Nepal’s major hospitals are not prepared for emergency response and care in an event of another earthquake or pandemic, according to a recent new study published in the International Journal of Emergency Medicine. The paper lists a serious lack of preparedness at emergency units of hospitals, and compares the capacity of private, government, and teaching hospitals in Kathmandu.
The study was the first of its kind conducted in Nepal and its investigators aimed to build on the Emergency Care Systems Assessment (ECSA) conducted by Nepal’s Health ministry the WHO in 2019. The ECSA report had identified 39 key items to improve emergency care in the country. <a href="http://archive.nepalitimes.com/news.php?id=17851#.ZA7O-3ZBy3A" target="_blank">Another survey in 2011</a> had shown that only two of the hospitals in Kathmandu Valley at the time had earthquake resistant buildings.
&nbsp;The cross-sectional pilot study looked into seven tertiary hospitals in the Valley out of which three are academic, two are governmental, and two are private institutions. Included in the study are TU Teaching Hospital, Patan Hospital, Dhulikhel Hospital, Bir Hospital, the National Trauma Centre, Grande Hospital and HAMS Hospital.&nbsp;
Researchers used a cross-sectional mixed-method study to gather data on facility characteristics, human resources, clinical services, and signal functions of seven major tertiary-level health facilities in the Kathmandu Valley.&nbsp;
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Investigators identified three respondents from each of the seven institutions who are directly involved with the emergency department in a clinical care or administrative leadership role. Respondents included physicians, nurses, hospital administrators, and general hospital staff.
Emergency response—which is at the forefront of natural disasters and pandemics—during two major disaster events in the country, the 2015 Gorkha earthquake and the Covid19 Delta wave in 2021, showed that Nepal’s emergency response and care was subpar, write the authors.
“This study was designed and conducted so that we recognise our weaknesses, and start slowly improving them,” said Olita Shilpakar, an emergency physician at TUTH, and one of the authors.
The study concluded that while all the facilities surveyed had general availability of round-the-clock emergency services, there were significant gaps as well as differences in infrastructure, diagnostic, consultant, and human resource availability.
“The WHO estimates nearly 40% of lives can be saved with appropriate emergency care,” said Ramu Kharel, an assistant professor of emergency medicine at Brown University in the USA who led the study. “Improving emergency care is one of the most efficient public health interventions. Our study identified many opportunities for us to improve emergency care at hospital levels.”
Government hospitals were characterised by a lack of a designated triage area, as well as the unavailability of Obstetrics/Gynecology (Ob-Gyn), orthopaedics, paediatrics, or psychiatry consulting services.
Academic hospitals had limited isolation rooms or infectious diseases and were found to not have adequate access to toilet facilities. There was limited availability of social work services and security personnel.&nbsp;
In private hospitals, protocols for time targets in triage, triage for children below five years of age, trauma care, and burn care among other services were found to be missing. Safety protocols for managing hazardous exposures were not there, and there was a lack of protection for staff and patients from violence.&nbsp;
While government hospitals that typically care for low-income populations reported better availability of ancillary services and social care services, private hospitals not supririsngly scored the highest in access to and availability of health infrastructure.
Meanwhile, academic facilities were found to have more written protocols given their increased likelihood for research and teaching compared to governmental and private facilities. However, academic institutions were found to have the highest rating with greater availability of consulting services.
Common barriers across all institutions included a lack of training in key emergency procedures, written protocols, point-of-care testing, and ancillary patient services.&nbsp;
Read also: <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">Is free health care possible in Nepal?</a> S P Kalaunee
Researchers have recommendations regarding the triage system and time metrics, training and education, written protocols for emergency care, and health infrastructure in order for the health facilities included in the study to improve emergency care. Investigators also highlighted a need for specific training, and cross-collaboration between the institutions to strengthen Nepal’s emergency services.
“The findings of this study will allow us to find areas of collaboration between institutions as well. For example, some hospitals have better protocols, others have better triage systems,” said Kamal Thapa, one of the study investigators and an emergency consultant at Grande Hospital. “We need to work together to improve emergency care. Ultimately, our concern is <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer">good patient care.</a>”
Emergency medicine is a new field globally, and especially so for Nepal but evidence from other countries has shown that even simple interventions— like having a good triage system in hospitals— have a significant impact in saving lives.
Said Kharel: “The next step for these hospitals is to use the findings as a guide to take steps towards addressing gaps identified in this report. Furthermore, we need to conduct larger research around the country to look at gaps in emergency care in rural area facilities.”
Read also: <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">Health tip</a>, Editorial

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Emergencies in Nepal's Emergency Rooms

<figure><img width="800" height="600" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101124/63720a059c7e80680e0b5579jpeg.jpg" alt=""/><figcaption>Photo: NEURO HOSPITAL</figcaption></figure>* A 32-year-old female patient was suddenly unable to move one side of her body. She was rushed to Upendra Devkota Memorial National Institute of Neurological and Allied Sciences (Neuro Hospital) where doctors used a new non-invasive treatment to remove a clot that was obstructing the artery supplying blood to her brain. The patient’s mobility was immediately restored and she walked out of the hospital.* A man in his mid-fifties arrived at Neuro hospital five hours after suffering a stroke. He underwent the 15-minute procedure after which he could move all of his limbs freely.The strokes could have been fatal for both patients if they had not been rushed to hospital, and if the new state-of-the-art mechanical thrombectomy procedure was not available.The prevalence of strokes in Nepal has increased 40% in the past decade, and more and more younger people are suffering the condition that could paralyse or kill them. Strokes are the third leading cause of premature deaths in Nepal, and ranks first for disabilities. A person somewhere in Nepal suffers a stroke every 20 seconds. Doctors say a changing lifestyle and <a href="https://www.nepalitimes.com/banner/nepalis-binge-on-junk-foods-the-west-rejected/">dietary habits</a>, including heavier drinking and smoking has led to an increase in <a href="https://www.nepalitimes.com/latest/why-do-so-many-nepalis-have-high-blood-pressure/">hypertension</a>, <a href="https://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018">diabetes</a>, high cholesterol — all precursors to strokes. <figure><img width="1201" height="660" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101124/63720a089c7e80680e0b557ajpeg.jpg" alt=""><figcaption>Subash Phuyal, Photo: AMIT MACHAMASI</figcaption></figure>Recent studies have also reported that people infected with Covid-19 have an elevated risk of ischemic stroke, adding to the burden of disease. Other risk factors include aging, congenital heart diseases, hormonal changes and pregnancy. Women are comparatively more prone to suffering strokes.Ischemic strokes account for 85% of all cases, where an artery supplying blood to the brain is blocked damaging it. Haemorrhagic stroke, on the other hand, occurs when blood from a ruptured artery collects in the brain.“A stroke is a medical emergency, especially ischemic stroke which can lead to permanent disabilities and even death if it is not treated immediately,” says Subash Phuyal, Nepal’s first interventional neuro-radiologist at the Neuro Hospital in Bansbari.In fact, speed is of the essence to save the life or prevent life-long paralysis of a patient. But patients in Nepal often are not aware of symptoms and get to hospitals too late, where the right treatment may not be available. <figure><img width="4032" height="3024" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101124/63720a0b9c7e80680e0b557bjpeg.jpg" alt=""><figcaption>Madhu Devkota, Photo: KUNDA DIXIT</figcaption></figure>Unlike a heart attack, stroke patients do not feel any pain, making it difficult to identify it. Which is why doctors have come up with the acronym BE FAST (Balance, Eyes, Face drooping, Arm weakness, Slurred speech, and Time) to identify signs of stroke in time.Patients usually experience a sudden problem with their sense of balance, have blurred vision, double vision or loss of sight in one or both eyes. There could be facial drooping, weakness or paralysis on one side of the body, and slurred speech.If a patient gets to hospital within four hours of a stroke, they are immediately given a medicine to dissolve the blood clot obstructing the artery, restoring blood flow to the brain. This treatment is effective in only 10% of patients. Read also: <a href="https://www.nepalitimes.com/banner/new-treatment-offers-hope-for-nepals-leprosy-patients/">New treatment offers hope for Nepal’s leprosy patients</a>, Sonia AwaleHowever, with mechanical thrombectomy, 90% of patients who get to hospital in time can be cured. A small incision is made in the thigh and catheters inserted using an imaging machine in the cath lab. The catheter travels along the major arteries until it retrieves the clot to allow the blood to flow again.In the case of haemorrhagic stroke, surgery to clip the blood vessel is now replaced with a method called endovascular coiling in which the catheter inserts platinum coils to block the aneurysm.This non-invasive mechanical thrombectomy was first devised in 2015, and it was already available at the Neuro Hospital in Kathmandu four years later. Its biplane cath lab has been treating up to 25 patients a month.The hospital’s founder <a href="https://www.nepalitimes.com/here-now/upendra-devkotas-lives/">Upendra </a>Devkota (see box) was determined to introduce the newly-developed endovascular treatment technology in Nepal, but did not live to see it save lives. He died of cancer in 2018. His wife Madhu Devkota completed the dream, and set up an interdisciplinary team for stroke patients. Neuro Hospital is also building a rehabilitation centre for recovering patients who often need physiotherapy.But despite having the most advanced stroke treatment in Nepal, most people are not aware of the danger signs of a stroke. They also do not know that such non-surgical treatment is available in Kathmandu. It is also not widely known that such care is available in the country, and up to half the stroke patients at Neuro Hospital are brought too late for treatment.Nepal’s topography adds to the problem of getting patients to hospital in time. Madhu Devkota suggests the government could provide an air ambulance facility, as it does for complicated maternity cases.Says Subhash Phuyal: “People must know that strokes are preventable, and that advanced treatment is available right here in Nepal. But the most important thing is to get the patient to hospital as quickly as possible.”  <img width="630" height="882" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101124/63720a0f9c7e80680e0b557cjpeg.jpg" alt="">Visionary doctorA young and talented doctor at Bir Hospital, Upendra Devkota, was sent on a scholarship to the Glasgow Neuroscience Institute in 1983 to train in neurosurgery. Under the guidance of the renowned Professor Graham Teasdale, Devkota proved himself among the best neurosurgeons in the world and had a bright career ahead of him in the UK.But the Gurkha-native left all that behind to return to Nepal in 1989 to set up the country’s first Neurological Trauma Unit at Bir Hospital. He worked day and night, while also training young neurosurgeons with limited resources.Devkota briefly served as the Health Minister under King Gyanendra in 2005, and a year later started setting up the National Institute of Neurological and Allied Sciences.“Many tried to dissuade us, but despite challenges we were determined to set up an institution dedicated to preventing paralysis and disabilities in Nepal,” says Madhu Devkota. “My husband had foreseen the need for an advanced neurological centre in Nepal. So we thought, if not us, who would? So, we ran with it.”Read also: <a href="https://www.nepalitimes.com/latest/why-do-so-many-nepalis-have-high-blood-pressure/">Why do so many Nepalis have high blood pressure?</a> Sonia Awale

New cure for stroke, but prevention is key

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110161148/636d1db19c7e80680e0af3d0jpeg.jpg" alt="" width="767" height="575"/><figcaption>Security personnel and relatives of the deceased attend a mourning at the premise of infectious disease hospital in Pokhara. Photos: BARSHA KAFLE</figcaption></figure>A 79-year-old woman lay on the emergency bed, diagnosed with pneumonia due to Covid-19. Even as she was gasping for breath she had a smile on her face, handing over an invitation card to the attending doctor who was also her relative.Her grandson’s wedding was four days later. Family members from across the world had flown into Pokhara for the ceremony. She died of severe acute respiratory distress syndrome with multiple organ failure a day before the wedding, and it had to be cancelled.As her physician, I had sleepless nights when her condition worsened. We <a href="https://www.nepalitimes.com/here-now/nepal-health-workers-battle-covid-19-but-also-stigma/" target="_blank" rel="noopener noreferrer">health-care workers are also human beings</a>. When we lose near and dear ones it takes a toll on our physical and mental health, we grieve when our patients die. We may hide our emotions but we suffer all the same.The woman was just one of many relatives I have lost during this pandemic. As I grieved with family members gathered at the hospital, we were once again reminded of the Buddhist teachings about impermanence. Yet none of us is ever ready.“But it must be easier for you to face death as a doctor,” one of the mourners said to me. No, it is just as difficult. If not more, because as a physician I had the added responsibility of saving her life.Army men dressed in PPE from head to toe had arrived to take her body for safe disposal. Relatives from across the world who had come to celebrate a wedding ended up attending a funeral.The Gandaki Province government established Nepal’s first provincial infectious disease hospital in July 2020. Since then, it has managed nearly 1,300 Covid-19 cases at a cost of Rs500 million.Tha Gandaki Province government established Nepal's first provincial infectious disease hospital in July 2020. Since then, it has managed nearly 1, 300 Covid-19 cases saving Rs500 million out of pocket expenditure of common people.We have lost 52 people to the coronavirus in the same period. The Covid-19 mortality rate in this provincial hospital is 4.1%, relatively high compared to the total number of people who were hospitalised.The global death rate now stands at 1.97% with a total of 5,318,277 fatalities. This figure is exceptionally high given it has only been two years. Even then, this figure does not include <a href="https://www.nepalitimes.com/banner/the-real-cost-of-nepals-second-wave/" target="_blank" rel="noopener noreferrer">the social, mental and economic consequences</a> to family and friends of the deceased.But each Covid death is also a lesson for us to learn from. Most of these deaths could have been prevented if only Nepal had a robust primary health care system, and if preventive measures were more strictly enforced.With the <a href="https://www.nepalitimes.com/here-now/omicron-may-not-be-as-risky-but-take-care/" target="_blank" rel="noopener noreferrer">rise of new variants like Omicron</a>, it is also advisable to up our vaccination drive and we should also start administering boosters to vulnerable populations given our stock of doses and those that are on the pipeline.A man in his late thirties was isolating at home in Pokhara after getting infected. He just had a common cold but I requested him to undergo hospital-based isolation as he was symptomatic. But just a few days after getting admitted, his symptoms worsened and his condition deteriorated. He was then transferred to another hospital, and died soon after.This was not a case that should have been fatal. Even after 12 years of clinical experience, some of the Covid-19 outcomes I have encountered in the past year have been unexpected and shocking. It must have been devastating for the young man’s family and friends.Earier this year, when a 86-year-old mukhiya from Mustang died at our hospital of Covid complications, hundreds of Thakalis travelled to Pokhara to show their respect to the deceased despite the coronavirus surge at the time. Young or old, the virus was indiscriminate.In November 2020, I myself had to self-isolate with an upper respiratory infection due to a coronavirus infection. I thought I would not survive the excruciating body ache, sleepless nights and high anxiety level. During those horrific 10 days at <a href="https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/" target="_blank" rel="noopener noreferrer">Bayalpata Hospital in Achham</a> I was battling an infection that I was treating my patients for.An elderly couple had been admitted to our hospital with Covid, both of them had severe symptoms. The husband died within a few hours of admission, but his wife was not aware of his passing until she became critically ill herself, and the family decided to tell her the truth. She passed away a week after her spouse. Medical staff usually have seen it all, but so moved with sorrow they mourned too.Holistic <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" target="_blank" rel="noopener noreferrer">health care</a> is the central core of modern medicine. But the caregivers can provide only acute biomedical care to alleviate the suffering of Covid patients. Their psycho-social wellbeing and that of their family members are often ignored. And we have not even begun to think about the mental health and trauma of the frontline workers.Over 800,000 Nepalis have been infected with the coronavirus and 12,852 have died of the disease. It is time we study this data, in particular the common causes of Covid-19 deaths in Nepal. Is it heart attack, blockage of vessels in the lungs, multiple organ failure or acute respiratory distress syndrome?We must reshape our health policies based on these facts and evidence. We must ensure adequate preparation with ICU beds, oxygen supply, <a href="https://www.nepalitimes.com/latest/donated-ventilators-gather-dust-in-nepal/" target="_blank" rel="noopener noreferrer">ventilators</a> and other equipment that were in short supply earlier this year.Only then can we design a robust and customised care system to protect our population from future surges.Bikash Gauchan is the Executive Director of the Infectious and Communicable Disease Hospital in Gandaki Province.

Diary of a Covid frontline worker in Nepal

<figure><img width="3510" height="1500" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151116/636a651f9c7e80680e059913jpeg.jpg" alt=""/><figcaption>Photo: MONIKA DEUPALA</figcaption></figure>Nepal’s <a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/">Bayalpata Hospital</a> has won an international award in the Health Category at the World Architecture Festival held in Amsterdam on Thursday.The hospital in <a href="http://archive.nepalitimes.com/news.php?id=17650#.Xens94Mza72">Nepal’s Achham district</a> is a public-private partnership between the group Nyaya Health and the Nepal government, and is built almost entirely using rammed earth technology using locally available material with an ambitious zero carbon construction.‘This is an example of when architecture provides more than a building. Although modest in scale and architectural expression is delivers a massive leap in healthcare provision in a region with scarce resources,’ jury members of the Global Architecture Festival said in their citation. ‘A great example of an architect listening closely and responding intelligently to site and situation. The building is rooted in its site through its use of onsite materials and has impeccable zero carbon design credentials.’ <img width="1500" height="1125" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151116/636a65229c7e80680e059914jpeg.jpg" alt="">Bayalpata was <a href="http://archive.nepalitimes.com/news.php?id=17650#.XensoYMza71">started by visionary Nepali and American public health experts in 2009</a>, and took over a defunct government hospital to show that accessible and free medical care was possible in a rural Nepal district that had the highest maternal and child mortality and lowest lifespan.Today, the hospital <a href="https://archive.nepalitimes.com/regular-columns/GUEST-COLUMN/upgrading-health-care-through-public-private-partnership-model,582">treats 100,000 patients a year</a> from Achham and six surrounding mountain districts. Paid for mostly by crowd-funding, the $4 million three-phase expansion of Bayalpata Hospital with its <a href="https://www.nepalitimes.com/banner/starting-nepals-green-school-movement/">state-of-the-art architecture</a> was completed earlier this year.“Our specs were to use local materials as much as possible, keep energy costs low, and respect the local context,” explains Arun Rimal, a Nepali architect with the US-based Office of Structural Design (OSD). “The rammed earth uses local clay and sand from the river. The thick walls give thermal mass for insulation, and the skylights optimise sunlight and ventilation.”  <img width="4416" height="3312" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151116/636a65279c7e80680e059915jpeg.jpg" alt="">The reliance on local material turned out to be a huge advantage because the project faced unforeseen logistical problems due to the 2015 earthquake and Blockade. However, the four-year construction was delayed by just six months because it did not rely too much on bricks, steel and other imported material. The facility has a <a href="http://archive.nepalitimes.com/news.php?id=5877#.XWZGkOMzaUk">rainwater harvesting system</a>, treats its wastewater and has a network of greywater-irrigated terraces and bioswales to control erosion and recharge the acquifer. A 100kw solar array on the roof meets most of the hospital’s electricity needs, even powering the facility’s only air conditioning unit in the surgical ward. “It was a deliberate design decision to work with the natural environment as much as possible and also to address the cultural context,” says Tyler Survant from Sharon Davis Design in New York, which also conceptualised the unique Women’s Opportunity Centre in Rwanda. “We had to plan for a different kind of hospital from the West: here you have patients and relatives who have travelled for days on foot to get here.” <img width="640" height="828" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151116/636a652b9c7e80680e059916jpeg.jpg" alt="">Bayalpata has public outdoor spaces and canopied courtyards to serve as comfortable waiting areas, while the operating theatres and wards are recessed. Unlike in the US, staff housing also had to be integrated into the facility since it has fulltime resident doctors, who live with their families.

Bayalpata Hospital in Nepal wins global design award

<figure><img width="1000" height="1500" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108111156/636a35fe9c7e80680e0482dfjpeg.jpg" alt=""/><figcaption>Pic: BIKRAM RAI</figcaption></figure>Suresh Shakya (pictured above) was sitting down for lunch with his family in his house in Itum Bahal four years ago when there was a terrifying, subterranean growl, and his building started shaking.Shakya, 46, knew it was an earthquake, and while he was concerned the house could collapse, he was even more afraid that an adjacent, new 10-floor highrise that a neighbour had built would topple on him.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108111156/636a36019c7e80680e0482e0jpeg.jpg" alt="" width="1000" height="454">Outside, it was difficult to stand as the ground rolled. An hour later, there was a big aftershock and Shakya remembers the tall building swaying like a tree in a storm, creating deep gashes on his house, which remains propped up by timber to this day.Seismologists warn that the quake four years ago this month was just a warning, and that Nepal faces serious risk from even bigger earthquakes in future. This precarious highrise is not likely to survive those ones.Read also: <a href="https://www.nepalitimes.com/?p=25092&amp;preview=true" target="_blank" rel="noopener">Lessons Unlearnt</a>, Editorial<a href="https://www.nepalitimes.com/?p=25110&amp;preview=true" target="_blank" rel="noopener">Shaking up the health sector</a>, Sewa Bhattarai<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/?p=25119&amp;preview=true" target="_blank" rel="noopener">Quake was a learning experience for Nepal’s schools</a>, Prakriti KandelOn the fourth anniversary of the 25 April 2015 earthquake, experts warn that attention should now shift to retrofitting and strengthening hospitals and schools across the country. More than 1,000 health facilities and 5,000 schools were completely destroyed in 2015, and tens of thousands of children could have been killed if the disaster had happened on a weekday.  Hospitals and schools flattened in the 2015 earthquake are being rebuilt, but what about the rest of Nepal vulnerable to future quakes? A recent Ministry of Health (MoH) study showed the government hospital in Nepalganj was structurally so weak that it needs to be demolished, and recommends retrofitting four other hospitals in Western Nepal that do not meet the WHO Health Safety Index."The study is a warning. The condition of rural health facilities across Nepal is similar, and we need to quickly retrofit them before the next disaster strikes,” says Chudamani Bhandari of the Health Emergency and Disaster Management Unit at the MoH. "Western Nepal is in greater danger of a big earthquake, so we have decided to focus there."The Disaster Risk Reduction and Management Act of 2018 stipulates that the main responsibility of managing crises now lies at the local level, but the MoH says it first wants to build capacity at the provincial level.Read also:<a href="https://www.nepalitimes.com/here-now/nepals-traditional-seismic-resistant-designs/" target="_blank" rel="noopener"> </a><a href="https://www.nepalitimes.com/here-now/nepals-traditional-seismic-resistant-designs/" target="_blank" rel="noopener">Nepal's traditional seismic resistant designs</a>, Sheilin Teo<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/here-now/building-back-cheaper-and-stronger/" target="_blank" rel="noopener">Building back cheaper and stronger</a>, Sapana Shakya and Aman Raj KhatakoHowever, the first step must be to carry out a baseline safety inspection of medical centres all over the country. The National Reconstruction Authority (NRA) plans a survey of schools and hospitals, but only after it is done with reconstruction.The National Society for Earthquake Technology (NSET) is also resuming its retrofitting of schools in Western Nepal that it had started before 2015. Says NSET’s Surya Narayan Shrestha: "We need to concentrate on Western Nepal because the vulnerability of public buildings there is high.” Western Nepal is said to be particularly at risk because it has not had a mega-earthquake for the past 500 years. DFID is supporting NSET with a Safer Schools Project to retrofit classrooms in the region.Schools are important community hubs and strengthening them can raise public awareness about safer construction in areas that are at high risk. In fact, 2015 itself provided a lesson for schools. Deepak Sharma of the Ministry of Education explains: "The few schools that were retrofitted before 2015 suffered no damage, so we are trying to retrofit schools in all districts for future earthquakes."Read also:  <a href="https://www.nepalitimes.com/here-now/nirmala-pariyars-2nd-life/" target="_blank" rel="noopener">Nirmala Pariyar's second life</a>, Ramu Sapkota<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/opinion/nepal-is-being-loved-to-death/" target="_blank" rel="noopener"> Nepal is being loved to death</a>, Anil Chitrakar

Tall Order

Nepal’s oldest maternity hospital is still recovering from the April 2015 earthquake: its main building had to be demolished after earning a red sticker because of its structural damage. Soon, it will move into a new seismic-resistant wing, designed to withstand future earthquakes. For now, the hospital is working out of temporary cramped quarters offering only 375 beds out of the normal 415. But when the new building is inaugurated next month, the hospital will have more capacity, lecture rooms, an emergency ward, operating theatres and an ante-natal section. <div class="embed-block"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108111156/636a36329c7e80680e0482f4jpeg.jpg" alt="" width="1000" height="454"></div> Hospital director Jageshwor Gautam looks excited to show &nbsp;visitors around the construction site. “We expect our work to be much easier when the new building is completed and we can use the new space,” he says. Read also: <a href="https://www.nepalitimes.com/?p=25119&amp;preview=true" target="_blank">Quake was a learning experience for Nepal’s schools</a>, Prakriti Kandel <a href="https://www.nepalitimes.com/?p=25092&amp;preview=true" target="_blank">Lessons Unlearnt</a>, Editorial&nbsp; <a href="https://www.nepalitimes.com/here-now/tall-order/" target="_blank">Tall order</a>, Sewa Bhattarai and Prakriti Kandel The project is supported by the Japan International Cooperation Agency (JICA), built by consultant Hazama Ando and is expected to be handed over on 15 May. The 2015 earthquake damaged 1,197 health facilities across Nepal, offering them a chance to rebuild so they can withstand future quakes. A survey done before the 2015 disaster had shown that of the 14 hospitals tested in Kathmandu, only 2 (Teaching Hospital and Patan Hospital, built by the Japanese) were seismic resistant. The situation in other parts of the country was even worse. <div class="embed-block"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108111156/636a36329c7e80680e0482f4jpeg.jpg" alt="" width="1000" height="454"></div> JICA is working to rebuild modern and safe hospital wings at Paropakar Maternity Hospital (pictured, right) and Bir Hospital, both in Kathmandu. They will enjoy advanced technologies like motion-sensor taps in order to reduce infections in washrooms, flush systems that reuse water from handwashing, handicapped-friendly toilets and treatment plants for hospital waste. Elsewhere in the quake-affected areas, however, reconstruction of health facilities is not going as well. Only 55% of the health posts and hospitals that were damaged or destroyed have been repaired, according to the National Reconstruction Authority (NRA). “The construction of hospitals was delayed due to technical reasons, but now they are our top priority,” says Manohar Ghimire of the NRA. “Of the 643 structures built, most are pre-fab structures which have already been handed over to the communities. Now we are focusing on rebuilding the rest.” The reconstruction of health facilities was delayed because the central government could not agree on who should rebuild them. The Ministry of Health and Population had planned to do it, before passing it on to the NRA almost a year after the earthquake, where the plans faced further delays. That cost a total delay of two years, resulting in a reconstruction rate of only 53%, when the target was 65%. Read also:&nbsp; &nbsp;<a href="https://www.nepalitimes.com/here-now/nepals-traditional-seismic-resistant-designs/" target="_blank">Nepal's traditional seismic resistant designs</a>, Sheilin Teo <a href="https://www.nepalitimes.com/here-now/building-back-cheaper-and-stronger/" target="_blank">Building back cheaper and stronger</a>, Sapana Shakya and Aman Raj Khatako <div class="embed-block"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108111156/636a36369c7e80680e0482f6jpeg.jpg" alt="" width="1400" height="786">Nepal's oldest maternity hospital is currently operating out of cramped quarters, forced to put some beds in corridors due to lack of space.</div> Of the 524 medical facilities that need to be rebuilt, 145 are under construction, while the rest seem to be inordinately delayed due to technical reasons. "Many health centres do not have their own land, and there are no guidelines for buying land. We can only build on already available land," says Pranaya Upadhyaya, senior Public Health Administrator at the Ministry of Health. "Before the earthquake, many were operating from schools or other government buildings. But now we have strict standards for medical facilities including size of land, type of soil, etc. The institutes that are having a hard time fulfilling these criteria are the one that are delayed." Upadhyay informs that work has not begun on the 250 health centres that the Indian government committed to, which contributes to the reason more than 500 of them remain to be built. Even if the earthquake had not occurred, Nepal’s health sector needed a structural revamp. A survey two decades ago of 14 hospitals in Kathmandu by the National Society for Earthquake Technology (NSET) showed that only two of the facilities would be fully functional if hit by a high-intensity earthquake, and four would be partially operational. Read also:&nbsp; <a href="https://www.nepalitimes.com/here-now/nirmala-pariyars-2nd-life/" target="_blank">Nirmala Pariyar's second life</a>, Ramu Sapkota <a href="https://www.nepalitimes.com/opinion/nepal-is-being-loved-to-death/" target="_blank">Nepal is being loved to death</a>, Anil Chitrakar Survey leader Ramesh Guragain explains that quake intensity is not just &nbsp;measured in the Richter scale, but by many other factors like depth, type of soil and distance from the epicentre. Which means that the intensity of the 2015 earthquake caused greater damage nearer the epicentre than in districts around Kathmandu. A subsequent NSET survey of five regional hospitals outside Kathmandu also showed that Nepal’s health care centres are structurally unprepared for future large-scale disasters. Although services and facilities in some of the hospitals have improved, the structures within which they are housed are weak and could collapse. Kathmandu’s oldest medical centre, Bir Hospital, in the heart of the city, has no space for expansion. After the 2015 earthquake damaged its mortuary, the hospital is constructing a new building in its place, which will also house its nephrology, cardiology and gastrology departments, but it is still short of space. “Even after we start using our new facilities, we will need more space for the nursing campus, pediatric and maternity departments, organ transplant centre and many other services,” says Bir’s director Kedar Prasad Century, adding that there is no option but to expand to Duwakot in Bhaktapur, outside of Kathmandu. Hospitals with large capacity will be much in demand after the next earthquake, and if they are knocked out of service, the injured will have nowhere to go. In 2015, many hospitals worked in the open or out of tents for months after the earthquake. “In order to avoid such a situation in future, it is imperative that the reconstruction and retrofitting of hospitals be carried out with the utmost priority,” says NSET’s Guragain. If this is the situation in Nepal’s privileged capital, one can only imagine what it is like in district hospitals. Many of the buildings are in advanced stages of disrepair, lack hygiene and are overcrowded, even in normal times. During disasters, hospitals will have to cope with a large influx of patients but the medical centres themselves will have suffered damage. Read also: <a href="https://www.nepalitimes.com/editorial/aint-seen-nothing-yet/" target="_blank">Ain't seen nothing yet</a>, Editorial

Shaking up the health sector

<figure><img width="1000" height="2392" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108111156/636a36059c7e80680e0482e1jpeg.jpg" alt=""/><figcaption>Photo: BIKRAM RAI</figcaption></figure>Four years later, Central Nepal is still being rocked by aftershocks of 2015. That peculiar earthquake shook everything to the east of the epicentre, and inflicted almost no damage at all to its west. The release of tectonic energy appears to have travelled along a rupture zone from Gorkha and ground to a halt somewhere beneath the southern edge of the Kathmandu Valley. The <a href="https://www.nepalitimes.com/editorial/aint-seen-nothing-yet/" target="_blank" rel="noopener">stored tension</a> of the 7.8 magnitude earthquake is only partially spent.Read also: <a href="https://www.nepalitimes.com/?p=25110&amp;preview=true" target="_blank" rel="noopener">Shaking up the health sector</a>, Sewa Bhattarai<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/?p=25119&amp;preview=true" target="_blank" rel="noopener">Quake was a learning experience for Nepal’s schools</a>, Prakriti Kandel<a href="https://www.nepalitimes.com/here-now/tall-order/" target="_blank" rel="noopener">Tall order</a>, Sewa Bhattarai and Prakriti Kandel<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108111156/636a36079c7e80680e0482e2jpeg.jpg" alt="" width="1000" height="454">For the first two years after the earthquake, memory was still fresh and we were careful about building back better. There was even talk of strictly enforcing the building code. <a href="http://archive.nepalitimes.com/article/nation/A-concrete-future,2251" target="_blank" rel="noopener">Look at us now</a>. The kinds of structures that are going up in Kathmandu prove that we have all but forgotten what an earthquake can do. There is still <a href="http://archive.nepalitimes.com/page/not-out-of-danger-the-big-one" target="_blank" rel="noopener">the unfinished business</a> of 2015 beneath the Valley, and below western Nepal is <a href="https://www.nepalitimes.com/here-now/past-disasters-foretold/" target="_blank" rel="noopener">the ticking time bomb</a> of tension from the <a href="https://www.unr.edu/nevada-today/news/2016/nepal-earthquake-danger" target="_blank" rel="noopener">subduction</a> of the Indian plate into the Eurasian landmass, which has not been released for nearly 700 years.We still don’t seem to fathom <a href="http://archive.nepalitimes.com/article/from-nepali-press/not-destructive-as-predicted-but-the-loss-is-still-great,2221" target="_blank" rel="noopener">how lucky we were</a> that the 2015 earthquake occurred on a Saturday, did not happen at night, and that it was below 8 magnitude. April 25 was a warning to enforce seismic-resistant designs in private homes, but especially public buildings. <a href="https://www.nepalitimes.com/banner/class-struggle/" target="_blank" rel="noopener">Schools</a> may not be so lucky next time, and classrooms need to be strengthened. Our hospitals have poor construction, as the destruction of a newly-built <a href="http://archive.nepalitimes.com/article/nation/being-prepared-for-monsoon-and-outbreaks,2293" target="_blank" rel="noopener">district hospital in Chautara</a> in 2015 proved. Pre-positioning supplies, digging equipment and designating open spaces for evacuation needs to happen now. Across Nepal, earthquake drills will be more important than singing the national anthem at assembly.https://www.youtube.com/watch?v=hpABIXZIp2k&amp;feature=youtu.beWhile thinking and preparing ourselves for future shocks, there is also all the catching up we have to do to reach the most vulnerable survivors of the 2015 earthquake. It is not just about distributing the insufficient amount earmarked for rebuilding homes, but also rehabilitating families, providing skills training and finding jobs near home for them.The <a href="https://www.nepalitimes.com/banner/disastrous-management-in-nepal/" target="_blank" rel="noopener">National Disaster Management Act</a> has been passed, but where is the <a href="https://nepalitimes.atavist.com/reconstruction-in-ruins" target="_blank" rel="noopener">Authority</a>? The NRA now needs to be phased out (it wasn’t much help anyway) to prepare for the Next Big Ones. It is a feeble hope, but let us not get bogged down in turf battles and allow the Home Ministry to mess it up with political appointments and job distribution to party faithful again.Under the federal structure, we have a new opportunity to decentralise disaster preparedness, planning and management.  Every municipality now has to take responsibility from ward level up, so that there is a search, rescue and relief plan in place. But given that so many mayors and local elected officials are contractors who are awarding construction jobs to themselves, there is not much hope. We wish the incompetence of Kathmandu Municipality in earthquake rehabilitation of monuments was an exception, but it is the rule. The delays in rebuilding <a href="http://archive.nepalitimes.com/blogs/thebrief/2016/08/29/halt-rani-pokhari-reconstruction/" target="_blank" rel="noopener">Rani Pokhari</a> and <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/rebuilding-kasthamandap-nepal,4012" target="_blank" rel="noopener">Kastamandap</a> are national disasters in themselves. It is hard to figure out who is more culpable — Mayor Shakya or the Department of Archaeology. There are lessons to be learnt about how not to organise compensation for rebuilding. While a lot more of the grants have been cleared, there are many families who have found loopholes to build tiny cement sheds just to get their hands on the cash.As our coverage this past month in the run-up to the fourth anniversary of the quake, and in this issue, indicate: it is now time to also turn our attention to the seismic risk in the rest of the country. For the past four years, we have been in rehab mode, picking up the pieces of the damage in Central Nepal’s 14 districts. It bears repeating that the risk is now to the whole country from the massive slip that is bound to occur sooner or later in Western Nepal. There is no other way to put it: the death and destruction from it will be nationwide and catastrophic. Read also: <a href="https://www.nepalitimes.com/editorial/aint-seen-nothing-yet/" target="_blank" rel="noopener">Ain't seen nothing yet</a>, Editorial <h2>10 years ago this week</h2> This Editorial titled ‘Half full’ from issue #447 of 16-23 April 2009 tried to look at the bright side, but could not find much to be cheerful about. Not much has changed in Nepal in 10 years. Excerpt:‘Wonder if Pushpa Kamal Dahal, sitting in Baluwatar and preparing for his China visit, has any clue about the rising frustrations of the people. The Maoists may have got three of the six seats in the by-elections, but that is not the real barometer. Ask people stuck inside buses for 24 hours because the government can’t clear the week-long blockade of the country’s main national highway by flood victims. Ask city-dwellers who have seen no respite from power and water shortages.This coalition has spectacularly failed to deliver. There is no law and order, youth wings of ruling parties roam the streets and the police have no orders to intervene.’<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108111156/636a36089c7e80680e0482e3jpeg.jpg" alt="" width="508" height="811">