By the time I was taken to the operating theater, I was groggy on painkillers, but I remember admiring the earthquake cracks creeping up the walls and snaking across the ceiling. Just before I drifted under anesthesia, my last thought encompassed my worries of my last two months in Nepal: "I hope the hospital has enough diesel for their generator."
I am very lucky. When I fell seriously ill in late October in Kathmandu and ultimately underwent a four-hour emergency surgery for a complete intestinal obstruction, my husband took me to Norvic, one of Nepal's best hospitals. It was during the height of the Hindu Dashain holiday, a mega-celebration where Nepal's capital empties out for more than a week, and the hospital had a skeleton staff.
But the hospital faced a more serious problem. Nepal relies almost entirely on fuel trucked in from India. For several months, this small Himalayan nation has been trying to function with about 10 percent of its daily standard consumption. For hospitals, fuel is life: it feeds the generators that take over during the long hours of daily power cuts, that in turn power the operating rooms, the incubators, the life-saving machines.
No hospital is immune to the escalating humanitarian and health crisis gripping this country, already hard hit by a 7.8 magnitude earthquake in April that killed 9,000 and left hundreds of thousands homeless. Since September, political parties on Nepal's southern border with India, protesting Nepal's new constitution, have disrupted cross-border trade through violent demonstrations. Strengthening the hand of the demonstrators, the Indian government has enforced an undeclared trade blockade, letting in barely a trickle of petrol, diesel and propane. Because of this blockade, Nepal, which imports 60 percent of its medicines from India, is neither receiving enough new medicine nor able to produce it locally without the raw materials that are also imported from India. At one point, more than 300 trucks full of medicines were stuck at the border, and Nepali protesters torched a truck carrying medicines as well as an ambulance carrying a child to hospital.
The United Nations Secretary General Ban Ki Moon has called on all sides to lift the restrictions and has underlined Nepal's right of free transit. So far, both Nepal's new government as well as the striking parties remain intransigent in their demands. Violent attacks on both sides are increasing. When protesters blocked a section of highway on November 22, pelting police with stones and later torching a police station, police killed four and injured scores, entering a hospital and beating up staff and patients, news reports said.
In the capital, large hospitals have said they are running low on stocks of adrenaline, saline and atropine. One heart hospital has postponed bypass surgeries because it has run out of the special thread needed to stitch the heart. The Nepali Red Cross, which runs more than 100 blood transfusion centers across the country, has shortages of blood bags.
I was treated in Kathmandu, which still gets the lion's share of the supplies that manage to cross the border. But even at Norvic, I had to be taken by rickety ambulance to another health care facility that had a more sophisticated CT scanner.
Even before the current crisis, health care was precarious in Nepal. Half of its 28 million people are desperately poor often living in remote mountain villages far from basic services and with high rates of malnourishment and child mortality. Nepal has only about 4 doctors, 11 nurses and 0.2 licensed pharmacists for every 10,000 people, according to a 2011 report by the Ministry of Health and Population in collaboration with the World Health Organization. Rural health-care services are rudimentary, and health posts can remain unstaffed for years. Vaccination rates are low. Health insurance is almost nonexistent, and health costs are mostly paid out of pocket by patients. Hospital visits mean poor families only sink deeper into debt.
A trip to see a doctor is often only taken as a last recourse. Rural pregnant women often choose to deliver at home to save money. Every six hours in Nepal, according to USAID Nepal, a woman dies from postpartum hemorrhage or excessive bleeding, causes that are preventable or manageable. Nepal is also affected by the brain drain of doctors and nurses emigrating to work abroad.
The blockade has hit rural health care hard. For the past two-and-a-half years, Leona O'Keefe, an American volunteer family physician with the Samaritan's Purse Post-Residency Program, has worked at the United Mission Hospital in the town of Tansen, more than a nine-hour jeep ride west of Kathmandu. It is one of Nepal's best-known rural hospitals with 23 doctors and 96 nurses and nurses aides. In 2014, the hospital had 12,500 admissions and 97,000 clinic visits, with over 7,100 surgeries and 2,100 deliveries. Some of the American medical staff work here for several years while others return regularly for shorter stints.
"It is a pleasure to care for the Nepali people," O'Keefe told me adding that her husband had had to undergo emergency surgery there just a few days after the April earthquake. "It is heart breaking to watch them have to suffer even more that they already have after Maoist fear, debilitating earthquakes and now further political strife."
The first challenge, due to lack of fuel, is reaching the hospital. There is little public transport. The patients arrive on overcrowded buses, often perched on rooftops or on foot or carried for days by relatives. The United Mission Hospital in Tansen is critically short on emergency cardiac medicines and obstetric medicine, low on antibiotics, anti-hypertensives and alcohol sanitizer. The hospital runs its generator about four hours a day, using about 10 gallons of diesel an hour. Their current diesel stock is under 530 gallons, which is purchased at the local government depot. But the depot is also at the mercy of government refueling and the amount per customer is rationed. If the hospital sparingly uses its vehicles and ambulances, they will have enough fuel to run the generator for another two weeks. After that the incubators will no longer be able to warm newborns during the frigid winter months.
O'Keefe told me the story of a young woman with one young child and a husband working overseas. When she got pregnant after her husband visited, he asked her to terminate the pregnancy because of the family's blockade-related financial difficulties. She got the medicine from a local shop with little advice on how to use it. After one and a half months of bleeding, she finally came to United Mission Hospital. "Family must accompany patients to care for them while in hospital," O'Keefe explained. "Someone needed to watch her young child while [she was] in hospital. These family members had to stay in nearby hotels. But our nearby hotels are out of gas for cooking so food is limited and what is available is more expensive. But incomes have been drastically cut due to lack of jobs and supplies. All these factors delayed her presentation to us." When the woman arrived she was extremely anemic and required three blood transfusions. The family members had to donate blood. In conversations, it was obvious that she had delayed coming to the hospital so as not to put a huge financial burden on her extended family, O'Keefe said.
Frequent fuel crises and political strikes have been part of my everyday life for the two-and-a-half years I have lived in Nepal. But this one has been overwhelming, all encompassing and ubiquitous. It is destroying lives, businesses, industries and tourism. It is visible in the miles of vehicles parked for days in Kathmandu, hoping for a gas station to open, and in the lines for firewood now used for cooking.
In my two days in the hospital intensive care unit, I was comforted by the smiles of my nurses and got relief from the painkillers.
But I couldn't get the blockade out of my mind. When my surgeon came into the ICU to show me the two feet of gangrenous intestine and "three liters of fluid" he had removed from my abdomen, I briefly emerged out of my mental fog, smiling and happy: "Three liters of fuel?" I asked.