The 25th of April

{Please visit http://www.hapsaglobe.org for more information and to find out how you can help. Thank you for reading!}

It’s April of 2015 and I’m a third-year medical student at UT Southwestern (UTSW) on a psychiatry rotation. It’s a warm Friday night in Texas and I’m in an Uber home after a lively night out with friends when I first receive the news. Being my usual chatty self, I’ve started a conversation with my driver and am soon trying to guess where he’s from. “You are from Nigeria!” I say. He doesn’t correct me and simply responds, “I’d say you are good, but you’re wrong,” and proceeds to ask me about my own roots. While I’ve been living in the U.S. for over a decade, Nepal had been home for the first 13 years of my life. Of course, I tell him, with no small amount of pride, that I’m from Nepal. Before I can finish my sentence, his entire expression changes and he asks me with a clear sense of urgency if my family is okay. I remember being momentarily confused, followed by an instinctive thought of a terrorist attack. The next second, my mind overrules that because Nepal doesn’t have a problem with terrorist attacks. Having no other ready explanation, I unlock my phone to look at the news. The Uber driver, by now recognizing my confusion says, “Did you not hear about the big earthquake?”

I sober up in the blink of an eye.

My heart starts to race and I break out in a sweat as I frantically confirm the news on my phone. There’s been a major earthquake reported in Nepal of 7.8 or 8.0 magnitude with “catastrophic” damage. I fail to find any other details on the news. I think back to the 2010 earthquake in Haiti. A 7.0 magnitude earthquake there had taken more than 100,000 lives and caused billions of dollars’ worth of damage. I panic thinking that an 8.0 magnitude earthquake would’ve destroyed my whole country. I incessantly refresh multiple webpages each minute to get the latest updates. Some websites have the death toll at 2500. I refresh again and the number increases to 2600. Another refresh and its risen to 3000. The death count and extent of damage would be more accurate later, but it was clear enough within the first few hours that it was bad. I panic, perhaps not unlike every other Nepali person I knew who was away from their motherland that day. I try frantically over and over again to reach my friends, cousins and relatives in Nepal. None of my calls go through. Every time the death toll rises, I can’t help but think that maybe my relatives and/or friends are among those numbers.

As an undergraduate student, I had studied Urdu poetry. A particularly memorable couplet speaks of how a fish feels out of the water. That day was the first time I ever experienced what that must feel like. It felt as if I was suffocating. Suffocating due to the lack of information and feeling utterly helpless as a distant bystander in this situation. I spent the rest of that early morning on the couch trying to connect with someone, anyone, in Nepal. As the sun rose, more information came through about the epicenter of the earthquake and the degree of damage. The death toll was still rising each time I refreshed a webpage. It was after noon when I was finally able to connect to my cousin in Kathmandu. T-Mobile and other phone companies had kindly made calls to Nepal free through their networks. My cousin, Pankaj Bhattarai, confirmed that everyone I knew was safe and that everyone in Kathmandu was staying outside their houses. Pankaj explained, “The house was like a swing when it happened first. We thought it was our end.” I was happy they were safe, but strong, continuous aftershocks continued to occur. Pankaj said that with every aftershock people feared losing their lives and houses. Though they were now physically safe, their continuing psychological stress worried me. During my psychiatry rotation, I was learning about the long term psychological impacts of such traumatic events.

GhumarChowk

As the day progressed, I received more information from multiple sources. Although initial news reports were dominated by the effects of the earthquake in Kathmandu, eventually we learnt about the extent of damage to the surrounding districts. Besides the death toll, the significant damage to schools, houses, roads, and livestock in almost half the districts in Nepal was bound to set the developing country back even more.

The news that was most devastating to me personally came on Saturday afternoon: Ghumarchowk was very severely affected. This community was dear to my heart since I had worked there in 2013 as a first-year medical student. Hem Sarita Pathak Foundation, a non-profit organization from Austin, had asked me to provide hand hygiene and health awareness education in the local school there. Ghumarchowk is a village located in the hills surrounding Kathmandu, and is about a 30 kilometers and a 1.5 hour drive from the city. It is a settlement of the Tamang community — one of the many communities in Nepal that has been marginalized due to the Kingdom’s nationalist, and often exclusionary, agendas. After experimentations with parliamentary democracy in the 1950s, a ban was implemented on party politics and power was centralized to the royal palace. Nationalist politics took a spotlight during this period with the royal kingdom pushing for a “Nepali” identity. In particular, a specific brand of Hinduism, a national dress, one Nepali language, and loyalty to state and dynasty were advocated by the state. The ruling elite inspired most of these nationalist agendas, and in the process, it alienated and oppressed many ethnic groups, including the Tamang people.

I had spent a month during the summer of 2013 teaching hand hygiene to the children of the local Ghumarchowk school alongside my cousin, Pankaj. On the first day, we noticed a poorly maintained toilet. Pankaj and I cleaned the bathroom and figured out a way to bring water to the toilet while the teachers and students watched. Our actions, though unconventional, got the students and villagers interested in our project. The villagers welcomed Pankaj and I as we visited the school each day for the next month. Most of the villagers were farmers and lived in poverty. Most of them consumed alcohol every day and weren’t educated beyond the 5th grade. The broken health center in the village remained closed for the most part, and the government health post was too far for the villagers reach. Despite all this, they loved their village. It wasn’t long before we fell in love with the community.

When I got back to Dallas as a second-year medical student, three students in an Innovative Healthcare Solutions course I was facilitating became interested in the work I did in Nepal. They wanted to continue the project the following summer. For this visit, we set two goals: (1) assess and re-teach hand hygiene curriculum, and (2) understand and improve the health care available to the people of Ghumarchowk. Ryan, Michelle, and Charlotte went to Nepal in the summer of 2014 and enacted our plan. They carried out a comprehensive health assessment of Ghumarchowk using surveys and focus groups. During the process, they also fell in love with the people of the village. We shared the results of the health assessment with the Hem Sarita Pathak Foundation, and together we tried to address the needs identified. Later in December of that year, we partnered with a local Kathmandu hospital and conducted a medical and dental camp for more than 300 villagers. Although the villagers were happy with what we were doing, our team was dissatisfied with our temporary, one-off interventions. We wanted to strive to change the system and offer a permanent solution for the healthcare needs of these villagers.

Before we could make much progress, the 25th of April 2015 fell upon us. The harrowing news that close to 80% of the houses in GhumarChowk were destroyed felt like a physical blow. I remembered the kids who would happily sing the hand washing song with me; the old lady who had come to the health camp after having drunk “only 2 glasses” of homemade liquor; the mischievous kid who would skip class when I was not around; and the sweet young girl who wanted to become a doctor. I was anxious to know if they were all okay. I also felt it was morally imperative for me to respond and support this community within my capacity.

Acute Response 

With this in mind, I created a GoFundMe page like many others trying to raise money for their communities that day. I knew I wanted to focus on long-term solutions and not on the acute care that was already being provided by multilateral agencies and governments. I had no game plan beyond that on how I would spend the money raised. With the goal of few thousand dollars, I started a campaign titled “Medical Student for Nepal.”

Meanwhile, the rigors of medical education did not allow me to have time off. I reported for my clinical duty at Parkland Inpatient Psychiatry Service at 6am on Monday morning and was assigned to see a patient. As I interviewed the patient, a schizophrenic young man, my brain was preoccupied with what happened over the weekend and the continuing aftershocks in Nepal. Shortly after, I had to present the patient’s history to my attending and I was speechless. I had not even noted down the patient’s age, a vital component of the first sentence of a patient history presentation. My attending pulled me aside to ask me what had happened. Once I explained the situation to her, she connected me with an expert at UTSW who deals with psychological trauma in disaster settings and told me to explore resources that would help Nepali communities. She was also kind enough to offer me some time off to deal with things.

Back at home that evening, I saw for the first time that within a day I had exceeded my fundraising goal and, as a result, raised the goal to $10,000. To reach this target, I started emailing and messaging everyone I knew including faculty that I had worked with before, Facebook friends, and even people I only met in passing. I also called all of my friends. Since they were all students like me, I requested them to ask their parents to donate. Most of their parents had already donated to international organizations like the WHO and UNICEF. Thanks to several more donations the $10,000 goal was reached within 2 days. I increased the goal twice more to a final sum of $25,000. As the money started coming in, I asked Pankaj, back in Nepal, to explore areas around Kathmandu that had not received any help from the early responders. After a 2-day search, he found a community on the hill opposite of Ghumarchowk located in the Lalitpur district

Meanwhile, I reached out to the Nepalese Society of Texas (NST), a Dallas-based organization for Nepalis. Within a few days of the earthquake, NST had raised more than $100,000 and was planning on sending a team of medical professionals to Nepal with supplies. All my research had taught me that it was not a good idea to send non-essential supplies (like diapers and juices) and people untrained for care in disaster settings to the ground during the acute phase. During earlier earthquakes, we had a surge of generous people wanting to do that, but this approach, while well intentioned, overburdens the already busy government and NGOs that are trying to manage the situation. Although I tried to explain, I was unable to convince an emotional group of people wanting to help.

Nonetheless, since they were going to Nepal, I wanted to help them obtain supplies that would be necessary. I reached out to my colleagues who worked in Nepal and began to compile a list of medical supplies that they had found useful. My search for these supplies led me to Baylor Healthcare, which had a warehouse filled with medical supplies for NGOs. I will never forget the generosity they showed when I met with them. Once I told them that the supplies were for the Nepal earthquake, the Baylor folks invited me to take whatever we wanted from the warehouse. Together with volunteers from NST, we gathered about 23 boxes of medical supplies that included orthopedic casts and IV start kits. Some friends from medical school also took time off with me and helped sort through the supplies.

Once the NST team left, I focused on raising awareness about the earthquake with the UTSW community. Although my initial visit to Ghumarchowk in 2013 had been in coordination with the Global Health office at UTSW, the school was unable to help in this instance. Shortly after, Dr. Kavita Bhavan, my mentor, connected me with the CEO of Parkland Hospital, Dr. Fred Cerise. Dr. Cerise had been the Secretary of Health in Louisiana during Hurricane Katrina in 2005. He took time to meet with me and extended his help. Apart from his personal contribution, he provided a platform for me to speak with the Parkland community and the executive committee of the hospital regarding the earthquake and how they could contribute. Parkland employs and also takes care of many Nepali people as patients in Dallas. Alas, acts of great kindness like these do offer profound hope during moments of despair.

Strengthening the System

In July 2015, I went back to Nepal with the goal of assessing the two communities we identified. On my first day there, we (the local team and I) visited Ghumarchowk and walked through the village to assess the damage. In addition to all the houses, the already broken-down health center was severely damaged. The devastation in Ghumarchowk was unreal yet the whole village greeted us with smiles. People had already set up temporary tents and tins. They had seen an abundance of support during the acute phase, but complained that help had stopped coming to the village as the months passed. Later, we visited Lakuri Bhanjyang in Lamatar, the other village across the hill from Ghumarchowk. After extensive meetings with the villagers of both villages, volunteers in Nepal, and advisors in America, we decided to use the money to improve primary healthcare services in the villages.

In a way, disasters are opportunities to shake things from the core. This was our chance to change the way healthcare is provided in these villages. As an initial step, we committed to rebuild the health post (a district-level health center theoretically run by the state) for Lamatar, and made plans to turn a community building into a health center at Ghumarchowk. During my trip, I was also fortunate to meet Nick Abraham, a young man from Australia who wanted to help build sustainable buildings in Nepal. Nick and his team partnered with our team to help build the health center in Ghumarchowk.

Soon after the trip to Nepal, I began a Masters of Public Health degree at Harvard University. I used that opportunity away from clinical medicine to strengthen my core understanding of population health and health systems. As the year went by, I gained a better understanding of population health and health systems, and received invaluable advice about how we could further help these villages. In December 2015, I went back to Nepal working with Jhpiego, an INGO affiliated with Johns Hopkins University. Through them, I met with leaders at the Ministry of Health, Department of Health Services, as well as other NGOs and INGOs. It was a terrifically valuable experience interfacing with and seeing all the arms of the health system at work.

Long Term Goal

Today, it is the 25th of April again, two years after the earthquake. Although work from government and NGO fronts have started, a lot remains to be done.My team and I spent 2016 re-building the health centers, creating teams in the community, registering our organization in Nepal (HAPSA-Nepal), and creating partnerships with NGOs and the government. The members of HAPSA-Nepal come from business, medicine, public health, and pharmacy backgrounds, and share the same goal of strengthening the heath services in these villages. Our team is driven by the belief that the community must be at the center of healthcare decisions. More details of our mission, plans, and project model can be found here. On the 2nd anniversary, we have officially unveiled our projects and health centers — one in partnership with the local community, and the other with the community and the government. Our long-term goal at these places is to improve along two metrics: (1) lowering out-of-pocket payments, and (2) increasing utility of state-run primary health services. Out of pocket payments are healthcare expenditures that people spend from their savings and loans. These expenditures are credited with extending the cycle of poverty for thousands of Nepalis every year. The systems-based approach we are using will aid in ensuring long-term and sustainable benefits. Similarly, we hope to advise policy change and replicate these models at other community health posts around Nepal in the future. More information can be found at our website here.

April 25th is the most important date in Nepal’s recent history. Not only because the whole country was shaken, but also because such disasters are bound to happen again in the country. Nepal is located in one of the most seismically hazardous regions of the world, due to the ongoing collision of the Indian and Eurasian tectonic plates. As a Nepali, a future emergency medicine resident, and a student of public health, I will never forget this date. An earthquake, in medical terms, can be called an “acute on chronic” event. The chronic flaws and weaknesses of our systems become obvious in the acute phase of the earthquake. As vital as acute care is, as a community, we must work to strengthen our systems: health systems, disaster response and preparedness systems, telecommunication systems, etc.

I thank everyone who stepped up after April 25th, 2015 and donated their time and money to help, and those who prayed for the people of Nepal. While your acute response was invaluable, I implore us all not to forget what happened in Nepal on the 25th April 2015. Through our ongoing voluntary efforts, my team and I have pledged not to forget April 25th. I will be starting my residency in Emergency Medicine at Emory University this fall and plan to use my training to improve emergency services, as well as improve the health system in Nepal. In many of the meetings I attend now with Nepali organizations, the agenda for April includes much discussion of the Nepali New Year (April 14th), printing of calendars, celebrations, etc. These are important for any community group, but there is a lot more work needed to build earthquake awareness in our country. The Nepali groups that were very active during the earthquake need to continue being involved and work with the government to improve our systems. The slow, systemic response is not as flashy or exciting as the acute response, but it is absolutely necessary if we are to mitigate damage from subsequent earthquakes. It will be another winter and rainy season without permanent houses for many of those that were affected two years ago. Let us remember that it is not the earthquakes that kill. It is the weak houses, roads, buildings, bridges, hunger and disease that kill. We have a solution for all of these. Let us collectively work towards that solution.

In the words of Urdu poet Faiz Ahmed Faiz:

“Chale chalo ke woh manzil abhi nahi aaie”–Let’s keep moving, the destination is yet to come!

Sincerely yours,

 

Ramu Kharel,

Founder, HAPSA

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s