Protecting those who protect us from Covid

On 20 May, the Health Ministry released a condolence message for doctors including Ishwor Lal Acharya, Mukesh Chaudhary and Pujya Shree Karki who lost their lives to Covid-19.

Nepal doesn't yet have an exact figure on the total number of medical staff infected by the SARS-CoV-2 but the Nepal Health Research Council (NHRC) is currently conducting a study to find out. 

“Majority of our frontline health care provides have been fully vaccinated, so even if they are being infected, they are only mild to moderately sick,” says cardiologist and chair of the Nepal Medical Council (NMC) Bhagawan Koirala. “This combined with a better understanding of Covid-19, they are now more confident and have a better sense of responsibility this time around.”

At the National Trauma Centre in Kathmandu, nursing staff Suman Chaudhary is back to work after recovering from the coronavirus herself and draws motivation from health workers who are battling the pandemic in major hotspots like Birganj.

“This is our chance to make a real contribution and having been infected myself has given me a new perspective on how patients feel,” says Chaudhary who was pursuing Masters in Nursing at Bir Hospital during the first wave. “It is difficult to work in a PPE all day without water or bathroom breaks. I still feel weak and have shortness of breath, but watching people recover keeps us going.”

Both Koirala and Chaudhary, however, agree that there is a chronic shortage of medical staff across the country. Hospitals outside Kathmandu and even Covid dedicated institutions are overstretched, and now doctors and nurses are themselves falling sick. In some hospitals, since patients and staff are all positive, nurses and doctors with mild symptoms have just kept working, since there is no one else to take care of the sick.

Last week, more than 47 of Dhading District Hospital’s emergency and ward staff were infected with Covid-19, with many of them in isolation and some requiring ICU treatment even as the facility was finding it difficult to source enough oxygen for existing patients.

“We are a hospital of only 8 doctors, 5 paramedics and 23 nurses and with no backup, we were very close to collapsing,” says Medical Superintendent at Dhading District Hospital Tribhuvan Jha, adding that everyone had to be called back to work after 10 days of isolation. “We are in this position due to a lack of preparedness, shortage of staff and limited infrastructure.”

At Charikot Hospital in Dolakha, which is also a Covid-dedicated hospital, the majority of coronavirus patients are critical and there is at least one fatality every day. The 17 nurses work three shifts a day, and are unable to handle patient inflow, so the hospital has brought in community nurses from outlying villages. The hospital is consistently reporting a 45% test positivity rate among those tested.

“If a majority of our health workers get infected and are in isolation, we have no Plan B and this is especially worrying because we are the sole care provider for Covid here,” says Binod Dangal of Charikot Hospital. “Medical staff are all  overworked, and they do not have any insurance or allowances.”

As dire as the situation is in Nepal’s big cities and district hospitals, the pandemic has now infiltrated rural Nepal where there is just one doctor for every 15,000 people. Kathmandu’s doctor-to-patient ratio is 1:850.

In her village of Phediguth of Okhaldhunga district, Rita Khatri is the only skilled birth attendant. Despite the growing risk of the second wave, she is still performing deliveries and ante-natal check-ups wearing a mask and her single PPE suit. There are no tests of health workers and the public.

“We are working despite fears of transmission, I wish we had more PPEs, masks and gloves so that we could conduct more regular check-ups and make home visits,” adds Khatri. “At the moment many people in the community have high fever and are staying at home, but there is no way to test them.” 

This time last year while in the grip of the first wave of a new pandemic, there was stigma associated with Covid-19 and people who were infected were ostracised in the community. There were many instances where healthcare providers were mistreated.

Doctors and nurses interviewed for this report say that is still the case, but there is also more praise for frontline medical workers risking their own health to save lives. However, there is growing concern about the worry and over-work affecting the mental health of nurses and doctors.

“Among other things we need psychological support and counselling. I have seniors who have children infected with the new variant, and they are having a hard time coping,” says Suman Chaudhary, nursing staff at the Trauma Centre in Kathmandu.

As most of Nepal enters the fourth week of lockdown, nationwide daily Covid-19 infections, positivity rate as well as fatalities are going down slightly. The number of recoveries have also risen to nearly equal new confirmed cases on some days.

Bayalpata Hospital in remote Accham District had to turn its Emergency Room into a Covid-19 ward last month to cope with a flood of patients. It had 33 patients, 18 of them needing high flow oxygen support. On Wednesday, it had only 12 Covid-19 patients with only two on oxygen. Four of those infected are medical staff. 

“The situation is easing somewhat here, in Mangalsen, Doti and Dadeldhura. There are beds available, and oxygen is coming in. But we are desperately short of medical staff,” says Mandeep Pathak, a physician at Bayalpata which is also caring for trauma and maternity patients from surrounding districts.

However, the cases and the test positivity rate have not gone down as expected and fatalities nationwide have stayed above 160 for nearly two weeks now as the highly contagious and more lethal B.1.617.2 variant spreads rapidly through communities.

Health Minister Hridayesh Tripathi sounded optimistic at a virtual press meet on Monday, predicting that there would be a decline in the infection rate in the next four weeks. 

As Nepal receives large shipments of oxygen cylinders, liquid oxygen, test kits, PPEs and masks, doctors say the emphasis now needs to shift to more testing, mass vaccination, and replenishing exhausted and over-stretched medical staff at hospitals, both in the cities and the districts. 

A non-profit One Heart Worldwide that works primarily in maternal care in Nepal’s 21 districts has been helping district hospitals by mobilising oxygen cylinders and medical kits it procured from China.

Executive director Surya Bhatta gives three reasons why despite the lockdown the infection rate is still high. “There is virtually no contact tracing, people are still not following health protocols and patients isolating at homes are not doing it right, resulting in a gross underestimation of total cases and fatalities.”

Weddings into hotspots

Gopal Dahal in Dhankuta

On 30 April, when a young man in Okhre village in Dhankuta district got married, the whole . The whole community was invited for the feast.

But a few days later, the groom suddenly fell sick. When he showed coronavirus symptoms, a test at the primary health care centre confirmed he was Covid-19 positive.

Now, every household in Okhre village has members showing similar symptoms. Most of them had attended the wedding. Of the 51 people tested, 25 tested positive. 

“This is a crisis, the pandemic has spread to the whole village now,” says Ward Chair Palak Basnet.

One of the guests at the wedding was a man who had returned recently from the Tarai with mild symptoms. He was hired to wash dishes at the wedding, and had died a few days after the feast. No one tried to find the cause of death, and there was no PCR test done. 

Dhankuta MP Jitendra Rumdali Rai says there are probably many more cases than the ones who have tested positive so far. “The pandemic is spreading out of control here because the municipality wasn’t able to manage it on time,” he adds.

Okhre village has now been sealed off till 8 June. Some of those infected are in critical condition, and six who were more serious were taken to hospital in Dharan. It is difficult for the others because the municipality does not have an ambulance, and some who had taken sick relatives to Dharan returned because there were no beds, or it was too expensive. 

“Initially they were charging Rs10,000 per day for the bed and we paid Rs4,000 daily for the doctor. But then they hiked it to Rs14,700 and I couldn’t pay it any more,” says one patient’s family who returned recently from Dharan’s Bijayapur Hospital.

Another coronavirus patient says ambulances are also expensive, making it hard to get patients to hospitals. Buses refuse to take passengers who are sick.

The municipality called an emergency all-party meeting and decided to set up a 10-bed isolation centre with two staff nurses, and a doctor. Talks are underway to get at least a pickup from Dhankuta Red Cross to use as an ambulance.