiti—about 9,000 in Nepal as compared to 200,000 in Haiti.

The death toll alone, however, does not show the full picture of the aid that Nepal will need to recover from this disaster. Accessibility to remote villages, adequate food, shelter and medicines for the survivors is a colossal challenge in Nepal, given the mountainous terrain and remote, solitary villages. Furthermore, there is a disorganized, often corrupt bureaucracy which makes the fulfillment of people’s rights to food, health facilities and services, and shelter difficult to achieve.

In the wake of the earthquake, Nepal is already instituting changes, including stricter building codes. But the country will need all the help it can get to ward off post-disaster health hazards, such as infectious diseases. There may be complications from the orthopedic surgeries that will need careful attention to avoid permanent damage. More sophisticated specialty care may yet be required, with expertise from abroad.

This earthquake, tragic as it was, may afford us an opportunity to make a fresh start for better health care services in Nepal, given the worldwide attention and potential funding becoming available from international sources. It is essential for this country to take the lead on how that funding is used, and for the Nepali government to implement new and innovative ideas, such as universal health coverage in keeping with the new UN sustainable development goals, and human rights. It would be a fitting outcome from our tragedy if international funds were used to make health services more readily accessible throughout Nepal.

 

Buddha Basnyat, MD, MSc, FACP, FRCP, Director of the Oxford University Clinical Research Unit-Patan Academy of Health Sciences, Kathmandu, Nepal, and Visiting Physician at the Banner University Medical Center, Phoenix, Arizona, USA.

Please address correspondence to Dr. Buddha Basnyat, Nepal International Clinic, Lal Durbar Marg-48, GPO Box 3596, Kathmandu, Nepal. Email: buddha.basnyat@ndm.ox.ac.uk.

 

 

 
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