Planetary health in Nepal's post-earthquake rebuilding agenda: progress and future directions
Authors: Shiva Raj Mishra, Bipin Adhikari
Journal: The Lancet Planetary Health (2019)

Planetary health is the health of the human civilizations and of the planet they inhabits; in particular, the health of their physical, political, economic, and social elements, as well as the health of human culture and heritage, which shape humanity.1Horton R Lo S Planetary health: a new science for exceptional action.Lancet. 2015; 386: 1921-1922Summary Full Text Full Text PDF PubMed Scopus (82) Google Scholar Disasters affect the health of humans and the planet alike. The earthquakes in Nepal in 2015 had a tectonic origin; however, the huge losses it caused (9000 deaths, 18 000 injuries, and >500 000 households and 1000 health facilities damaged) could have been mitigated if there had been a rapid response.2Adhikari B Mishra SR Babu Marahatta S et al.Earthquakes, fuel crisis, power outages, and health care in Nepal: implications for the future.Disaster Med Public Health Prep. 2017; 11: 625-632Crossref PubMed Scopus (30) Google Scholar Environmental losses from the earthquakes have been overlooked. Ongoing rampant urban development coupled with unsystematic recovery efforts after the earthquake has had the greatest toll on lives. Overlooking the planetary health agendas that arose from these earthquakes will continue to threaten the existence of one of the oldest civilisations of southern Asia. In this Comment, we identify and discuss key challenges that need to be addressed immediately and could be part of local advocacy. The National Reconstruction Authority (NRA)—a legally mandated agency for leading the earthquake recovery and reconstruction efforts in Nepal—estimated that US$7 billion are required for rebuilding, of which $2·9 billion were to be sourced internally.3Adhikari N Nepal's earthquake disaster: two years and $4·1bn later.https://www.aljazeera.com/indepth/opinion/2017/04/nepal-earthquake-disaster-years-41bn-170412110550808.htmlDate: 2017Date accessed: April 1, 2018Google Scholar Still, 3 years after the earthquakes, the NRA has only managed to disburse 16% of the total 4.1 billion USD pledged by donors. The owners of only 544 996 of 900 000 damaged houses have received their first payment, which accounts for only 17% of the total reconstruction grants.3Adhikari N Nepal's earthquake disaster: two years and $4·1bn later.https://www.aljazeera.com/indepth/opinion/2017/04/nepal-earthquake-disaster-years-41bn-170412110550808.htmlDate: 2017Date accessed: April 1, 2018Google Scholar People from impoverished communities, who are at high health risk, are the most heavily affected by this lumbering distribution of funds. The impact of the earthquakes on the economically vulnerable population has been rising steadily, and has caused an increase in the illegal sale of organs (such as kidneys) to pay for costs of living.4Cousins S Nepal: organ trafficking after the earthquake.Lancet. 2016; 387: 833Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 5Adhikari B Organ and human trafficking in Nepal.Lancet. 2016; 387: 1907Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar The increase in employment abroad has caused a huge proportion of male labour to migrate to Gulf nations, leaving thousands of families split. As a result, many villages are left without men, which added to the strain of the already substantial male-labour migration trend in Nepal.6Agarwal GRP Rebuilding Nepal: creating good jobs amid reconstruction and migration.https://www.solidaritycenter.org/wp-content/uploads/2017/04/SC-JJN-Nepal-Project-Report-25042017-webversion-1.pdfDate: 2017Date accessed: April 1, 2018Google Scholar The latest data for out-migration for labour work has shown a steady rise trend since the earthquakes, with almost 500 000 emigrants in 2015.6Agarwal GRP Rebuilding Nepal: creating good jobs amid reconstruction and migration.https://www.solidaritycenter.org/wp-content/uploads/2017/04/SC-JJN-Nepal-Project-Report-25042017-webversion-1.pdfDate: 2017Date accessed: April 1, 2018Google Scholar Hence, poor families are forced to pay for expensive labour and construction material for rebuilding their homes. The momentum for building back better has dampened, particularly as conventional construction methods without retrofits have been used in rebuilding the houses. The extensive extraction of clay soil for bricks, deforestation to supply wood to kilns and construction, and extraction of sand from quarries are causing concern. In a community-based study in Nepal, more than half of the respondents felt the impacts of climate change, such as a rise in temperature and episodes of droughts.7Mishra SR Bhandari PM Issa R Neupane D Gurung S Khanal V Climate change and adverse health events: community perceptions from the Tanahu district of Nepal.Environl Res Lett. 2015; 10: 034007Crossref Scopus (17) Google Scholar Indiscriminate sand and gravel extraction and deforestation in Nepal's southern plains have failed to draw the government's attention or to prompt it to take action. Increased overexploitation of ecosystem resources causes deepening and widening of river beds, which in turn affect the flow of surface water. Unsurprisingly, the consequences of deepening and widening of river beds have been evident in the flooding patterns in past years. In 2017, 160 people were killed and 26 went missing in a major flood that inundated the southern planes of Nepal, stretching over an area of 1355 km2 that borders India.8Uprety A Ozaki A Senoo Y et al.Flood damage in Nepal exacerbated by underlying conflict with India.Lancet Planet Health. 2017; 1: e351-e352Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar The unsystematic reconstruction continues to affect air quality in Kathmandu. Roads are further damaged by heavy vehicles, landslides, and unrepaired potholes. Heavy-duty trucks carrying construction materials in the narrow and winding roads of the capital, coupled with high-speed driving practices have increased the number of road-traffic accidents. More than 2385 deaths were attributed to road traffic accidents in 2016–17, a 16% increase compared with the previous year.9Times THRoad accident fatalities continue unabated.https://thehimalayantimes.com/nepal/road-accident-fatalities-continue-unabated/Date: 2017Date accessed: April 2, 2018Google Scholar Air pollution in Kathmandu is worsened by CO2 emissions from vehicles and brick-kilns located in and outside the valley. An ongoing potable-water pipeline project has further added to the amount of dust in Kathmandu. The air quality index in Kathmandu exceeds the threshold established by WHO (the air quality index was reported to be >200, which indicates poor air quality), during all days of the week.10US Embassy K, Nepal Air PollutionUS Embassy, Kathmandu air pollution: real-time air quality index (AQI).http://Aqicn.Org/City/Nepal/Kathmandu/Us-Embassy/Date: 2018Date accessed: April 1, 2018Google Scholar Concern for the situation has been repeatedly raised by WHO, other health agencies, and civil society, but it has yet to be addressed. Uncoordinated and inappropriate construction methods have also put Nepal's cultural heritage at risk. The reconstruction of one of the most iconic sites of Kathmandu, Rani Pokhari, was started with concrete and mortar, but was halted after widespread resistance from the public and environmentalists. Reconstruction of Dharahara, a tower built two centuries ago, is still uncertain. 822 monuments from seven UNESCO heritage sites were either partially or completely destroyed and await reconstruction.11Himalaya E UNESCO World Heritage Sites.https://www.explorehimalaya.com/nepal-information/unesco-world-heritage-sites/Date: 2018Date accessed: April 2, 2018Google Scholar In 2017, UNESCO cautioned against the government's current practice of reconstruction, particularly the practice of selecting the lowest bidder to take the contract even if they do not have proper specifications and craftsmanship, and stated that poor maintenance of these sites could be deadlier than earthquakes themselves.12UNESCOProtecting cultural heritage: lessons from the Gorkha Earthquake.https://en.unesco.org/news/protecting-cultural-heritage-lessons-gorkha-earthquakeDate: 2018Date accessed: April 2, 2018Google Scholar One of the cornerstones of planetary health is sustainability—ie, the ability to sustain our lives and civilization without putting a strain on countries' economies and ecosystems. Nepal's need for sustainable resources to drive the rebuilding process has only been recognised recently, but many donor-funded projects will end soon. The exhaustion of donor funding probably means that in later years Nepal will have to manage the postearthquake recovery process alone, and substantial local resources will need to be mobilised. Quoting a recent media report13Times THForeign aid commitment down nearly 30 percent.https://thehimalayantimes.com/business/foreign-aid-commitment-nearly-30-per-cent/Date: 2016Date accessed: April 2, 2018Google Scholar of a 30% drop in external assistance, we further highlight the need for an economic rebuilding process, such as through community engagement. Since the earthquakes, Nepal has already seen three governments, and political interference with NRA has grown out of proportion. The gaps in the regulatory mechanism and the lack of transparency of progress,14Lee AC Barriers to evidence-based disaster management in Nepal: a qualitative study.Public Health. 2016; 133: 99-106Summary Full Text Full Text PDF PubMed Scopus (28) Google Scholar which have left the Government of Nepal alone in rebuilding, can lead to another year of futility. The formation of a task force that combines the NRA, members of the donor agencies, and neutral observers (eg, UN or other independent international authorities) could become an operational tool. Such a task force could enhance the operational management for reconstruction by widely engaging with the stakeholders and the affected communities, the members of which need to be involved, trained, and given responsibilities.15Newnham E Patrick K Balsari S Leaning J Community engagement in disaster planning and response.https://cdn2.sph.harvard.edu/wp-content/uploads/sites/5/2015/11/Community-Preparedness-Policy-Brief-10.28.15.pdfDate: 2015Date accessed: April 1, 2018Google Scholar, 16Adhikari B Mishra SR Raut S Rebuilding Earthquake Struck Nepal through Community Engagement.Front Public Health. 2016; 4: 121Crossref PubMed Scopus (42) Google Scholar Stakeholders and community members with increased awareness of planetary health can themselves become the foundation of a sustainable and environmentally friendly rebuilding movement. We declare no competing interests.