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Even though its government has announced an all-out effort to stop the spread of Covid-19, the Karnali Province is facing an acute shortage of doctors and medicines. People in the province are going back to villages from urban centers, hoping to save themselves from infection. But they get more worried when they get to the villages and find that even basic medical facilities are missing.

Historically, even a simple disease routinely becomes an epidemic in far-flung regions of Nepal. In 2014, almost 200 people died from diarrhea in Jajarkot of western Nepal as its villages lacked even basic medicines and health workers. Last year, flu killed 12 in two weeks in Humla district.

Forget specialist doctors, even general practitioners are not available in the remote mountainous districts of Karnali. While the district headquarters has some medicinal supplies, remote villages are without even basic drugs such as paracetamol. The provincial government has centered its anti-coronavirus efforts in the provincial capital Birendranagar. Although there are plenty of awareness programs, both the provincial and local governments have failed in arranging medicines and doctors. 

Even the district hospitals—the biggest in the districts—don’t have doctors to fill the vacant positions. Dolpa District Hospital has positions for four specialist doctors and five nurses. But only one doctor (under temporary contract) and two nurses are currently serving there. 

Such is also the case of Mugu District Hospital where 10 doctors including four specialists have been provisioned. But all four specialist positions are vacant. “There are some medicines in the drugstore, but we don’t have a single specialist doctor. What little medicines we have will not be enough if the pandemic spreads here,” says Dr. Nirmal Nagarkoti, chief of the District Public Health Office. 

The situation in Kalikot and Jajarkot is no better. People in remote areas of these districts do not get paracetamol if they get a fever. “As many as 200 people come for treatment for seasonal ailments every day. But treating them is a single doctor, instead of the eight provided on paper,” says Dr. Bhisma Pokharel, chief of Kalikot District Hospital. Jajarkot, which has time and again hit by epidemics, also lacks doctors. Most health institutions in the province are run by employees under temporary contracts. 

The Provincial Hospital in Birendranagar is no better. “Of the 50 positions for specialist doctors, only seven have been filled,” says Binod Adhikari, information officer of the hospital. “Of the 25 positions for resident doctors, there is only one.” 

Likewise, Dailekh District Hospital employs one doctor while there are seven positions for specialist doctors. All five resident doctors’ positions lay vacant. 

Although the district hospitals have set aside isolation rooms, they lack basic equipment to identify and treat Covid-19 patients. However, the provincial government keeps promising it will arrange for necessary drugs and doctors. “We are serious about sending medicines and doctors to rural areas. We have asked for medicines from Kathmandu also,” says Rita Bhandari, chief of the Provincial Health Directorate. 

Kathmandu: With the country locked down, people are confused about their freedom of movement. The government has urged them to stay indoors except in ‘emergencies’. 

Social media users are requesting the government to clarify lockdown guidelines. Government sources, however, say the guidelines are clearly established in the Essential Services Operation Act, 2014. The Act covers 19 areas under essential services, including transport and storage of goods, supply and distribution of drinking water, services related to hospital, collection of waste, and printing.

The recent government directive states that people can come out only to purchase essential stuff like food and medicine. 

Police deployed on the streets have been convincing people who have ventured out to return to their homes. In the event of a violation of the lockdown, people would be subjected to six-month jail or Rs 600 in fines, or both. In Chitwan, police have already arrested over a dozen people for violating the lockdown. 

Mentioning Deputy Prime Minister and Minister for Defense Ishwor Pokhrel, Nepali Congress leader Gagan Thapa tweets, “People seem confused about what they can do and what they cannot—please make that clear immediately. Please tell them how this lockdown helps prevent the spread of coronavirus.”

Speaking to APEX, Nepal Police Spokesperson Shailesh Thapa Kshetri says that if people have to travel in a vehicle, they first need to dial 100, the police hotline, and then visit the District Administration Office to get a pass.

“As far as getting vegetables and medicines in nearby shops and stores are concerned, people you can go outside and buy. But you cannot linger there,” Kshetri says. “If someone is seriously ill, we can arrange for an ambulance or even use our own vehicles to take them to a hospital.” Kshetri says the police have also been informing those who are confused about the lockdown.

In other countries, governments have come up with various guidelines on lockdowns. For instance, the United Kingdom has asked people to leave home only for four reasons: to buy medicine and food, to walk (alone), for children below 18 to meet their parents, and for travel to jobs which cannot be done at home. 

Across the world, a lockdown is considered more flexile than a curfew.

No, Covid-19 had nothing to do with Event 201 on 18 October 2019 in New York City. Yet it turned out to be an ominous herald. The Johns Hopkins Center for Health Security had hosted the high-level pandemic exercise in partnership with the World Economic Forum and the Bill and Melinda Gates Foundation. In attendance were global public health leaders. 

Summarizing the event’s goal of asking vital questions, renowned infectious disease specialist Judy Stone wrote in the Forbes, “What will happen when an unexpectedly virulent flu, or SARS, or Disease X—any other rapidly spreading viral infections—spreads globally causing a pandemic? How prepared are we? What do we need to do to be ready?” 

Soon after, the coronavirus epidemic started in Wuhan of Hubei province in China and quickly spread across the world. As Stone suggested, the old public health systems in both the developed and developing worlds seemed unprepared, hinting at the need for an overhaul with a new kind of long-term planning. 

Nepal’s former Health Minister Gagan Kumar Thapa says a change in mindset is vital. “The 2015 earthquake taught us that we were short on long-term disaster planning and in dealing with health issues in such cases.” Thapa thus proposed a Mass Causality Center under the ministry, which would be operated with the help of security agencies. The proposal was forwarded to the finance ministry. “But nothing happened thereafter,” Thapa laments. “Such a center could have simultaneously treated thousands of patients.” 

He also points out that the other essential during a pandemic is the capability of testing “thousands of suspected people quickly”, which should thus be our “long-term strategy.” 

Missed tests

The coronavirus has exposed the weaknesses of health systems of the US and other powerful European countries. As short-term measures, they are rushing to build temporary hospitals and testing facilities. But most of these facilities have either been built too late or are overwhelmed. Nepal’s existing hospitals are also desperately short of ICU beds and ventilators. Nor have there been nearly enough tests to detect the presence of Covid-19 among the broader population. Broadening testing is also crucial in stopping the spread of the virus, as China and South Korea have recently shown. 

More than that, there is a need for greater investment to build a robust public health system capable of dealing with pandemics. Dr. Sushil Nath Pyakurel, former Director General of Department of Health Services under the Ministry of Health and Population, says there have been several policy recommendations. “We had suggested setting up regional testing labs, to no avail,” Pyakurel says. 

“It’s a tragedy that samples collected from Dhangadi and Biratnagar need to be brought to Kathmandu for tests, in what is a tardy process,” adds Pyakurel, who has also served as the chief specialist at the Ministry of Health and Population. 

Pyakurel suggests the establishment of a Center for Disease Control (CDC) and its expansion in all seven provinces without delay. “We see such entities in countries like the US and India. They can conduct researches on how to deal with new viruses like corona, train healthcare workers, and inform the public,” he says. 

Similarly, security agencies like Nepal Army, Nepal Police, and Armed Police Forces can be trained to prevent, detect and respond to infectious disease emergencies. Right now the security forces have their own hospitals but they have only limited capability and are in no position to handle the corona pandemic. “We have a coordinating mechanism called Health Emergency Operative Center under the Ministry of Health, a combined body of Nepal Army, police forces, the Home ministry, the Rotary club, and Red Cross. It can be activated during a pandemic,” Pyakurel says. 

Indices of failure

According to the Global Health Security Index published in October 2019, none of the 195 countries in it, including developed ones, were well prepared for a pandemic. Nepal ranked 111th in the index prepared by The Economist Intelligence Unit in cooperation with the Nuclear Threat Initiative and the Johns Hopkins Center for Health Security. 

In South Asia, India, Bhutan, and Pakistan are better positioned to deal with pandemics than the other five countries in the region. Although the GHSI ranking puts Nepal in a ‘more prepared’ category in ‘maintaining health security’, the country lags in ‘detection and reporting’. The report indicates that Nepal’s laboratories, real-time surveillance and reporting, and epidemiology workforce are unprepared to tackle pandemics. Government officials say when there are outbreaks of infectious diseases like Zika and Ebola, there is some discussion on how to deal with them. Yet a collective long-term plan to handle pandemics is sorely missing. 

Dr. Anup Subedi, an infectious disease physician, says dealing with pandemics is more difficult in a federal system with its fragmented and decentralized health systems. “There is a need for close coordination among federal, provincial and federal governments during pandemics,” he says, adding Nepal’s government agencies work in ad hoc manner and reactively during a crisis. “We need comprehensive measures to deal with pandemics. We also have capable manpower but the state has been unable to tap their talent.” 

Due to phenomena like climate change, urbanization and globalization, more pandemics are likely in the days ahead. The Ebola in West Africa earlier this decade prompted many countries to take steps to fight large-scale epidemics but when the outbreak was controlled, their preparations were shelved too. As a long-term measure, Prime Minister KP Sharma Oli has instructed the Ministry of Health to start the process of building a separate hospital to deal with pandemics.

Common corona course

What can regional organizations do to tackle such pandemics? The successful video conference among the heads of SAARC member states suggests such regional organizations can chalk out a common strategy to fight such pandemics. Former Foreign Secretary Madhu Raman Acharya says SAARC and BIMSTEC can play a vital role in controlling pandemics both in the short and long runs. 

“As a short-term measure, there could be a proper exchange of information on the virus among the countries. Both SAARC and BIMSTEC have millions in unspent money. This can be used to buy test kits, arrange for protective equipment and other logistics, and distribute them across the region,” says Acharya. “Those organizations should prepare a long-term regional strategy to build new institutions and revitalize old mechanisms.” 

Now the countries are sealing their borders and canceling flights unilaterally, leaving many people stranded. Acharya reckons “perhaps organizations like SAARC and BIMSTEC can help bridge this communication gap as well.”  

A 58 MW Vision Hydro­power Project plant is being developed at Lahachhewar in the northern part of Ramech­hap. Access road and other structures are being built, in addition to a powerhouse near Umatirtha of the district.

Likewise, 77 MW Likhu-1 has reached the last phase of construction, with the injection of funds from Prime Bank, among six other banks. The Dugar Group has the largest shares (30 per­cent) in the project whose estimated cost of production is Rs 180 million per mega­watt. The project will be com­pleted this August, according to Rajan Chhetri, an official with the Group.

Water coming out of the project is utilized for another project, 55 MW Likhu-2, with Machhapuchhare Bank as the largest investor. A third project, 29.4 MW Likhu-3, is being simultaneously devel­oped downstream. It was also supposed to start generating electricity by August. Works on tunnels, powerhouse, and transmission lines are underway in all three proj­ects. The generated elec­tricity will be connected to the national grid at Garjan sub-station at Chuchure of Ramechhap district.

Meanwhile, about 30 per­cent work of 52.2 MW Likhu-4 has been completed. The project site lies between Khi­jidemba of Okhaldhunga and Umakunda of Ramechhap and the powerhouse will be built at Limti of Okhaldhunga. Similarly, Lower Likhu proj­ect is under construction at Dhande along the border of Okhaldhunga and Ramechhap districts. About 50 percent work on the 28.1 MW project has been completed.

The projects will directly benefit two rural municipali­ties each in Okhaldhunga and Ramechhap. Locals are happy to see the seven projects being developed simultaneously.

“Likhu River is becoming a hydro hub. We are happy that roads, drinking water sup­plies, and other infrastructure are being built in our area,” says Mawar Sunuwar, coun­cil member of Likhu Rural Municipality. “The entire area will soon see a facelift.”

“Crucial infrastructure will be built in the villages with the seven projects,” says Lila Sunuwar, a social activist of Khijidemba Rural Municipal­ity. “Locals of the affected area will get compensations, and the entire area will be developed. Moreover, locals will have shares in the hydro­power projects, which in turn will help improve their eco­nomic conditions.”

“There is also a possibil­ity of water-tourism in Khi­jidemba and Likhu areas,” Sunuwar adds.

Says Chandrakanta Sunuwar, public relations officer of Likhu Rural Munic­ipality: “Locals hugely benefit from the projects’ by-prod­ucts, which include infra­structures for health, edu­cation, drinking water, and transport”.