<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20230112100136/63bfd50f9c7e80680e0d30d0jpeg.jpg" alt="" width="1024" height="576"/><figcaption>Health workers transporting Covid-19 vaccines in rural Nepal. Photo: NARENDRA SHRESTHA/ADB NEPAL</figcaption></figure>It was exactly three years ago that the novel coronavirus first emerged from Wuhan. SARS-COV-2 has now come full circle as cases soar and hospitals are overwhelmed across China.Beijing abandoned its zero-Covid policy, and has stopped registering fatalities from Covid-19. Official case load and death figures are said to be underreported. International health experts believe more than 1 million people may die from the disease this winter.Several countries now require mandatory Covid tests from passengers arriving from China, after Beijing eased travel restrictions in the new year. Countries in the region including Nepal are on high alert.The Health Ministry last week made masks once again mandatory in public places while appealing to people to resume hand washing and social distancing. On 28 December Nepal reported only 8 cases and zero Covid deaths.The Ministry has also urged the public <a href="https://www.nepalitimes.com/banner/why-is-there-vaccine-hesitancy-in-nepal/">to take booster shots, and second boosters</a> for people above 55 and the immunocompromised. The Drug Advisory Committee on 27 December granted emergency use approval for the Pfizer-BioNtech bivalent vaccine of which Nepal is set to receive 1.5 million doses from the COVAX global initiative by mid-January.Read also: <a href="https://www.nepalitimes.com/here-now/three-years-of-living-dangerously/">Three Years of living dangerously,</a> Sonia Awale“What is of utmost priority now is to protect our elderly and vulnerable populations. We need to fully vaccinate them if they have not or give them a booster, bivalent would be even more effective as it can fight both the original and Omicron strains,” explains Sher Bahadur Pun at the Teku Hospital.Pun likens what is happening in China now to the Omicron surge in Hong Kong earlier this year which also saw a significant rise in hospitalisations and deaths. Nepal also suffered a spike in fatalities among the elderly towards the end of the <a href="https://www.nepalitimes.com/here-now/omicron-may-not-be-as-risky-but-take-care/">Omicron third surge in 2022</a>. In both cases, the unvaccinated were victims.“Omicron might be less severe but in vulnerable groups who have not been vaccinated, even this strain can cause complications,” he warns.More than 80% of Nepal's eligible population (above 5) have been fully vaccinated against Covid-19. But the booster uptake is much lower at only 27%. There is also concern that it has been more than a year since most Nepalis got their last shots, and their immunity might be waning. Officials recommend a booster even though memory cells could provide some residual protection.The WHO has asked China to reveal its true Covid figures, and the nature of the prevalent strain. Experts attribute its surge to vaccination hesitancy among the elderly, stringent zero-Covid strategy which suppressed natural immunity, and Chinese vaccines like Sinovac being less effective than mRNA jabs.Read also: <a href="https://www.nepalitimes.com/banner/why-is-there-vaccine-hesitancy-in-nepal/">Why is there vaccine hesitancy in Nepal?</a> Sonia Awale“China did great with lockdowns and restrictions but took it to unnecessary levels, which means the population is Covid naïve compared to other countries. When they reopened, the variants already present multiplied rapidly,” explains Buddha Basnyat, physician at Patan Academy of Health Sciences. “It also seems they did not learn from the rest of the world, did not vaccinate their elderly sufficiently and relied only on their own vaccines.”The efficacy of Chinese-made vaccines has long been debated, but there are no studies to prove their efficacy, or lack thereof. However, experts agree that all the available vaccines recommended by WHO considerably reduce the severity of the disease.Media amplification of the China surge has caused some panic in the neighbourhood. Japan, Malaysia, Taiwan and India are the latest countries to require Chinese passengers to have Covid tests. India has also introduced nasal vaccine this week, those who had taken Covishield and Covaxin can take it as a heterologous booster dose.Read also: <a href="https://www.nepalitimes.com/banner/nepals-uneven-covid-19-deaths/">Nepal’s uneven Covid-19 deaths</a>, Ramesh KumarHowever, the BF7 Omicron strain has already spread around the world and it is not virulent, and does not seem to adversely affect vaccinated individuals. Experts also caution that although 1 million deaths sounds like a lot, it is a tiny fraction of China’s population. The Chinese government has accused the West of ‘hypocrisy and hyping the threat’.“The BF7 is not a new variant, it has been around for a while. It has been circulating in Europe, America and parts of Asia. It has been reported in India and chances are high it is in Nepal too, we probably just haven’t detected it yet,” says Sameer Mani Dixit of the Centre for Molecular Dynamics Nepal.He adds: “Nepalis have developed enough resistance through reinfections and vaccinations, especially as subsequent strains have been more contagious but less virulent.”The WHO says it is concerned about further mutations and the emergence of new variants, but mutations do not necessarily mean increased severity. Just like Omicron is more contagious but less severe than Delta.Says Pun: “There are at least 17 sub-variants of Omicron in Nepal. This means we have had enough immunity gained via reinfections. We also have protection from vaccination and the proof of this is how we marked our festivals, and elections without following safety measures and without any resulting surge.”Read also: <a href="https://www.nepalitimes.com/here-now/omicron-may-not-be-as-risky-but-take-care/">Omicron may not be risky, but take care,</a> Sonia AwaleHaving said that, the <a href="https://www.nepalitimes.com/latest/rural-nepal-fights-back-covid-19/">pandemic is not yet over.</a> Parts of China including Hong Kong, South Korea, Hong Kong and Japan which have high mobility of Nepalis are also seeing a Covid-19 surge this winter.The health desk at Kathmandu airport is not strictly checking vaccination or PCR tests anymore, and some experts say it should increase surveillance — especially when flights from Chinese cities resume on 8 January. After being locked down for so long, many Chinese are already booking holiday travel to Asian destinations.The Rasuwa border post also reopened this week to resume the cargo transport at Kerung and the trade between the two countries. The checkpoint which has been shut due to the pandemic since early 2020.Says Buddha Basnyat: “There is no harm in continuing to follow safety measures, it is now proven that masks and hand washing saves lives. It also protects us from a host of infections including typhoid and TB and more importantly from air pollution, all non-Covid silent killers.”

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China’s surge: should Nepal be worried?

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111413114/63722f979c7e80680e0c2523jpeg.jpg" alt="" width="4096" height="2731"/><figcaption>Photo: AMIT MACHAMASI/NEPALI TIMES ARCHIVE</figcaption></figure>A new surge in Covid cases in Nepal has served as a reminder that <a href="https://www.nepalitimes.com/latest/not-over-till-its-over/" target="_blank" rel="noopener noreferrer">the pandemic is not over yet</a>, and on the need to keep masks one, avoid crowds, and get booster shots.Hospitals have not reported an increase in admissions, and no fatalities from Covid have been reported since March. But <a href="https://www.nepalitimes.com/opinion/omicron-is-coming-to-nepal-be-prepared/" target="_blank" rel="noopener noreferrer">highly transmissible</a> new sub-strains like BA.4 and BA.5 have also been detected in Nepal, as they have elsewhere in the world.“For the most part, people who have been fully vaccinated are unlikely to get very sick from the new strains, there has been no real increase in hospitalisation,” confirms Sher Bahadur Pun, virologist at Teku Hospital in Kathmandu.The fact that the new sub-strains are all Omicron variants means that, unlike the <a href="https://www.nepalitimes.com/here-now/delta-variants-wake-up-call-for-nepal/" target="_blank" rel="noopener noreferrer">deadly Delta variant</a>, they mostly infect the upper respiratory tract and not the lungs. Delta was responsible for millions of deaths in India in 2021, and killed at least 8,000 people in Nepal as hospitals ran out of oxygen and vaccines were delayed.But with 82% of the eligible population now<a href="https://www.nepalitimes.com/editorial/deubas-mixed-report-card/" target="_blank" rel="noopener noreferrer"> fully vaccinated</a>, Nepalis are now more protected from severe illness. But the virus is still mutating, and scientists are engaged in a cat-and-mouse to stay one step ahead of new strains.“Covid-19 has proven itself to be even more cunning than we thought. It is clearly still prevalent, and can be life-threatening for some,” warns Buddha Basnyat, physician at the Patan Academy of Health Sciences. “This is not the end of the Covid story.”That is not to say that the present surge is a <a href="https://www.nepalitimes.com/latest/from-pandemic-to-epidemic-to-endemic/" target="_blank" rel="noopener noreferrer">new wave</a>. While each new sub-lineage of Omicron is more contagious, they are also milder. That is good news, but asymptomatic infected people are also spreading the virus wider.While active cases are on the rise in Nepal, hospitalisations are not, and infected individuals could be putting the elderly and <a href="https://www.nepalitimes.com/latest/nepal-needs-to-prepare-for-new-covid-wave/" target="_blank" rel="noopener noreferrer">those with co-morbidities</a> at risk at home, or at work.Studies overseas have shown that up to half of those infected with the new sub-strains are asymptomatic. As people travel more this summer and shed masks, the BA.5 and other variants are<a href="https://www.nepalitimes.com/latest/nepal-has-all-the-conditions-for-an-omicron-surge/" target="_blank" rel="noopener noreferrer"> infecting and re-infecting</a> even those who are vaccinated.“We must continue to vaccinate and take a booster, especially those who haven’t even had their first shot. It might also be the time to start thinking about a fourth dose for vulnerable populations,” says Buddha Basnyat.Because ‘immune escape’ is putting more people who have had Covid-19 still at risk of reinfection, scientists are trying to improve the <a href="https://www.nepalitimes.com/banner/vaccines-variants-and-a-third-wave/" target="_blank" rel="noopener noreferrer">efficacy of vaccines</a> as they try to keep up with mutations of the coronavirus.“Eventually, Covid-19 will be like seasonal flu, and perhaps we will have vaccines for different strains,” says Sher Bahadur Pun at Teku.BA.4 and BA.5 were first seen in South Africa, and are currently the dominant strains in Nepal. This is surprising because it is BA.2.75 that was spreading in India last month, and the surge is now peaking there. Whatever happens in India <a href="https://www.nepalitimes.com/banner/vaccines-or-no-vaccines-mask-and-distance/" target="_blank" rel="noopener noreferrer">comes to Nepal with a two-week lag</a>,  experts say, and predict the same scenario could play out again here with the present surge.“Newer strains, and mutations are nothing abnormal but we have to continue to mask up and vaccinate. As for the new surge, it is peaking at the moment and it will have subsided by end-July,” predicts Sameer Dixit at the Centre for Molecular Dynamics.The Centre is leading Covid-19 gene sequencing in Nepal, and it worked with the Nepal Health Research Council, Birat Nepal Medical Trust, Liverpool School of Tropical Medicine and Oxford to study 1,800 Covid-19 samples collected from all over Nepal in the past year. The findings will be released soon, and could reinforce the importance of genetic sequencing in Nepal so scientists can predict the behaviour of the next variant.Nepal is also a part of the largest Covid-19 recovery study, currently being undertaken in the UK which has come up with significant findings, including the use of some steroids in the treatment of coronavirus diseases.But the fact that the new strains are milder does not discount the inherent correlation between health and the economy. Even the best health care systems can collapse as seen in Sri Lanka. Moreover, <a href="https://www.nepalitimes.com/banner/state-sponsored-economic-crisis-2/" target="_blank" rel="noopener noreferrer">we now have record inflation</a> brought on by the Russian invasion of Ukraine, which has made healthcare even more unaffordable for most Nepalis.“Nepal with its limited resources and government indifference needs to be even more prepared for a health crisis, which often spells disaster for those unable to afford treatment,” cautions epidemiologist Lhamo Yangchen Sherpa.She adds: “The new surge may look mild, but it is always better to be over-prepared than under-prepared.”

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1. Mask Up.  2. Avoid Crowds. 3. Get Boosters

<figure><img width="960" height="640" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101148/63720ee29c7e80680e0b7942jpeg.jpg" alt=""/><figcaption>BRIDGING THE HEALTH GAP: Community health worker Birma Devi Kunwar, 32, crosses a bridge in Darchula with a Covid-19 vaccine box on her back. Nepal’s success with previous vaccination drives is the main reason the country has now fully-inoculated 81% of its eligible population against Covid-19. But booster doses are trailing.</figcaption></figure>On 23 March, Nepal recorded 38 new Covid-19 cases, one of the lowest figures since early 2020. The pandemic does not make it to the headlines anymore, and Nepalis are going about as if the crisis is a thing of the past. 
But it is not over until it is over. Given the latest outbreaks in Hong Kong and China, the WHO has warned that we may only be ‘halfway’ through the pandemic. That surge is just across Nepal’s northern border. 
Parts of China are back under lockdown. Hong Kong with its world class health care system, is seeing high fatality rates from the Omicron and BA.2 sub-lineage.
Omicron and its stealth variant <a href="https://www.nepalitimes.com/here-now/omnipresent-omicron-starts-to-lose-its-edge/" target="_blank" rel="noopener noreferrer">may have run their course in the Subcontinent</a>, but the Deltacron hybrid has been detected in several countries, including India. 
While there is no evidence yet to suggest that the recombinant virus is more contagious or virulent than previous strains, it is too early to make any assumptions. 
“If the new surges around the world are due to the BA.2 variant, we might not have to be as concerned,  but the same can’t be said for Deltacron since we have not yet established its transmissibility and virulence,” says virologist Sher Bahadur Pun at Teku Hospital.
Physician at Patan Academy of Health Sciences Buddha Basnyat agrees: “It is an unfolding story, but it will be prudent to assume that the pandemic is not yet over. And if there is anything we should learn from the past two years, it is that this is a very wily virus.”
In January, the WHO projected that the <a href="https://www.nepalitimes.com/latest/from-pandemic-to-epidemic-to-endemic/" target="_blank" rel="noopener noreferrer">acute stage of the pandemic would end in 2022</a> provided that there was necessary treatment and equitable distribution of vaccines worldwide. 
But citing the latest rise in case numbers, it has changed its forecast saying the world is only in the middle of the pandemic. 
Universal vaccine coverage is the only way to prevent another surge, and newer variants from coming up. In the last two years, SARS-CoV-2 has proven to be very adaptable, naturally mutating and attacking the unvaccinated. 
In Hong Kong, the majority of those hospitalised had not been vaccinated, or had received the less effective Sinovac jabs. 
Nepal’s inoculation status is now relatively high: over 93% of the adult target population is partially vaccinated while 81% have got both doses. Much of the credit goes to <a href="https://www.nepalitimes.com/latest/enlisting-female-health-volunteers-to-fight-covid-19/" target="_blank" rel="noopener noreferrer">grassroots health workers mobilised across the country</a> who built on Nepal’s past success with vaccination drives for other diseases (pictured above).  
However, the figure for booster doses is at only 9.8% even though Pfizer vaccines are now easily available, and the government may soon start offering it to children up to five years. 
Nepalis do not show vaccine denial so much, but there is some Covid complacency. 
“We have to keep up with the pace of vaccination, but we must continue prioritising vulnerable populations and children," adds Pun. "And it might help to provide the rationale and evidence to back the need for a booster because for most people, complete vaccination means only two doses.” 
Nepalis are slowly becoming careless about <a href="https://www.nepalitimes.com/banner/vaccines-or-no-vaccines-mask-and-distance/" target="_blank" rel="noopener noreferrer">masking up</a> and avoiding crowds but, experts say, this must continue to be a part of prevention measures. Testing needs to continue, especially as countries around the world open up for businesses and tourism. 
Nepal has also now <a href="https://www.nepalitimes.com/latest/no-more-pcr-for-nepal-passengers/" target="_blank" rel="noopener noreferrer">removed mandatory PCR test</a> and quarantine for fully vaccinated visitors, but the country cannot let its guard down.
Says Buddha Basnyat: “Masks are protecting us, there is no harm in continuing to wear them. They in fact defend Nepalis from a myriad of other infections, as well as air pollution.”

Not over till it's over

<img width="1808" height="1251" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101144/63720e8e9c7e80680e0b7926jpeg.jpg" alt=""/>One month after <a href="https://www.nepalitimes.com/opinion/comment/ukraines-lessons-for-sandwiched-nations-like-nepal/" target="_blank" rel="noopener noreferrer">Russia’s invasion of Ukraine</a>, the fallout of the war on global fuel prices threatens to derail Nepal’s aviation and tourism sector which was finally reviving after two years of the Covid pandemic.
Nepal Oil Corporation (NOC) has raised prices for petrol and diesel at filling stations several times, but it is aviation turbine fuel (ATF) that has seen the steepest hike.
International airlines serving Kathmandu which had already seen some booking cancellations due to the Ukraine war are now paying double the rate for refuelling their planes at Kathmandu airport.
ATF cost in Kathmandu has risen steeply from $715 per kilolitre in June last year to nearly $1,500 after the latest NOC price hike on 17 March (see graph). 
But the NOC appears to be passing on the rising import bill for petroleum products to its customers, while keeping its profit margins intact. The <a href="http://noc.org.np/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=http://noc.org.np&amp;source=gmail&amp;ust=1648181914714000&amp;usg=AOvVaw2vxZrc3-FmibmlA9NtNpz7">state-owned monopoly’s own website</a> shows that the profit it makes from <a href="http://noc.org.np/fortnightly" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=http://noc.org.np/fortnightly&amp;source=gmail&amp;ust=1648181914714000&amp;usg=AOvVaw30xV_D5k1K3ycFpKU14IgA">ATF sold to airlines has risen</a> from Rs23.92 per litre inJanuary to Rs67.93 this week.
The NOC’s overall fortnightly losses have also soared from Rs1.83 billion to Rs4.66 in that same period. It is clear that NOC is compensating for its losses from petrol, diesel and LPG sales at fuel stations by doubling the price it charges airlines in order to subsidise Nepali customers.
NOC officials have justified the <a href="https://www.nepalitimes.com/business/petroleum-price-hike-3/" target="_blank" rel="noopener noreferrer">price hike</a> saying that the fuel needs to be transported in tankers from the Indian border, and the hike in diesel prices has added to the cost of ATF in the international market.
However, the price of aviation fuel at Indian airports was only $900 per kilolitre — which is $600 less than in Kathmandu. 
Nepal’s domestic airlines, which were <a href="https://www.nepalitimes.com/here-now/pokhara-will-be-a-game-changer/" target="_blank" rel="noopener noreferrer">seeing a boom</a> since the Omicron wave started to subside earlier this year, have passed on the added cost to passengers with a hefty fuel surcharge. 
However, it is medium and long haul operators to Kathmandu like Singapore Airlines, Korean Air, Turkish Airlines, Qatar Airways, Himalaya Airlines and Nepal Airlines which have been hit hardest. Airlines have started flying in on full tanks only topping up in Kathmandu to save on fuel costs. 
Read also: <a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/here-now/ukraine-climate-and-nepal/" target="_blank" rel="noopener noreferrer">Ukraine, Climate, and Nepal</a>, Sonia Awale
A Boeing 777 or Airbus 330 on a 7-hour flight from Kathmandu to Incheon or Istanbul, for instance, burn 40 tons of fuel at a cost of $75,000. That cost will now soar, but airlines cannot raise prices on pre-booked tickets.
“Because of the rise in passenger demand we were thinking of increasing our frequency to daily flights, but with this kind of fuel cost it is just not feasible,” says one Kathmandu-based international airline executive. “Aviation fuel prices have gone up everywhere, but in Kathmandu it is 50-90% higher than any other Asian airport.”
NOC first raised its price of aviation fuel steeply to $1,095 on 2 March after the Russian invasion sent international oil prices sky high. It then raised it to $1,295 on 4 March, and again hiked it to $1,495 on 17 March. 
Brent crude prices had dropped somewhat last week, but with Russian counter sanctions against oil and gas supplies to European countries and the spectre of a long-drawn war of attrition in Ukraine, it again climbed above the $120 per barrel mark.
Some US states have legislated to temporarily waive taxes on fuel to stabilise gas prices at filling stations and reduce burden on consumers. Nepal also has heavy taxes on all petroleum products, but it cannot afford to reduce the levee at a time when it faces budgetary pressures, a spiralling trade deficit, and plummeting foreign exchange reserves. 
To be sure, Nepal is not alone in being hit by volatile oil prices because of Russia’s invasion of Ukraine, and <a href="https://www.nepalitimes.com/here-now/ukraine-crisis-hits-nepal-economy-hard/" target="_blank" rel="noopener noreferrer">the entire economy is affected</a> — not just the aviation sector. However it could not have come at a worse time, just as the country’s tourism was starting to show signs of revival after two years of Covid closure.
Several European tour operators have cancelled bookings to Nepal at the last moment. The crisis has coincided with the start of the peak trekking and mountaineering season, and a large Ukrainian expedition to Mt Everest has been cancelled. The number of climbers who had booked Himalayan peaks is expected to go down by half.
More than 1 million people depend directly on <a href="https://www.nepalitimes.com/latest/nepal-reopening-for-tourists/" target="_blank" rel="noopener noreferrer">Nepal’s tourism industry</a> and they have been without income for more than two years because of the pandemic. There was considerable optimism that Spring 2022 would see a revival, but those hopes have been dashed. 
There have been other indirect impacts from rising energy prices in Nepal, with electricity rationing this week along industrial corridors in the Tarai. As the dry season flow of Himalayan rivers reduces generation capacity, demand this week outstripped supply by 600MW. 
The Nepal Electricity Authority (NEA) was meeting this shortfall with imports from the Indian grid, but on Tuesday and Wednesday it was outbid by other purchasers. Most of India’s electricity is generated from coal and diesel powered plants, and this has nearly doubled the price of peak power imports from India to INR13 per unit on Wednesday.
Read also: <a href="https://www.nepalitimes.com/latest/what-does-defending-europe-mean/">What does ‘Defending Europe’ mean?</a>, Slavoj Žižek

Sky high fuel price hits Nepal’s tourism, airlines

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101144/63720e899c7e80680e0b7923jpeg.jpg" alt="" width="1400" height="933"/><figcaption>Photo: ANTONIO BELTRÁN RODRÍGUEZ</figcaption></figure>Daily wage labourers Dharma and Gita lost their jobs during the pandemic. The young couple exhausted their meagre savings in less than a month, after which they started to buy food on credit. Still unable to repay loans, they limited their diet to one small meal a day.Soon, Gita started feeling weak. She often had a fever and cough. As the lockdown extended, her health deteriorated and the medicines were of little help. The couple even took a PCR test which came out negative. They visited five different health centers and bought bags full of medicines. The treatment was so expensive they had to sell their two cows. A month later, and heavily in debt, she was diagnosed with tuberculosis.Tuberculosis mainly afflicts the poorest. The numbers are staggering: one in every three people globally is infected by Mycobacterium tuberculosis, and even if they carry the bacteria most people do not get sick unless their immune system is weakened due to disease or malnutrition.And yet, this easily preventable and curable biblical disease thrives in Nepal and the Subcontinent due to inadequate measures taken to prevent, diagnose and treat the infection.A 2020 National TB Program report revealed that over 100,000 people are living with tuberculosis in Nepal. This figure is much higher than previously estimated but has most likely increased since as many patients have been unable to access treatment during the pandemic.Of these cases, 40,000 patients were not diagnosed or treated at government centres, which means nearly one in every two people were not diagnosed. Oftentimes, people reach standard TB treatment and care after months or even years. Their pathway to cure is complex, long and include misdiagnosis leading to unnecessary prescriptions. This in turn could lead to unnecessary death and suffering. Patients are also ostracised by friends and families, resulting in self-isolation from communities.These challenges are exacerbated by Nepal’s limited health infrastructure. Health care centres are understaffed and poorly managed, maintenance of laboratory equipment, as well as supply of quality chemicals for tests, are erratic.Across Nepal’s Tarai, settlements are overcrowded, people live in extreme poverty, hygiene and sanitation are at a bare minimum. In the hills and the mountains, difficult geographical terrain and poor road networks pose obstacles for people seeking health care.These deeply-rooted structural inequities collectively resulted in magnified impact on TB service delivery during the pandemic. As a result, we observed increased deaths from the disease.In 2018, global leaders committed to reducing TB by 2022. To meet this goal, we need comprehensive intervention programs with sufficient investment for prevention, early diagnosis and treatment. There are four key areas that require increased funding to decrease TB fatalities:1 PreventionWe saw how the world community got together to rapidly develop vaccines for Covid-19 with unprecedented funding and resources. TB on the other hand has only one vaccine and a very weak one at that. Developed over a century ago, BCG does not prevent adults from developing TB disease.UnderNepal's national TB program, young children living with adults who have TB are provided medicines to kill any TB bacteria they have inhaled and prevent the development of the disease. The Birat Nepal Medical Trust for the first time in Nepal is providing a shorter 12-dose course of TB preventative medicine to adults infected with the bacteria to stop them from getting sick and spreading the disease.In 2020, only $684 million of the estimated $2.16 billion needed globally for TB research and development was available from donors. Covid-19 on the other hand received over $100 billion in just two years to develop vaccines. The pandemic exposed this global inequity, and is proof of what sufficient funding and political commitment can achieve.If funding for the global TB prevention program is increased by 3-4 fold, we could design better community-based services, develop a more effective vaccine and promote shorter treatment regimens, all of which will achieve a TB-free Nepal sooner.TB awareness and health promotion messages also do not get as much coverage in the media as they used to. World TB Day, observed every year on 24 March, should serve as a reminder that TB is an epidemic and needs accelerated efforts for elimination.2 Diagnosis and InnovationGovernment health centres provide TB diagnosis and treatment free of cost. Yet, people spend a lot of money and time before they are correctly diagnosed and enrolled in treatment. This is because symptoms of the disease are common to many infections. People develop cough and fever and immediately resort to taking paracetamol and general antibiotics before realising that they have TB.Moreover, Nepal needs to quickly adopt GeneXpert machines which use PCR testing, and chest X-ray that diagnoses early-stage TB effectively and efficiently. Investment should be concentrated to expand, strengthen and maintain these diagnostic tools at health centers all over the country. Health care providers should be similarly trained to operate these machines.GeneXpert technology should be deployed with active case finding where community health workers make home visits to screen and identify TB patients. This method also commonly known as contact tracing was applied in containing the spread of the Covid-19 virus, and has been used in TB programs for decades.Although proven to be effective, new diagnostic technologies are expensive and active case-finding strategies require large and sustained financial commitments. One might question if a country like Nepal can afford such investments. But the question we should be asking is, can we afford not to?The costs of the continued TB epidemic are far greater than the investments required to reduce it. Investing in better  tools including tax waivers on the import of TB diagnostic machines and test kits, and increased global funding for implementation of active case finding strategies for low and middle-income countries like Nepal are urgently needed.3 Community-based Treatment and Care Incomplete or delayed treatment can cause drug resistant TB and even death. Therefore, the treatment of tuberculosis should be patient-centred.TB programs have been implemented in Nepal for over half a century, we now have plenty of experience to employ the best strategies and  to eliminate the scourge.One of the challenges to eradicating TB is the long duration of treatment. Under the DOTS program, tuberculosis patients have to visit health centres daily for medication to be taken in the presence of care providers. But this could expose them to other TB patients, and resulting stigma. It is also time-consuming and comes with additional transport expenses.Investment in research and development of shorter course treatment regimens, and scaling up telemedicine is a priority area.4 Social Protection TB and poverty form a vicious cycle, each fuelling the other. It is mainly the neediest in society who are most affected. Having TB increases financial strain in their families with far-reaching socio-economic consequences. Children may have to forgo education and seek employment to compensate for the loss of income in families with an infected adult. Providing cash to families after the diagnosis will alleviate the financial burden.TB also causes malnutrition making people more vulnerable. Providing diversified food packages with appropriate nutritional value will be a big support, it will also help reduce the mental stress of fulfilling family needs.But these are just a few recommendations, a study to identify feasible and acceptable support for people with TB will enable us to design an improved tuberculosis support program. These should incorporate health education to people with TB and their families to better understand the disease, cope with its treatment and overcome stigma.Ultimately, it is the government’s responsibility to protect the lives of its people. Therefore, investing in and incorporating locally appropriate social protection schemes within the TB program should be the key agenda and priority of policymakers.The slogan this World TB Day today on 24 March is ‘Invest to End TB. Save Lives’, which reiterates the need to increase funding to prevent, diagnose and treat TB. Without substantial investments that will accelerate collective efforts of the community, country and the world, it is unlikely we will win the fight against TB, reverse the huge setback caused by the pandemic or save lives.Kritika Dixit is the Research Manager at Birat Nepal Medical Trust (BNMT) and a doctoral student at Karolinska Institutet, Sweden. Rajan Paudel is the Research Associate at BNMT.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101144/63720e8c9c7e80680e0b7924jpeg.jpg" alt="" width="80" height="109"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101144/63720e8d9c7e80680e0b7925jpeg.jpg" alt="" width="82" height="109">Read also: <a href="https://www.nepalitimes.com/banner/for-nepal-a-game-changer-in-tb-control/">For Nepal, a game-changer in TB control</a>, Buddha Basnyat and Maxine Caws

Pandemic eclipses Nepal's TB epidemic

<img width="2048" height="1282" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101144/63720e1d9c7e80680e0b78fcjpeg.jpg" alt=""/>While many countries <a href="https://www.nepalitimes.com/latest/nepal-reopening-for-tourists/">lift mask mandates and coronavirus restrictions</a>, Hong Kong and China are reeling from an Omicrons surge. Britain, the US and some parts of Europe are seeing a new spike in cases. In Nepal, the <a href="https://www.nepalitimes.com/here-now/omnipresent-omicron-starts-to-lose-its-edge/">public is determined to believe</a> that the worst is over. But there is a danger that China's Omicron surge will bring out a new variant. Hong Kong's Centre for Health Protection, Department of Health has urged all residents to avoid non-essential travel. The territory may soon impose a lockdown, just as China has isolated entire provinces. The surge in China and Hong Kong has been attributed to low natural immunity because of the zero-Covid strategy, the relative inefficacy of Chinese vaccines to Omicron, and the emergence of the Omicron BA.2 sub-variant.Meanwhile cases of a new hybrid strain that is as transmissible as Omicron and as serious as Delta, dubbed the 'Deltacron', has broken out in the United States and Europe.The WHO warned this week that the world is “only half-way” through the pandemic, and although news of <a href="https://www.nepalitimes.com/here-now/ukraine-crisis-hits-nepal-economy-hard/">Russia’s invasion of Ukraine</a> has overshadowed Covid-19, the virus is still spreading in unpredictable ways.Given all this, it may be prudent for Nepal not to lift all vaccine restrictions just yet. Masks and avoiding crowds must still be enforced to spread a future surge. Even though, as we have seen in the last two years, new variants can easily come in <a href="https://www.nepalitimes.com/latest/nepal-on-high-alert-for-omicron/">from travelers and spread in the community</a>.Read also: <a href="https://www.nepalitimes.com/latest/the-story-of-nepals-first-covid-19-fatality/">The story of Nepal’s first COVID-19 fatality</a>, Laxmi BasnetA number of European countries have relaxed restrictions and several states of the US have moved to eliminate mask mandates after a new guideline by the Centers for Disease Control and Prevention (CDC). The hope is that the pandemic is giving way to an endemic. An endemic has been described by the CDC as a ‘constant presence and/or usual prevalence of a disease or infectious agent in a population within a geographic area’. "We're almost there, it is now the beginning of the end, at least in the UK," Prof Julian Hiscox at the University of Liverpool told the BBC recently. "I think life in 2022 will be almost back to before the pandemic.” CDC director Rochelle Walensky echoed this, saying earlier this year that the pandemic is likely to become endemic in the US and around the world. Virologist Ian Jones of the University of Reading in the UK also said recently: “There is now no doubt that Omicron is attenuated and taking as a step toward endemicity”. Medical historians argue that most pandemics last between two and a half to three and a half years. Without a clear explanation and vaccination, the <a href="https://www.nepalitimes.com/opinion/remembering-a-pandemic-100-years-ago/">1918 Spanish pandemic</a> that infected one-third of the world’s population and claimed over 50 million lives fizzled out in 1919. An analysis suggests that the Omicron variant has now changed the shape of the global pandemic and this is likely to lead to the 'endemic world'. Chris Murray of the University of Washington takes the fact that despite the surge in infections, hospitalisation and fatality rates are still low as indication that we are now entering an endemic phase.Stephen Kissler at the Harvard T H Chan School of Public Health has been quoted as predicting: “Omicron will soon become endemic much like flu." Read also: <a href="https://www.nepalitimes.com/editorial/survive-revive-thrive/">Survive, revive, thrive</a>, EditorialWhat is puzzling scientists is why Hong Kong’s fatality rate is so high, while Omicron has not killed people at the same rate elsewhere. The risk of reinfection from Omicron is estimated to be 5–fold higher and this poses a danger to the high risk groups, elderly and to those not yet infected.Epidemiologists warn that the worst may yet to come of new variants emerge from the spread in China. Spreading to other parts of the world not yet infected to Omicron, this could have a devastating effect. Nevertheless, turning back the pages of the history of pandemics, we have seen that viruses naturally mutate and slowly evolve into an endemic phase that circulates at more manageable levels. The 1918 <a href="https://www.nepalitimes.com/editorial/preparing-for-a-no-normal/">influenza strain may never have disappeared, and continued to mutate and circulate</a> to this day. What we need to develop and adopt is <a href="https://www.nepalitimes.com/banner/why-is-there-vaccine-hesitancy-in-nepal/">sustainable coping strategies, including vaccinations</a>. What are critically missing and paying least attention to is social interventions such as behavioural change, communication for mask wearing and avoiding crowds for the near future.Medical historians also agree that the pandemic ends socially before it ends medically. And proof of that is Nepal, where mot people seem to think that they no long have to worry about the pandemic. What if the virus has decided not to enter an endemic phase just yet?Mohita Upreti is Journalism student at St. Xavier's College, she regularly contributes to the College’s monthly newsletter - The Xavierian Chronicles.Read more: <a href="https://www.nepalitimes.com/banner/why-is-there-vaccine-hesitancy-in-nepal/">Why is there vaccine hesitancy in Nepal?</a> Sonia Awale

From pandemic to epidemic to endemic

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101140/63720d5e9c7e80680e0b78bdjpeg.jpg" alt="" width="1226" height="773"/><figcaption>Photo: NEPALI TIMES ARCHIVE</figcaption></figure>Travellers to Nepal now do not need to present previously mandatory PCR-RT test results to be granted entry into the country. The latest regulations released by the Department of Immigration and confirmed by international airlines say arriving passengers only need proof of vaccination.The provision of hotel quarantine has also been scrapped. Only those unable to present vaccination proof will need a PCR negative result, but the regulations say visitors must abide by health protocols including wearing masks in public and maintaining physical distance irrespective of vaccination status.Passengers will still need to fill out their <a href="https://www.nepalitimes.com/latest/ccmcs-serious-infringement-of-citizen-privacy/" target="_blank" rel="noopener noreferrer">CCMC forms</a> and get a digital QR code and show it at the health desk on arrival at Kathmandu airport.Outgoing passengers, however, need to abide by the regulations in the destination country as well as the rules set by airlines, which vary widely.The decision comes a week after Kathmandu Valley removed all Covid-19 restrictions due to a sharp decline in the number of daily new cases, and the positivity rate. <a href="https://www.nepalitimes.com/here-now/omnipresent-omicron-starts-to-lose-its-edge/" target="_blank" rel="noopener noreferrer">The Omicron variant</a> which is thought to be the dominant strain circulating in the region is also largely mild, keeping hospitalisation figures low in Nepal.On Friday, there were 77 new Covid-19 cases against 7,981 PCR and RDT tests. There was only one fatality nationwide. The figure for active cases across the country is also down to 5,212 whereas a total of 189 individuals recovered in the last 24 hours. Nepal recorded 10,052 new cases on 20 January, it’s highest, during <a href="https://www.nepalitimes.com/here-now/3rd-wave-in-2-years/" target="_blank" rel="noopener noreferrer">the third wave</a>.The easing of the restriction has come as a respite for tourism entrepreneurs and operators who have suffered heavily in the past two years due to the pandemic. Nepal's spring trekking and mountaineering season has already started and there were 16,000 tourists entering the country in February, about one-tenth of pre-pandemic figures for that mounth, but still higher than in February 2021.At least 1 million Nepalis depend on <a href="https://www.nepalitimes.com/editorial/survive-revive-thrive/" target="_blank" rel="noopener noreferrer">the tourism sector</a> which makes up nearly 8% of the GDP. Before the outbreak of the coronavirus crisis, the government had declared 2020 Visit Nepal Year with a target of bringing in 2 million tourists.However, the figures dropped to 230,085 in 2020 and further down to 150,962 in 2021 due to travel restrictions, lockdowns and <a href="https://www.nepalitimes.com/banner/call-to-ease-entry-of-tourists-to-nepal/" target="_blank" rel="noopener noreferrer">complicated entry provisions</a> when the country was periodically open for travellers.Heavy losses incurred during the pandemic forced many star hotels and restaurants to shut down. But perhaps the hardest hit are trekking porters and guides who depend on seasonal income during spring and autumn.Initial projections estimated that it will take <a href="https://www.nepalitimes.com/latest/nepal-tourism-may-take-5-years-to-recover/" target="_blank" rel="noopener noreferrer">five years for the industry to pick up</a> and tourists to return to pre-pandemic levels, but tour operators are optimistic with more businesses opening up and expanding with services geared towards adventure and nature tourism, which is expected to take off in the post-Covid world.Health experts have also predicted the pandemic to end in 2022 with equitable distribution of vaccines and access to treatment, further normalising the situation. But perhaps the biggest reassurance for the industry is the <a href="https://www.nepalitimes.com/latest/all-vaccines-prevent-severe-covid/" target="_blank" rel="noopener noreferrer">increasing rate of vaccination</a> in and outside the country.A total of 62.5% of Nepal’s population has been fully inoculated while 74.5% have taken at least one dose. The figure for a booster dose is however low at 5.2%. Even so, Nepal is still on the travel red list of many European countries, the US, and Australia.

No more PCR for Nepal passengers

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101140/63720d119c7e80680e0b78a4jpeg.jpg" alt="" width="960" height="640"/><figcaption>Imja Glacier has turned into a lake 3km long and 1km wide in the last 30 years due to global warming. Photo: KUNDA DIXIT</figcaption></figure>The double-barrel crisis of climate and Covid <a href="https://www.nepalitimes.com/banner/human-face-of-a-himalayan-climate-crisis/" target="_blank" rel="noopener noreferrer">has hit Nepal’s Himalayan communities hard </a>with its impact on livelihoods and the natural environment.I myself have witnessed first-hand the vast changes in the lives of our people in the mountains for over six decades. As a mountaineer, trekker, environmental activist, and someone in the mountaineering, trekking and tourism sector, I have seen the <a href="https://www.nepalitimes.com/here-now/epicentre-of-two-disasters-in-west-nepal/" target="_blank" rel="noopener noreferrer">impact of the twin crises</a>.Although we share the Himalaya with Bhutan, India, China and Pakistan, it is Nepal that hosts most of the highest peaks. Both the Buddhists and the Hindus who live here consider the Himalaya sacred.Much of our socio-cultural practices of diverse ethnicities from the mountains to the plains evolved amidst the great lakes and rivers emanating from the Himalaya. Protecting the precious natural beauty of the mountains is important not just for Nepal, but also for the planet.Much of Himalayan region is poor, many remote areas still do not have electricity, <a href="https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/" target="_blank" rel="noopener noreferrer">health facilities </a> are dismal, children are deprived of quality schooling, and educated <a href="https://www.nepalitimes.com/banner/no-country-for-young-men/" target="_blank" rel="noopener noreferrer">youth migrate because there are no jobs</a>.Nepal is known for its mountains, but it is the <a href="https://www.nepalitimes.com/opinion/right-at-home-with-nepalis/" target="_blank" rel="noopener noreferrer">spontaneous warmth and natural friendliness of its people</a> that impresses visitors. This multi-ethnic society living in harmony for centuries has weaved a rich cultural tapestry.Read also: <a style="font-weight: 600; letter-spacing: 0.15px;" href="https://www.nepalitimes.com/banner/global-heating-melts-mountains/">Global heating melts mountains</a>, Nepali TimesThe Himalaya, and more specifically the<a href="https://www.nepalitimes.com/banner/on-thin-ice-in-the-khumbu/" target="_blank" rel="noopener noreferrer"> Khumbu region</a> represents the opportunities and challenges of Nepal in a microcosm. I grew up there taking my family’s yaks to graze, climbed for a living to support my family, and awakened to my life’s mission. The mountains are literally melting before my eyes. Hundreds of glacial lakes have swelled up dangerously in recent decades. Imja is now one of the biggest, and I have seen it grow enormously since my childhood. As children, we used to cross the Imja Glacier with our yaks. Then ponds started to appear, and grow. The lake is now 3km long and 1km wide, and in danger of bursting. The Khumbu Glacier in the adjacent valley may not have a big lake, but the firm ice we used to walk on is all gone, replaced by boulders and debris.The Himalaya is already one of the most <a href="https://www.nepalitimes.com/nepali-times-search/?q=melting+shake" target="_blank" rel="noopener noreferrer">seismically active areas </a>of the world. Future earthquakes can bring down avalanches into these lakes, causing them to top over the fragile moraine dams, sending vertical tsunamis rushing down the narrow valleys.In my lifetime, I have seen two of these glacial lake outburst floods with my own eyes: in 1977 below Ama Dablam in Pangboche, and in 1985 after the Dig Tso burst in Thame. Both caused death and destruction downstream, washing away trails and bridges, drinking water systems, a hydropower plant and decades of development.We in Nepal’s mountains did not cause the global climate breakdown, yet <a href="https://www.nepalitimes.com/banner/a-terrifying-assessment-of-himalayan-melting/" target="_blank" rel="noopener noreferrer">we are paying the price</a>. This is why I formed the Climate Alliance of Himalayan Communities (CAHC) to bring the impact of climate change in the Himalaya to world attention, and work on risk reduction through traditional knowledge and native experience.Trekking and mountaineering had also fouled the mountains, giving Mt Everest a bad reputation for being <a href="https://www.nepalitimes.com/banner/most-days-its-not-so-crowded-on-mt-everest/" target="_blank" rel="noopener noreferrer">overcrowded</a> and garbage-laden. But in recent years, through initiatives like the annual Eco Everest Expeditions and the Sagarmatha Pollution Control Committee, the routes are much cleaner. The ‘Cash for Trash’ started by Asian Trekking has brought down 24 tonnes of garbage from Mt Everest in the past 14 years. Seven bodies of climbers have also been retrieved for dignified funerals.<a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/here-now/managing-everests-waste-problem/" target="_blank" rel="noopener noreferrer">Cleaning Himalaya</a> is not as easy as picking garbage in the streets of Kathmandu. Some of the frozen bodies were brought down from Balcony at 8,400m, below the summit of Mt Everest. The Sherpas risked their own lives to dig out the bodies entombed in ice.Tourism has played a pivotal role in the economic transformation of the Khumbu. But it has suffered many crises. The deadly avalanche at Everest Base Camp in 2014, the earthquake the next year, and in the past two years the Covid-19 pandemic, as well as more recent conflicts and instability.Read also: <a href="https://www.nepalitimes.com/banner/living-below-nepals-melting-mountains/">Living below Nepal’s melting mountains</a>, Alton C Byers<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101140/63720d149c7e80680e0b78a5jpeg.jpg" alt="" width="1244" height="500"><figcaption>Locals used the pandemic lockdown to repair and spruce up the trekking trail to Everest Base Camp. Photo: ANG RITA SHERPA</figcaption></figure>Nepal needs a post-Covid strategy to <a href="https://www.nepalitimes.com/banner/model-for-post-covid-ecotourism/" target="_blank" rel="noopener noreferrer">revive its tourism industry</a>. The Khumbu, Annapurna, Langtang and Manaslu areas have been hit particularly hard because trekking provided 80% of the income for families.What has made the situation worse has been winter drought, extreme monsoon weather in the last two years. This has meant poor harvests, <a href="https://www.nepalitimes.com/banner/nepal-is-going-up-in-smoke/" target="_blank" rel="noopener noreferrer">wildfires and other disasters</a> that have made it difficult for people to cope.The pandemic hit just as Nepal was preparing to welcome the Visit Nepal Year 2020 campaign. The tourism sector had invested a lot of resources through bank loans to promote Nepal and upgrade facilities. But when <a href="https://www.nepalitimes.com/latest/nepal-tourism-may-take-5-years-to-recover/" target="_blank" rel="noopener noreferrer">tourism collapsed</a>, the loans added to the burden for businesses.A post-Covid resurgence of tourism in Nepal could be adopted with the following strategies and policies:Banks should reschedule repayment of loans, demand only interest payments now and the principal a year after tourism revives and the cash flow is better. This would lessen some financial burden of the already floundering industry.As tourism recovery seems uncertain, there is a need for state support for those dependent on trekking and mountaineering.Read also: <a style="font-weight: 600; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/opinion/climate-for-change/the-great-himalayan-thaw/" target="_blank" rel="noopener noreferrer">The great Himalayan thaw</a>, Ajaya DixitCovid vaccination should be prioritised for frontline tourism workers. More PCR test centres should be opened at airports for hassle-free entry for tourists without quarantine. Health protocols should be followed but without making a Nepal trip unpleasant for travellers.Introduce and promote more tourism destinations and products, such as sky diving, winter skiing, high altitude ice hockey competitions, mountain biking, agro tourism, etc.Tourism infrastructure should be <a href="https://www.nepalitimes.com/banner/tourism-that-treads-lightly-on-the-land/" target="_blank" rel="noopener noreferrer">rebuilt using an eco-design</a> approach to optimise the use of locally-available resources and expertise that generates employment.Special packages must target repeat international tourists, the Nepali diasporas, expatriates and domestic tourists.Provide vocational skills (plumbing, carpentry, electrician, masonry) for local people dependent on tourism jobs.Revival of tourism will only happen if there is survival. More than anything else, we need to get people back to work so that they can look after themselves. And that means we need to get tourism up and running, as it is one of the biggest employers.We need to let the world know that the best way to help the Himalayan people is by visiting the country. Visitors will also see first-hand the enormity of the climate crisis, and will thus help focus global attention to it.The Himalaya is not just a tourist destination providing income to Nepalis. It is also a gigantic water tower for much of humanity that lives downstream in Asia. Saving the Himalaya means saving the planet.Read also: <a href="https://www.nepalitimes.com/banner/danger-nepals-glacial-lakes-are-filling-up/">DANGER: Nepal’s glacial lakes are filling up</a>, Nepali TimesAng Tshering Sherpa is a tourism entrepreneur and has served with the Nepal Mountaineering Association.

Himalayans on the frontlines

<figure><img width="640" height="427" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101128/63720a5e9c7e80680e0b559bjpeg.jpg" alt=""/><figcaption>Photo: SONIA AWALE</figcaption></figure>The spread of <a href="https://archive.nepalitimes.com/article/nation/long-distance-medicine-in-nepal,3521" target="_blank" rel="noopener noreferrer">telemedicine</a> is one of the most remarkable spillover effects of the <a href="https://www.nepalitimes.com/here-now/3rd-wave-in-2-years/" target="_blank" rel="noopener noreferrer">Covid-19 pandemic</a> worldwide, and could also transform healthcare in Nepal.In the US, the Center for Disease Prevention and Control (CDC) specifically recommended that health care facilities and providers offer clinical services through virtual means as a result of which growth in telehealth usage is 38 times higher than before the pandemic.The US was amongst the first adopters of telehealth and has also been a mature user of tele-ICU services, with an estimated 11% of American ICU beds under telemonitoring. Adoption of telemedicine was <a href="http://archive.nepalitimes.com/news.php?id=14607#.YhzApy8w3u1" target="_blank" rel="noopener noreferrer">slow to catch on </a>in the developing world due to insufficient communication infrastructure and status quo biases plus regulation deficiencies. But it witnessed a breakthrough during the pandemic, thus making the virtues of telemedicine apparent. Argentina had passed legislation to validate electronic prescriptions and launched TeleCovid, a public telemedicine provider.In Australia, Singapore, Indonesia, and the Philippines, governments have been making consistent efforts to advance the use of telehealth through subsidies, funding, and loosening certain health regulations during the pandemic.In developed countries, this was enabled by three factors: increased consumer willingness to use telehealth, greater provider willingness to use telehealth, and regulatory changes enabling greater access and reimbursements.While it is evident that government intervention and public sector support have been the key to creating favourable business environments for telehealth in those regions, Nepal seems to stand out.Read also: <a href="https://www.nepalitimes.com/latest/covid-crisis-can-spur-digitisation/" target="_blank" rel="noopener noreferrer">Covid crisis can spur digitisation</a>, Ashutosh M DixitDuring the pandemic, many startups and corporates in the country launched telemedicine and digital health services to meet the growing need. But, will the surge in telemedicine services be sustainable post the pandemic or will it retreat? In Nepal, the majority of dispensaries, hospitals, and doctors are located in urban areas where only 21% of the population resides. Even then, they are concentrated in better off urban centres.Which means rural, peri-urban, and urban slums lack adequate access to quality primary healthcare. Much of the care delivered in underserved areas is through public sector primary or community health centers.Health tech startups and firms have made a successful market entry at the height of the pandemic, the result of which led to an exponential boom in online consultations via apps, medicine delivery, and even health service at the patients' door.These gains should not detract from the need to enable to specialist and super-specialist care to the untapped population of Nepal.The government's telemedicine strategy in 25 remote districts in Nepal is defunct due to financial and operational constraints. How strategic choices and the manner of those choices cascade to the bottom of pyramid markets will determine the sustainability of health tech startups.During the Covid-19 pandemic, telehealth companies recorded an average growth of 70% in basic telemedicine demand as compared to 2020. As promising as it sounds, online consultations on their own may not be enough for it to thrive post-pandemic.It has to be integrated into other services like home healthcare where the physicians go to the patients' home to provide medical services including routine checkups, administering medication and collection of medical samples for diagnostic purposes. Read also: <a href="https://www.nepalitimes.com/banner/drones-to-the-rescue/" target="_blank" rel="noopener noreferrer">Drones to the rescue</a>, Lucia de VriesFully integrated patient record allows clinicians to serve the people best, no matter whether they are present physically or remotely. Home delivery of prescribed medications adds to the safety and convenience of patients. Another emerging trend in the industry is modern healthcare subscriptions which may help expand the service offerings through the app and make services financially accessible to patients.Built on proprietary technology, telehealth apps are seen to be the core products. Through the app, patients or their dependents can avail services of online video consultations, book hospital appointments, or even order medicines online.However, acquiring and retaining customers may be challenging due to changing customer needs and preferences in the long run. It is for this reason that companies have to offer more than the basics, with better user engagement and experience.This means business analysis and planning exercises, phase-wise implementation, regular updates, and zero errors leading to faster processing of information and lower latency.Globally, telemedicine has the potential to revolutionise healthcare by bringing down provider and patient costs as well as improving the accessibility to quality medical professionals.In Nepal, telemedine should not just be an off shoot of the pandemic lockdowns but a deliberate strategy to improve the state of public health infrastructure and services with digital connectivity options.But the private sectors' efforts to bring innovation and improvements towards digitalisation in the health care ecosystem in Nepal can be a precursor for the country's healthcare transformation. Due to this the sustainability of telehealth companies must be reviewed time and time again.Read also: <a href="https://www.nepalitimes.com/here-now/digitial-path-to-social-buffers-in-nepal/">Digital path to social buffers in Nepal</a>, Ashraya DixitBishal Raj Paudyal is a Chartered Accountant and an MBA from Asian Institute of Technology in Bangkok.

Sonia Awale

Healthcare moving from hospitals to homes

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101128/63720a259c7e80680e0b5587jpeg.jpg" alt="" width="1000" height="602"/><figcaption>All photos: ABHYU GHIMIRE</figcaption></figure>Scientists have found <a href="https://academic.oup.com/mbe/article/34/3/775/2967141?login=true">genetic evidence</a> that dogs were first domesticated by early humans on the Tibetan Plateau, and interbreeding with the Himalayan grey wolf gave them the ability to adapt to high altitude living. So, it is no wonder that dogs feel so much at home in the mountains.When a team did the first traverse of <a href="http://archive.nepalitimes.com/news.php?id=19057#.YhnstC2B2CR">the Great Himalayan Trail</a> in 2017, a mastiff they named Setuk joined the group for 300km from Khumbu to Helambu, even climbing over the 5,700m high Tashi Labtsa pass. Setuk once <a href="http://archive.nepalitimes.com/news.php?id=19216#.Yhnsti2B2CR">accompanied mountaineers</a> up the Khumbu Icefall to Camp 2.Another <a href="http://archive.nepalitimes.com/news.php?id=17935#.Yhnsui2B2CR">Tibetan mastiff named Tashi</a> once walked back from a village in Ramechhap to Kathmandu after his Japanese owner, at the end of his job in Nepal, took him back to the place where he adopted the puppy.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101128/63720a279c7e80680e0b5588jpeg.jpg" alt="" width="1000" height="563">Dogs often trail trekkers in Nepal, they bond with them acting as guides and camp watchdogs in return for food and adventure. Some of these dogs stay on in the mountains and are feral, hunting in packs like their evolutionary ancestors. Wild dogs have been known to attack yaks in high pastures in Khumbu.A community dog from Dingboche once accompanied us on the climb up to Nangarshang peak. He was a perfect gentleman (a gentledog if you will), and carried himself with much dignity. Not obtrusive or greedy, he was just there all the time, walking ahead of us on the trail.<a href="https://www.nepalitimes.com/banner/a-dog-with-altitude/">Tibetan mastiffs</a> look intimidating at first glance, but they seldom quarrel among themselves when resources are plentiful. They however can be loyal and fiercely protective of the yaks, sheep or humans that they watch over, and do not hesitate to attack “outsiders”.https://www.youtube.com/watch?v=IUNCMaIlNB4There is a difference between domestic dogs confined to households, and community canines that watch over the whole village they belong to. As an example, this particular tourist dog was attacked by local dogs at Namche Bazaar. As my patient wouldn't let me suture the lacerations, wounds were cleaned and repaired using staples.Lately, however, I have noticed that with the drop in tourism following the pandemic in the past two years, previously <a href="https://www.nepalitimes.com/review/a-tibetan-mastiff-pup-who-dares-to-dream/">friendly community mastiffs</a> in the Khumbu have become more aggressive.As a doctor here, I have had to treat an increasing number of dog bite cases. Not only have the incidents of dog-attack increased, but the injuries are also more serious. No longer are they casual fang marks and scratches, but deep wounds as if the predator had the intention of killing and eating its prey.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101128/63720a2a9c7e80680e0b5589jpeg.jpg" alt="" width="445" height="462">Some people have stopped walking alone along village trails, and children are warned by parents not to go out alone. I had to treat a child who was attacked by a group of dogs in Pangboche and had deep life-threatening injuries on her back. She was lucky, as neighbours chased away the dog pack in the knick of time.There used to be a puppy in Dingboche that used to play with a yak calf which was about his size. He was being raised by the community to be a watchdog to protect the yak herd from wolves and snow leopards.Recently, the pup was killed and eaten — not by a <a href="https://www.nepalitimes.com/here-now/nepal-leads-in-snow-leopard-study/">snow leopard</a>, but by other feral dogs. There have been other instances of dog-eat-dog, a phenomenon locals here had never heard of before.The people of the Khumbu rely heavily on trekkers for income, and the collapse of tourism has had a domino effect on families here. The fall in income has also meant that the dogs now do not get enough to eat<a href="https://www.nepalitimes.com/banner/bhaktapurs-dog-catchers/">Community dogs</a> that used to be well-fed, and sleep all day in the sun, are now showing more aggressiveness. Triggered by hunger, they have fallen back on their primitive wolf instincts.They hunt in packs, and there are frequent territorial gang wars between rival groups. Dog fights have become more common, and dogs do not hesitate to eat their own kind if one is killed in a fight.Khumbu’s langur monkeys, which were wary only of snow leopards and <a href="https://www.nepalitimes.com/banner/crying-wolf/">wolves</a>, are now being attacked and eaten by dogs. In Dingboche, one unfortunate monkey met such a fate and was left half-eaten by dogs.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101128/63720a2c9c7e80680e0b558ajpeg.jpg" alt="" width="329" height="462">It is an indication of how much locals are worried about dog attacks that the deeply religious people here, who usually do not harm animals, have started requesting the authorities to poison rampant dogs. This is against what doctors believe in and practice, and hence was denied.Luckily, with the Covid-19 pandemic tapering off, there is a trickle of trekkers. With more food available, the number of <a href="https://www.nepalitimes.com/banner/dog-bites-man-is-still-news-in-nepal/">dog bite cases</a> at the health posts in the Khumbu is going down noticeably.This behavioral change in Khumbu's dogs should be studied in more detail but what we witnessed first hand was thousands of years of domestication fading away in a matter of months, as a result of food deprivation, an interesting side <a href="https://www.nepalitimes.com/banner/singha-darbar-dogs-go-hungry-in-lockdown/">effect of the whole Covid-19 pandemic</a>.Abhyu Ghimire is a Medical Officer at The Mountain Medical Institute at Namche Bazar and Dingboche in Solu Khumbu.

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