It’s April 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 going home in a cab after a lively night out with friends. Being my usual chatty self, I’ve started a conversation with the driver, who asks me about my roots. While I’ve been living in the US for over a decade, Nepal had been home for the first 13 years of my life. 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 if my family is okay. I remember being momentarily confused, followed by an instinctive thought of a terrorist attack. The next second, my mind dismisses that as Nepal doesn’t have a terrorism problem. The driver, recognising my confusion, says, “Didn’t you hear about the big earthquake?”

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 in Nepal of magnitude 7.8 or 8.0 with “catastrophic” damage. 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 to get the latest updates. Some websites have the death toll at 2,500. I refresh again and the number increases to 2,600. Another refresh and it’s risen to 3,000. The death count and extent of damage would be more accurate later, but it was clear within the first few hours that it was bad. I panic and try frantically 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 included in those numbers.

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 epicentre of the earthquake and the degree of damage. The death toll kept rising. It was after noon when I was finally able to connect to my cousin in Kathmandu. 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 aftershocks continued. Pankaj said that with every aftershock, people feared losing their lives and houses. Though they were now physically safe, their psychological stress worried me. During my psychiatry rotation, I was learning about the long-term psychological impacts of such traumatic events.

Village of Ghumarchowk

As the day progressed, I received more information from multiple sources. The news that was most devastating to me personally came on Saturday afternoon: the village of Ghumarchowk was severely affected. This community was dear to my heart. Hem Sarita Pathak Foundation (HSPF), a non-profit organisation from Austin, had asked me to provide hand hygiene and health awareness education in the local school there. During the summer of 2013, I, and my cousin Pankaj, had spent a month there teaching hand hygiene to the children of a local school. Ghumarchowk is located in the hills surrounding Kathmandu, about 30km and a 1.5 hour drive from the city. It is a settlement of the Tamang community, one of the many long-marginalised communities in Nepal.

Most of the villagers there are farmers, live in poverty, and have little more than a 5th-grade education. Most of them consume alcohol every day. After working there myself, in the following year we expanded the hand hygiene project and undertook a broader health needs assessment. I recruited three junior medical school colleagues to visit the village in July 2014 and carry out the assessment. We shared our results with the HSPF, and together we partnered with a local Kathmandu hospital to conduct a medical and dental camp for more than 300 villagers. Although the villagers were happy with what we were doing, our team was unsatisfied with our temporary, one-off intervention. We wanted to change the system and offer a permanent solution for the health 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 percent of the houses in Ghumarchowk were destroyed felt like a physical blow. I remembered the names, faces and voices of individuals I had met there. I was anxious to know if they were okay. I also felt it was morally imperative for me to respond by supporting this community within my capacity.

Strengthening health systems

With this in mind, I created a GoFundMe page titled “Medical Student for Nepal” with the goal of raising a few thousand dollars. 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 about how I would spend the money I raised.

Within the first day, the donations poured in, exceeding my initial fundraising goal. As a result, my hopes were emboldened, and I raised the goal to $25,000. I started calling, emailing, and messaging everyone I knew, even people I had only met in passing. As the money started coming in, I felt that we could and should extend our reach beyond just the village of Ghumarchowk. I asked Pankaj, back in Nepal, to explore areas around Kathmandu that had not received any help from the early responders. After a two-day search, he found a community on the hill opposite of Ghumarchowk located in the Lalitpur district. It was Lakuri Bhanjyang, another Tamang village.

Meanwhile, I became involved with Nepalese Society of Texas (NST), a Dallas-based organisation for Nepalis, to gather about 23 boxes of necessary medical supplies including orthopedic casts and IV start kits to be sent to Nepal. I also focused on raising awareness about the earthquake with the UTSW community. My initial visit to Ghumarchowk in 2013 had been in coordination with the Global Health office at UTSW, but the school was unable to help with our earthquake response. However, Dr. Kavita Bhavan, my mentor, connected me with the CEO of Parkland Hospital, Dr. Fred Cerise, who had previously served as Louisiana’s Secretary of Health 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 provides health care to many Nepali people in Dallas. Acts of great kindness like these offer profound hope during moments of despair.

In July 2015, I went back to Nepal with the goal of assessing the two communities we identified.  On my first day there, the local team and I visited Ghumarchowk and walked through the village to assess the damage. The devastation was unreal, yet the whole village greeted us with smiles. People had already set up temporary tents. They had seen an abundance of support during the initial phase, but rued that help had stopped as the months passed. Later, we visited Lakuri Bhanjyang in Lamatar. After extensive meetings with the residents of the two villages, volunteers in Nepal and advisors in America, we decided to use the money to improve primary healthcare services in these 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 centre theoretically run by the state) for Lamatar, and made plans to turn a community building into a health centre 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 centre 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, getting invaluable 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 a lot of work has been done, much more remains to be done. My team and I spent 2016 re-building the health centres, creating teams in the community, registering our organisation 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 health services in these villages. Our team is driven by the belief that the community must be at the centre of healthcare decisions. On the 2nd anniversary, we have officially unveiled our projects and health centres—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: lowering out-of-pocket payments, and 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 known to extend the cycle of poverty for thousands of Nepalis every year. We believe our systems-based approach will address these two issues and ensure a long-term, sustainable solution. Furthermore, we hope to replicate these models in other community health posts by advising national policy change based on our results.

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. 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. Just like with many medical illnesses, 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 25, 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 April 25, 2015. Through our ongoing voluntary efforts, my team and I have pledged not to forget April 25. 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 organisations, 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 their involvement 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 monsoon and winter without permanent houses for many of those who were affected two years ago. Let us remember that it is not the earthquakes but 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.

Kharel has a Masters of Public Health from Harvard and is a founder of HAPSA