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From remote Nepal, a warning against ahistorical disaster relief

Villagers wait in the rain as an aid relief helicopter lands at their remote mountain village of Gumda, near the epicenter of Saturday's massive earthquake in the Gorkha District of Nepal, Wednesday, April 29, 2015. AP

Editor’s note: David Citrin is a medical anthropologist who has lived and worked in remote western Nepal since 2001. He was there when the earthquake hit and offers advice on how to make this recovery response more lasting and effective. 

By David Citrin, special to Humanosphere

Map of Nepal. The star is Accham, where Citrin and his colleagues are  located.

Map of Nepal. The star is Accham, where Citrin and his colleagues are located.

When the magnitude 7.8-earthquake struck Nepal on Saturday, we thought it was a small, localized tremor. Here in the remote Achham District of western Nepal, where we are working at Bayalpata Hospital, we simply exited the buildings and stood under a covered walkway, listening to the thunder and the rain.

Some wondered what would happen to this poor country if the dreaded, and expected, “Big One” struck. The speculation ended when we began receiving phone calls from friends and family members reporting what had happened some 200 km to the east – the massive destruction in Kathmandu, the landslides, building collapses and the rapidly increasing death toll.

If there is any silver lining to this catastrophe, it’s that the quake hit on a Saturday afternoon – when schools were empty and many were outside their homes. The official death toll, now above 5200 killed, will likely double as rescue and recovery teams reach more communities. And yet it could have been much, much worse.

But long-term success in helping Nepal recover from this disaster will not come from the standard response – an outpouring of humanitarian efforts, good intentions, donations and flying in talented folks to provide emergency help. These things are needed, yes, but not sufficient.

Put another way, we need to make sure the international community’s response to Nepal does not end up looking like Haiti. After the massive quake in 2010 there killed more than 100,000 people, the world launched an equally massive relief response involving just about every humanitarian organization and, eventually, billions of dollars of aid.

Yet some say Haiti has improved little and we still don’t know where all the money went.

It is hard to apply a critical lens to disaster relief; it can so easily appear cruel, misplaced and selfish. Yet, we have the obligation to consider both the possibilities and limits of medical humanitarianism, or any humanitarian effort, as the international community wrestles with how best to help Nepal.

This is a country in the throes of a fragile process to rebuild democracy following a decade-long civil conflict that claimed a conservatively estimated 13,000 lives. The international community has done a lot to undermine that process. This is not a historical footnote, but rather these circumstances make up the backdrop against which the immediate disaster relief efforts—and the rebuilding to come—are set.

Bayalpata Hospital in Accham.

Bayalpata Hospital in Accham.

The monsoon season fast approaches. Thousands of people are sleeping in cars or in open spaces because they have lost their houses, or fear more tremors. Reports of hoarding supplies in affected areas are minimal, but prices are soaring.

The shelves of groceries are bare in Kathmandu, and a 10-Rupee packet of instant noodles now sells for 75, a bar of soap is going for 100 Rupees. I spoke to a friend on the phone yesterday who witnessed a scuffle over petrol, which ended with a rock soaring through the front window of a passenger car.

The indirect effects of this natural disaster will be the threats to public health and sanitation, food insecurity, homelessness, and the grief and trauma of loss that will follow. To some extent, these threats existed before this tragedy, due to the same international development community now seeking to offer emergent help.

Decades of the West’s so-called structural adjustment programs have capped expenditures on Nepal’s public health care system, leaving the country often unable to respond to the day-to-day needs of its largely rural population of 29 million. Social services have been steered towards the private sector, and in the neo-liberal drive towards free-market policies, as with other low- or middle-income countries, NGOs (non-governmental organizations) have been promoted to fill the gaps in public services that resulted from reduced public spending.

Remote areas of Nepal, like where we work in Accham, have been especially excluded from the benefits of so-called “development” – bikās, as it’s commonly translated in Nepal – and the attendant socio-political and economic spheres.

Peter Redfield reminds us that humanitarian responses to suffering cannot escape the historical conditions to which they respond. To be sure, the circumstances that leave Nepal now coping with the herculean task of disaster relief are tectonic and geo-topographical, but they are simultaneously historical and human made.

The question at hand now is what to do, and what not do. Here, I humbly offer some guiding principles, and compile my and others’ thoughts on ways to channel efforts and resources:

  1. Coordination. The deluge of international aid and relief efforts already underway in Nepal are rooted in global citizenry, in personal connections to Nepal, in love and in sadness. This challenge of coordination will be nearly as herculean as the heroic relief efforts to rescue those still trapped under rubble, and to treat the 10,000+ injured. Nepal is a country already brimming with NGOs; some put the actual figure at around 40,000, constituting what the late Nepali anthropologist Saubhagya Shah referred to as a veritable “NGOdom.” The efforts of international relief organizations and NGOs will need to be systematically coordinated: we must act with conviction, but we must act together, lest we run the risk of tectonically colliding with one another, collapsing the potential multiplicative effect of our efforts.
  1. Transparency. We must heed the lessons learned from the 2010 earthquake that devastated Port Au Prince, where only 1 percent of the 3.6 billion dollars that went to Haiti through international donors for immediate disaster relief and recovery went to the government. Online one can already see the pleas to avoid giving money to the Nepali government for fear of corruption and misuse. We must reject these claims; this is a matter of autonomy and governance. Ultimately it will be the Nepali government charged with rebuilding a home for its people. Please make sure to coordinate efforts with Nepal’s National Emergency Operation Centre, and find transparent organizations that have deep connections to the country and/or specialize in effective disaster relief management. Working with engineers from Google, the American Nepal Medical Foundation is operating a real time needs assessment to coordinate efficient supply chain management with hospitals and care teams to treat trauma victims. The international organization Médicins San Frontièrs is another reputable organization with personnel currently on the ground, as is the Red Cross. But, don’t simply go with the big names out there, it is most important that you find an organization you, or someone you know with a deep understanding of Nepal, can trust.
  1. Avoid medical voluntourism. All non-Nepali medical practitioners going to Nepal to engage in direct service delivery are obligated to register with the Nepal Medical Council. This regulation rightly remains in place even in the face of such a tragedy when medical skillsets and supplies are so widely and immediately needed. Reports from colleagues working closely with the government on response efforts confirm that there are ample Nepali medical professionals to deploy, though, again, the challenge remains in coordination. If you are a non-Nepali credentialed professionals (no students, please!) going to Nepal, remember that this is not about you or your feelings of guilt or competency. Remember to ‘first do no harm.’ Defer to local Nepali medical professionals about how you can best support their existing efforts. Match specializations with need. Consider staying home and sending the money you would have spent on a flight to support the efforts. As Dr. Stephen Bezruchka reminds us, “Don’t just do something, stand there’ — unless it is obvious that doing something will help.”
  1. Reach the rural poor. The loss of historical monuments and UNESCO world heritage sites are immeasurable. Still, reports of villages outside the Kathmandu Valley remind us that the true loss of livelihood will most certainly be concentrated in rural parts of the country. In the words of Sienna Craig, “True to the logic of structural violence, women, children, and those at the bottom of Nepal’s socioeconomic and caste hierarchies will be severely impacted. ”We must focus on ensuring essential material resources—food, medicines, water and shelter—reach the rural poor. The ethnically Tibetan community of Bridim in Rasuwa district north of Kathmandu where, in 2001, I spent a week during my first trip to Nepal is reported to have been “virtually flattened.” Our relief efforts must extend to these areas if they are to roll back up steep gradients of inequality; this challenge will be monumental.
  1. Build back better. Nepal only seems to make the international headlines when there is a royal massacre, a Maoist war, an avalanche on Everest, or a devastating earthquake. As a global collective consciousness, we have a rather short attention span, and as the headlines fade from the newspaper in the coming weeks, so will the immediacy of crisis. The real challenge now lies in rebuilding Nepal’s roads and infrastructure, which some estimate might cost up to around $USD 10 billion, or approximately 20 percent of the country’s GDP. My own government, the United States, should be ashamed of the pittance $1mm donated to Nepal. We must ensure that, alongside the pressing need to solve for people suffering right now, we also commence the work of addressing the longstanding unmet basic material and nonmaterial needs of Nepali people. We can do this by working alongside the Government of Nepal to build structures and systems that will not collapse. In this there is hope, and renewal.

David CitrinDavid Citrin, PhD, MPH, is an affiliate instructor of anthropology and global health at the University of Washington, and has been working and conducting research in Nepal since 2001. He writes from a remote western region of the country where he is working with the government and a non-profit organization Possible to improve rural health care. 


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