Nepal this week entered the third month of lockdown and during this time businesses have ground to halt, schools are closed, tourism has collapsed, overseas remittances are down. Places of worships are closed, and public spaces are abandoned.
Nepalis sacrificed their freedom of movement and suffered serious income loss so as to give the government lead time to scale up testing, equip hospitals with protective gear, set up isolation wards and ICUs in preparation for a rise in the number of infections.
But health units along the border are already overwhelmed with those returning from India. Hospital isolation wards in the Tarai towns are full, quarantine centres are inadequate, test kits have run out. All this even before we have seen a serious surge in domestic cases, and the return of hundreds of thousands of overseas Nepalis.
The reason Nepal initially appeared to have escaped relatively unscathed was because there had not been enough tests done. There is a rise in daily reported cases now mainly because contact tracing and testing of high risk groups has picked up. Cases in a Dhankuta hospital and in a Kathmandu neighbourhood this week proved there is community spread.
“We started out with bare minimum testing, we had one PCR laboratory that performed single digit test a day, and that is why the numbers were low,” explains Roshan Pokhrel of the Health Ministry. But in the past two months 18 labs across the country are analysing 2,500 samples a day, and this is one reason for the increase.
The government now has a plan to test overseas returnees at the airport, move them to temporary quarantine centres in Kathmandu while PCR results come in, and send those testing negative to self-isolation in home districts. Those testing positive will be taken to special hospital wards.
But the existing 3,400 quarantine centres and 500 ICUs beds across the country may not make a dent on the need. The logistics alone would be a nightmare The flight ban has been extended till 15 June, and may last till end-June.
On Thursday, Nepal had a total of 453 confirmed cases and three fatalities. Most of those testing positive were asymptomatic or are mild cases. Nepal has so far avoided a major crisis, but public health experts say the country cannot be complacent. It only took two months for the US to report from first 100 cases to 1 million.
Public health experts warn that the next four weeks will be crucial, and special attention needs to be placed on the border after India partially opened the lockdown and allowed public transport.
With the funeral complications for the first two COVID-19 fatalities over the weekend, the government has issued funeral guidelines in case there is a big increase in the number of deaths.
All three COVID-19 deaths also brought home a reminder of Nepal’s pre-existing burden of disease. The new mother who died in Dhulikhel appeared to have suffered post-partum sepsis while the returnee from Mumbai in Nepalganj had a severe case of diarrhoea.
The 41-year-old teacher who passed away in Gulmi on Thursday morning was admitted for liver cirrhosis. Comorbidity is going to be a challenge in treating COVID-19 patients.
At Bayalpata Hospital in Accham, healthcare director Bikash Gauchan says the lockdown has lead to a dramatic rise in maternal mortality in the country. Nepal saw 53 mothers dying at childbirth in the past month compared to 0 fatalities in the same period last year. The reason appears to be a rise in home deliveries, and the difficulty of getting to a hospital in time due to the lockdown.
Gauchan spoke with Nepali Times on phone just after performing an emergency Caesarian section, and said: “We have made some progress in preparations for future COVID-19 outbreaks in the past two months, but it is not enough. This is on top of the challenges of attending to pre-existing conditions which have become more acute because of the lockdown.”
One positive impact of the lockdown in Nepal’s urban areas has been the decline in the number of patients suffering from respiratory ailments aggravated by air pollution. COVID-19 has also made most Nepalis aware of the importance of hand washing, wearing masks and physical distancing which will prevent other chronic infections like tuberculosis and typhoid.
The dilemma for Nepal, as with all governments around the world, is to balance protection of public health with public welfare The World Health Organisation has warned that the virus is here to stay for years, but most economies will not be able to endure more full lockdown.
COVID-19 is a highly transmissible disease, but with a lower fatality rate. The question for the government is whether it wants to risk some deaths with COVID-19, or risk many more deaths from other diseases where patients are suffering from inadequate care because of the lockdown Then there are the health risks of an increase in the poverty rate due to joblessness. It is not an easy choice.
Says Roshan Pokhrel at the Health Ministry: “We have to learn to live with the virus until a vaccine comes along. Till then, we have to maintain physical distance, practicing hygiene, and strengthen our health system.”
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