Duncan Maru is an instructor in medicine at Harvard Medical School and co-founder of Possible, which provides health care in Nepal in partnership with the Ministry of Health and Population. Senendra Uprety is director general of Nepal’s Department of Health Services.
Our lives have been divided between before and after. For all of us, from Achham to Ilam, from those who felt only a tremble to those whose houses turned to dust, an irrevocable moment arrived at 11:56 a.m. April 25. We all knew, with every glance northward to the towering Himalayas, that this moment would come. We knew this, but when it finally arrived, it still somehow felt impossible.
The earthquake is the largest test for Nepal’s young, poverty-afflicted democracy since the end of civil conflict in 2006. The local and global response to this tragedy has been swift and compassionate, and we hope that it can alleviate much of the immediate suffering. Militaries and relief organizations from around the globe have moved decisively into the affected areas. Individual acts of generosity and courage have abounded.
Now, a huge amount of financial aid is needed to save lives, keep people in safe housing and prevent epidemic disease. At a cost likely to exceed $5 billion in a country whose gross domestic product is $20 billion, much of that financing needs to come from outside. It is the “how” and the “what” of that aid, rather than the amount, that will determine its impact.
The phrase that guided the response to the 2004 Indian Ocean tsunami — “building back better” — has become common parlance in such recovery efforts. The idea is to use an acute crisis to address chronic problems and injustices. As tragic as the catastrophe in Nepal has been, we must not forget the preventable death and disability, housing instability and food insecurity that are rampant in the country. Week after week, more than 450 infants die needlessly. Every year landslides kill more than 300 people. The march of death from such daily tragedies goes on.
Indeed, even as relief workers tend to victims of the earthquake, public-sector health-care workers must contend with a lack of resources. The $18 per capita spent each year on public-sector health care is insufficient, by any reasonable measure, to meet the needs of the population. That was true before the earthquake, and it has forced a deplorable calculus upon government hospitals and clinics: Should health-care workers travel to Kathmandu to join in the relief effort? If they do, who will treat the maladies that present themselves in large numbers every day throughout rural Nepal? This is a trade-off no government should have to make. Can we reach a time when there are resources, both human and financial, for both?
That time is far off. For now, the country is consumed with treating survivors and providing housing, food and water.
Haiti should serve as a cautionary tale on the promise and pitfalls of outside aid. In the first two years following the 2010 earthquake there, more than $6 billion in international aid poured in. The Haitian government, however, was largely bypassed, and the aid resulted in a parallel system dominated by international organizations. Haitians were marginalized, and long-term institution-building was limited. “Building back better” came to mean building back in a way dictated by international interests, not Haitians.
We prefer a phrase inspired by former Massachusetts representative Marie St. Fleur: “Building back differently.” In a speech two months after the quake, St. Fleur implored the international community to work through the government and to make sure funds were primarily used for Haitians. Her words went unheeded.
Such mistakes have been made time and again. Democratic institutions and the people they represent constitute any country’s greatest hope for rebuilding. The government of Nepal has both the right and responsibility to care for and protect its citizens, particularly the most vulnerable. And its citizens have the right and responsibility to hold their government accountable.
This can be a bitter pill to swallow for many donors. Confidence in a government in need may be low, but a capable and independent government is the only path to genuinely build back differently. If donors have legitimate governance concerns, they can address them by working with civil society to improve accountability. But let there be no bypassing of the government. Democratic institutions and their possibilities — responsive health-care systems, effective disaster response systems, good roads, enforceable building codes — require time and investment. We can envision such a future in Nepal only if aid and recovery efforts are employed to strengthen government, not undermine it.
This can be done. After the 2001 earthquake in Gujarat, India, private industry, government and local communities came together to have a transforming effect. While there was a substantial global response to the disaster, much of the credit for the successes that followed goes to national, state and local actors who built back differently. This included earthquake-resistant homes designed and constructed by local people, as well as investments in schools, clinics, roads and telecommunications infrastructure, which created jobs.
There is reason to hope that Nepal will proceed more like India in 2001 than Haiti in 2010. At the emergency operations center at Nepal’s Ministry of Health and Population, the coordination of relief efforts has been improving since the earthquake struck. In the immediate aftermath, confusion, frustration and stress dominated communication. A week later, thanks to the vision of government officials, technical advisers from civil society and external development partners, a basic electronic tracking and mapping system was in place. This both improved the immediate response and strengthened the longer-term capacity of the ministry to address acute and chronic human resource, communications, and supply chain needs.
As we move from relief to reconstruction in Nepal, the stakes will only increase. Can we funnel the majority of aid through the government in order to employ Nepalis, fund earthquake-resistant homes and truly build back differently? We stand hopeful that Nepal will emerge from this crisis with a stronger government and stronger communities resistant to the ravages of both earthquakes and poverty.