After more than 36 hours of darkness, Garima Saha, 12, woke up on Monday morning in a makeshift orthopaedic surgery ward in the reception hall of a hospital in central Kathmandu.

When she opened her eyes, finally regaining consciousness having been buried for nine hours in rubble after Saturday’s earthquake, she found she was safe, but in great pain with multiple fractures to her shoulder. She also learned that her mother and elder brother were dead.

An hour or so later, held by her sobbing grandmother who had rushed from a distant village to be with her, she was gently raised to a semi-upright position in the bed she had been placed in after a long surgery on Saturday night.

Garima looked out with stunned eyes on a scene that many in earthquake-prone Kathmandu suspected they might one day see, but fervently hoped they never would. Lit by flickering fluorescent lights, she saw a dozen exhausted doctors, many on their feet for days; a score or so of white-coated nurses, their faces blank with fatigue; a western tourist who had volunteered that morning and was clumsily rolling bandages.

And she saw rows of other patients on old beds, stretchers, or just the floor. Opposite was Chirim Baby Sahi, a 55-year-old newspaper seller and the sole breadwinner in his family of five, who had been trapped by masonry falling from a temple and is now paralysed. To one side was Anusha Khatry, a 16-year-old schoolgirl from the hard-hit Sindhulpalchowk district a five-hour drive from Kathmandu. Propped up against her bed were the x-rays which, Prof Gopal Raman Shama said, show she has spinal injuries that mean she is unlikely to walk again.

“She does not know yet,” whispered her mother.

What all these casualties share, like almost all the 3,729 dead and nearly 7,000 injured confirmed by late Monday afternoon, is that they are poor. Though many had predicted that an earthquake in Kathmandu would bring the newly constructed cement apartment blocks tumbling down, it was the older, brick and wood homes that, almost exclusively, were reduced to rubble. Anyone who stayed in these could not afford better.

“Outside Kathmandu it’s the rural poor. But in the city it’s the people in the older precarious housing. It’s obvious: the wealthier you are, the stronger the house you have,” said Bhaskar Gautam, a local sociologist.

Often four or five storeys high and subdivided into cheap family apartments like tenements in Victorian London, the homes of people like Garima have long been known as a risk.

Garima’s brother, a waiter in a noodle shop, said the family’s home was their “bad luck”. “We should have moved 20 years ago,” he said.

The wife of Sahi, the paralysed newspaper seller, was angry and desperate. To add to her misery, the family’s home had also collapsed and now they, like hundreds of thousands of others across Nepal, were homeless.

“If we had had money we would have built a strong house. But we had none. There is no place to go. There is no one to look after us. Life was hard for us already. I don’t want to be alive,” she said.

Parts of Kathmandu are coming back to life. Hawkers sell limes and cabbage on pavements. One or two shops are open, even a bank. The city’s notorious traffic is still far from its usual level but is returning to chaotic, congested normality.

Yet thousands are still camping on open spaces, frightened to return to their homes. Some say they will wait until 72 hours have passed, but continuing aftershocks scare. Many, too, are still seeking treatment for bad injuries, some waiting outside hospitals. The morgue at Bir hospital, the city’s biggest, is overflowing, with bodies now lined up outside.

There is also the fear of disease. “Now there could be communicable illnesses, diarrhea, flu and so forth. The earthquake will have broken all the sewers and pipes so the water supply will be contaminated,” said Dr Sameer Thapa, as he looked out over a carpark and garden covered in tents sheltering patients at the Tribhuvan University teaching hospital.

Aid is beginning to arrive. Incoming western humanitarian organisations are taking the hotel rooms of departing tour groups. On Monday flights were being turned back from Kathmandu’s airport, the only international strip in the country, because there was no space for them to land, let alone unload.

Lila Mani Poudyal, the government’s chief secretary and the rescue coordinator, said recovery was also being slowed because many key workers – such as water tanker drivers, electricity company employees and labourers needed to clear debris from the streets – had all gone home to their families.

As the injured continued to arrive at hospitals, “we especially need orthopaedic (doctors), nerve specialists, anaesthetists, surgeons and paramedics,” Poudyal told reporters.

If in Kathmandu, life is slowing returning to normal, out in the rural areas, the situation is very different. In Dhulikhel, the main hospital, one of only two serving Kabre district, with its population of 380,000, was due to run out of diesel fuel for its generator at midnight. “We are trying to get more but it’s difficult. We’ve a little bit of solar but not enough to light the operating theatres and the wards,” said Dr Deepak Shrestha.

With so many fractures and spinal injuries, there is an acute shortage of wheelchairs, crutches, even stretchers. In Dhulikhel too, patients are being treated outside under makeshift shelters of plastic sheeting. Under one, labelled “simple injuries”, an elderly man wept in pain as a wound to his leg was dressed, the white of the bone clearly visible.

The situation in Ghorka district, the epicentre of the quake, is still unclear. Though the death toll remains about 200, it is expected to rise, though not “into the thousands”, said local officials. However vast numbers of homes have been destroyed, leaving tens of thousands at least exposed to chill late spring Himalayan temperatures and frequent rain.

As elsewhere across Nepal, one of the poorest countries in Asia and long known as a state with limited administrative capacity, much depends on a small number of key bureaucrats.

One is Sudarshan Parshad Dhakal who, from his hilltop residence in Dhulikhel, manages the lives of the 80,000 households of Kabre district with a handful of mobile phones. On Monday he was plunged in meetings, his officers, the local chief of police, and representatives of other services sitting on battered chairs on a terrace overlooking a plunging valley.

The good news, Dhakal said, was the low level of fatalities, relative to what had been feared. In Kabre, the death toll is likely to reach somewhere between 200 to 250, with about 900 injured. The bad news is the number of homeless.

“We have tens of thousands of homes destroyed and many more rendered uninhabitable. I estimate there are perhaps 100,000 people who are now displaced. We need at least 3000 family tents, blankets too and dry food for three days,” Dhakal said.

The meetings continue, the telephone rings, the ground shudders with another aftershock and Kabre’s top bureaucrat wearily shrugs.

Jason Burke in Kathmandu