<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111016110/636d12069c7e80680e0a98b4jpeg.jpg" alt="" width="844" height="570"/><figcaption></figcaption></figure>I knew I wanted to get vaccinated as soon as the Covid-19 jabs were made available to the general public in the US, and that when it was my turn I would have access to it.It was not the same for people in Nepal, and I remember family and friends back home telling me how hard it was to get a vaccine earlier this year. And a lot of it depended on whether you had the right connections.People in Nepal were <a href="https://www.nepalitimes.com/banner/anger-grows-in-nepal-over-covid-vaccine-delays/">struggling to find their first doses</a>, whereas in the US people did not want to get vaccinated against Covid-19 despite a raging pandemic. Those without access to jabs were confused with those who did not want to get vaccinated.All international students studying in the US must provide proof of immunisations against <a href="https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/">MMR (Measles, Mumps and Rubella)</a>, Varicella Tdap (Tetanus, Diphtheria, Pertussis) and Meningitis.I completely understand the reasoning behind requiring those vaccinations, it is to keep people safe, and it never entered my mind to argue the logic.Did I ever feel like my freedoms were being curtailed because I needed to show proof of those inoculations? No. Did I feel like someone was infringing on my choice? No. Did I have a problem getting the necessary vaccine for the greater good? No.So why is it different with the Covid vaccine? The main reason to be vaccinated was so that I do not spread the infection further, as well as protect myself. The sooner we all got vaccinated, the sooner we would be post-pandemic.Which is why it surprised me that unlike <a href="https://www.nepalitimes.com/latest/too-early-for-nepal-to-let-its-guard-down/">Nepal</a>, where the vaccine acceptance rate is 97%, many in the US were choosing to not to get the jab because it curtailed their freedom of choice. The anti-vaxxers were also anti-maskers — and the puzzling thing was that they would however not protest against wearing seat belts to abide by laws against drinking and driving.They say Pfizer and Moderna have side effects. Of course they do, every modern medicine has some side effect. Even junk food has horrible side effects, but that hasn't stopped people from eating fries and burgers.And while anti-vaxxers are worried about their health, they have not taken the time to consider the health of millions of others they directly or indirectly interact with.I had spent most of my life in the US in liberal and progressive cities, so when I was met with the comparatively conservative crowd, I felt it was pointless to argue the subject because they had made up their minds and were not open to other opinions.Nothing has brought out the gap between haves and have nots than the Covid-19 pandemic. The global gap between the jabbed and jabbed nots is growing, increasing the chances of mutant strains evolving.In Nepal, we are not privileged enough to choose whether or not we will get a vaccine for a disease that has killed millions. We cannot even choose which vaccine we want: <a href="https://www.nepalitimes.com/banner/despite-doubts-nepal-sticks-with-astrazeneca-jabs/">AZ-Covishield</a>, VeroCell, J&amp;J. We take whatever is available.For most Nepalis, if there is a disease and there is a way to protect yourself from it, you just do it. There are no what-ifs.The fact that you even have the option to decide if you want to get inoculated against the virus in a country which has the highest national total of fatalities from Covid-19 shows how privileged people are in the US.When you are a <a href="https://www.nepalitimes.com/banner/the-real-cost-of-nepals-second-wave/">daily wage worker</a>responsible for feeding and clothing your family, and when your government doesn’t give you a weekly unemployment allowance for staying at home unable to go to work, you want to return to your job as soon as possible. The only way to do that at the moment is to vaccinate and make it safe for everyone to be out again.I would respect the choice of the anti-vaxers not to get vaccinated if they stayed home and did not interact with the public. But they are out and about (and without masks) claiming that it is their right to do so.Being a citizen means having a sense of responsibility towards oneself and others and not using selfish excuses in the name of freedom to do whatever you want.It is a sensitive topic, and those who are most vocal and against the vaccine seem to be also the least informed about masks, <a href="https://www.nepalitimes.com/banner/climate-change-is-a-disaster-in-the-nepal-himalaya/">the climate emergency</a>, guns, abortion and politics. They live in social media echo-chambers where algorithms expose them to ever more radical posts.Recently, I asked a friend in the US if he had been vaccinated. Later, I was told that it is impolite to ask such questions. But if someone is out in public, mingling and exhaling, they need to be responsible about the health of those around them.The boundary of an individual’s freedom is when it infringes on someone else’s freedom.The decision not to be vaccinated is a matter of life or death for those not fortunate enough to have access to doses. While Americans are refusing to take <a href="https://www.nepalitimes.com/opinion/to-boost-or-not-to-boost/">booster third shots</a>, 70% of Nepalis have not even got their first doses.The next time I see a person drinking a beer while smoking a cigarette trying to rationalise their choice to not vaccinate, you know how that conversation will go.I can already tell you that my Thanksgiving and Christmas in the Land of the Free and the Home of the Brave will be a lot of fun.Anjana Rajbhandary writes this fortnightly Nepali Times column Life Time about mental health, physical health and socio-cultural issues.

Anjana Rajbhandary

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To vax or not to vax

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141152/636d02a39c7e80680e0a368fjpeg.jpg" alt="" width="1360" height="680"/><figcaption>Photo via PROJECT SYNDICATE</figcaption></figure>The upsurge of Covid-19 cases, hospitalisations, and deaths in the United States serves as a bitter reminder that the pandemic is not over. The global economy will not return to normal until the disease is under control everywhere.But the US case is a true tragedy, because what’s currently happening here is so unnecessary. While those in emerging markets and developing countries are longing to get the vaccine (with many dying because they cannot get it), the US supply is ample enough to provide a double dose – and <a href="https://www.nepalitimes.com/opinion/to-boost-or-not-to-boost/" target="_blank" rel="noopener noreferrer">now a booster shot</a> – to everyone in the country. And if almost everyone got vaccinated, Covid-19 would almost surely just “fade away,” as former President Donald Trump memorably put it.And yet not nearly enough people in the US have been vaccinated to prevent the highly contagious <a href="https://www.nepalitimes.com/here-now/delta-variants-wake-up-call-for-nepal/" target="_blank" rel="noopener noreferrer">Delta variant</a> from driving case numbers in many areas to new highs. How do so many in a country with seemingly well-educated people act so irrationally, against their own interest, against science, and against the lessons of history?Part of the answer is that the country, for all of its wealth, is not as well-educated as one might expect – which is reflected in the country’s comparative international performance on standardised assessments. In many parts of the country – including some with the highest rates of resistance to vaccination – science education is particularly poor, owing to politicisation of fundamental issues like evolution and <a href="https://www.nepalitimes.com/banner/un-climate-report-declares-planetary-emergency/" target="_blank" rel="noopener noreferrer">climate change</a>, which in many cases have been excluded from school curricula.In this environment, misinformation can gain traction with many people. And social-media platforms, insulated from liability for what they transmit, have made a business model of maximising “user engagement” by spreading misinformation, including about Covid-19 and the vaccines.But a key part of the answer is a deep misinterpretation, especially among the right, of individual liberty. Those who refuse to <a href="https://www.nepalitimes.com/here-now/3-pronged-strategy-to-save-nepal-from-covid-19/" target="_blank" rel="noopener noreferrer">wear masks</a> or socially distance often argue that requirements to do so infringe on their freedom. But one person’s freedom is another person’s “unfreedom.” If their refusal to wear a mask or get vaccinated results in others getting Covid-19, their behaviour is denying others the more fundamental right to life itself.The essence of the matter is that there are large externalities: In a pandemic, one person’s actions affect the well-being of others. And whenever there are such externalities, the well-being of society requires collective action: regulations to restrict socially harmful behaviour and to promote socially beneficial behaviour.Any ordered society entails restrictions. But while prohibitions against killing, stealing, and so on restrict an individual’s freedom, we all understand that society could not function without them. In our post-Covid world, we might interpret the Ten Commandments to include: “Thou shall not kill, including by spreading infectious diseases when thou can avoid doing so.”Similarly, “Thou shall get vaccinated.” Any infringement of an individual’s liberty by requiring safe and highly effective <a href="https://www.nepalitimes.com/opinion/why-vaccination-should-be-compulsory/" target="_blank" rel="noopener noreferrer">Covid-19 vaccination</a> pales in comparison to the social benefits – and consequent economic benefits – of public health. It is a no-brainer to require all individuals, with only limited medical exemptions, to be vaccinated. While many governments appear to be too timid to impose this requirement, employers, schools, and social organisations – any organised activity that brings individuals into contact with others – should do so.As we have been learning for the last 18 months, global health is a global public good. As long as the disease rages in some parts of the world, <a href="https://www.nepalitimes.com/latest/too-early-for-nepal-to-let-its-guard-down/" target="_blank" rel="noopener noreferrer">the risk of a deadlier</a>, more contagious, more vaccine-resistant mutation grows.In most of the world, however, the problem is not resistance to vaccination but a <a href="https://www.nepalitimes.com/opinion/hope-hyperbole-and-hypocrisy-of-covax/" target="_blank" rel="noopener noreferrer">severe shortage of vaccines</a>. Evidently, the private sector is unable to scale up production to ensure an adequate supply. Is that because vaccine producers lack capital? Is there a shortage of glass vials or syringes? Or is it because they hope that fewer doses will lead to higher prices and even bigger profits? Among the key barriers to greater supply is access to the requisite intellectual property, which is why the IP waiver being discussed at the World Trade Organisation is so important.Given the urgency and scale of the challenge, more is needed: Among the steps US President Joe Biden’s administration could take is to invoke the Defense Production Act and leverage the federal government’s ownership of key patents. The US has been allowing the pharmaceutical companies to use this public IP freely, while they reap billions of dollars in profits. The US must use every instrument at its disposal to increase production at home and abroad.This, too, is a no brainer. Even if the costs of global vaccination totaled tens of billions of dollars, the amount would pale in comparison to the costs of <a href="https://www.nepalitimes.com/banner/how-nepal-must-prepare-for-3rd-covid-wave/" target="_blank" rel="noopener noreferrer">persistent Covid-19 outbreaks</a> to lives, livelihoods, and the world economy.By arrangement with © <a href="https://www.project-syndicate.org/" data-saferedirecturl="https://www.google.com/url?q=https://www.project-syndicate.org/&amp;source=gmail&amp;ust=1607178503443000&amp;usg=AFQjCNHSbaaYvdpDj2FQzkDgwL7xNFnkWg">Project Syndicate</a>Joseph E. Stiglitz, a Nobel laureate in economics and University Professor at Columbia University, is a former chief economist of the World Bank (1997-2000), chair of the US President’s Council of Economic Advisers, and co-chair of the High-Level Commission on Carbon Prices. He is a member of the Independent Commission for the Reform of International Corporate Taxation and was lead author of the 1995 IPCC Climate Assessment.

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Covid-19 and Human Freedom

<figure><img width="1594" height="986" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111015114/636d05889c7e80680e0a5f11jpeg.jpg" alt=""/><figcaption>Photo: AMIT MACHAMASI</figcaption></figure>Much has been said about ‘vaccine apartheid’ and how instead of levelling out rich and poor, it has widened inequities. Nepal today is living proof of this. 
As the government lurches rudderless from one failure to another — nowhere does SARS-CoV-2 have such fertile ground to spread as in Nepal.
The government declared a <a href="https://www.nepalitimes.com/banner/kathmandu-covid-19-lockdown-relaxed/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/kathmandu-covid-19-lockdown-relaxed/&amp;source=gmail&amp;ust=1625191485755000&amp;usg=AFQjCNH7xitObX_aJhpMCkps_jMvT6YgLA">‘smart lockdown’</a> after infection rates dropped, but with only 2.6% of the population vaccinated, the virus is getting ready to pounce back. In 2020, the first wave actually started only after the lockdown was eased and lifted. It can happen again.
The Delta variant is three times more virulent than the original virus, it rides unvaccinated hosts in crowded places, who do not wear masks, and do not have access to adequate healthcare. It has mutated into an even more dangerous Delta+ strain.
Prime Minister K P Oli and four health ministers who have served under him in the past year have cried wolf with sweeping promises of “full vaccination in a few months”. 
We have also heard <a href="https://www.nepalitimes.com/latest/vaccines-are-the-only-solution/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/vaccines-are-the-only-solution/&amp;source=gmail&amp;ust=1625191485755000&amp;usg=AFQjCNEA8CBMu7v8LiyErgNnzw9NMkzWwg">promises from the US President</a>, G-7 and Team Europe of a billion of doses, but there is no sign of surplus vaccines being shipped out. The Danes, Norwegians and Czechs want to send Nepal unused Oxford AstraZeneca doses, but Brussels is <a href="https://www.nepalitimes.com/opinion/hope-hyperbole-and-hypocrisy-of-covax/">forcing them to go through COVAX.</a>
A laudable initiative, COVAX has been undermined by its own funders. Its Japan-hosted pledging summit in early June was proof of how quickly a global mechanism with an equity plan can fall apart when <a href="https://www.nepalitimes.com/here-now/nepal-needs-urgent-american-vaccine-support/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/nepal-needs-urgent-american-vaccine-support/&amp;source=gmail&amp;ust=1625191485755000&amp;usg=AFQjCNGelKWa2vhYATH_AZOtcqkw-g8WVA">national narrow-mindedness</a> prevails over enlightened self-interest. No country is safe from future mutants until everyone is vaccinated. 
We will not even bring up moral and ethical considerations here. <a href="https://www.nepalitimes.com/banner/anger-grows-in-nepal-over-covid-vaccine-delays/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/anger-grows-in-nepal-over-covid-vaccine-delays/&amp;source=gmail&amp;ust=1625191485755000&amp;usg=AFQjCNFfqMeD8wLHk4i9fwxnhcCtYX5Utw">Commentators have drawn attention</a> to veterans from the Indian and British militaries who have died of Covid-19 complications in Nepal’s second wave because India did not send vaccines that had been paid for, and Britain sent us loads of PPEs. 
Please <a href="https://www.nepalitimes.com/here-now/aid-pours-into-nepal-but-where-be-vaccines/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/aid-pours-into-nepal-but-where-be-vaccines/&amp;source=gmail&amp;ust=1625191485755000&amp;usg=AFQjCNEEAA9_pE28k01bucV-_40hsl7myQ">spare us more selfies</a> by diplomats at Kathmandu airport posing with yet another ‘relief’ flight full of latex gloves. We know they know that what Nepal urgently needs right now is vaccines that they themselves promised, or are willing to buy. 
Even if, by some miracle, <a href="https://www.nepalitimes.com/banner/anger-grows-in-nepal-over-covid-vaccine-delays/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/anger-grows-in-nepal-over-covid-vaccine-delays/&amp;source=gmail&amp;ust=1625191485755000&amp;usg=AFQjCNFfqMeD8wLHk4i9fwxnhcCtYX5Utw">1.4 million elderly Nepalis</a> get their second doses of Covishield, it looks impossible that we can procure the 40 million doses needed to inoculate 70% of our eligible population even by the end of 2022 at the earliest.
Our government has failed us, the international community has let us down. We better start looking after ourselves in a vaccine-less future.
As if the Covid-19 crisis was happening on a distant planet, the Supreme Court is consumed by hearings on the future of the government. It will decide by next week the <a href="https://www.nepalitimes.com/banner/court-debates-nepal-pm-olis-future/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/court-debates-nepal-pm-olis-future/&amp;source=gmail&amp;ust=1625191485755000&amp;usg=AFQjCNGethsg3p9twp9kU49cPc4TjdjMmA">fate of Parliament </a>and there isn’t much of a choice: either the current prime minister will get to swear himself in once more, or we will get one who has been prime minister four times in the past 20 years already. 
We cannot expect effective vaccine diplomacy, or needed policy interventions to contain the virus from this inept lot. The daily death toll when the lockdown was announced on 29 April was ten, this week we averaged 35 fatalities a day. Total active cases are higher as restrictions lifted, than they were two months ago. 
And all this is happening even while public health experts warn of a third wave, as the virus mutates in an unvaccinated world. We also know that the official infection and death rates in India and Nepal are underestimated. <a href="https://www.nepalitimes.com/latest/nepal-covid-19-impact-worse-than-official-figures/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-covid-19-impact-worse-than-official-figures/&amp;source=gmail&amp;ust=1625191485755000&amp;usg=AFQjCNGRjVWVJtLoZDB85E9MRNVTuOQugA">Excess mortality in the population</a> caused by Covid-19 is said to be much higher than official figures.
Projections by the <a href="https://covid19.healthdata.org/nepal?view=cumulative-deaths&amp;tab=trend" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://covid19.healthdata.org/nepal?view%3Dcumulative-deaths%26tab%3Dtrend&amp;source=gmail&amp;ust=1625191485755000&amp;usg=AFQjCNFOSUIRAHJP3kcd8ORL-tNXOKKeFg">University of Washington School of Medicine in Seattle</a> show that on 29 June, when the official fatality tally nationwide was 20, the real death toll from Covid-19 in Nepal was probably closer to 95. 
This week, the official count for the number of people who have died in the pandemic crossed 9,000 — overtaking the total death toll in the 2015 earthquake. But the models suggest that the actual fatalities could be more than 31,000.
At present only 72% of Nepalis wear masks, if that can be raised to 95% as the country opens up, the models show, nearly 1,500 additional deaths due to Covid-19 could be prevented by 1 September.
We have to plan as if there will be no vaccines, and behave <a href="https://www.nepalitimes.com/latest/learning-to-live-with-covid/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/learning-to-live-with-covid/&amp;source=gmail&amp;ust=1625191485755000&amp;usg=AFQjCNHqUkg3c9x8Swh1bHMT1S9RssPOBQ">as if we are still in isolation</a>. The mantra is: mask up and avoid crowds.

No vax? Ask for Mask.

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109121144/636b92f69c7e80680e06f17cjpeg.jpg" alt="" width="1500" height="1000"/><figcaption>Photo: MONIKA DEUPALA</figcaption></figure>This op-ed is being simultaneously published in the Indian Express (India), The Daily Star (Bangladesh), Nepali Times (Nepal) and DAWN (Pakistan).In February 2021, Covid-19 numbers started increasing again in South Asia with official daily case counts rising beyond 400,000 in India, 6,000 in Pakistan and 7,500 in Bangladesh, straining health systems.The massive surge in India soon <a href="https://www.nepalitimes.com/banner/we-knew-the-tsunami-was-approaching/" target="_blank" rel="noopener noreferrer">spilled over across the border into Nepal</a>, leading to ‘apocalyptic’ scenes of overwhelmed hospitals.This virus knows no borders. Containing it has necessitated global cooperation among scientists, policy makers and society. Despite a wide variation in how nations have responded to the pandemic, the most successful strategies adhere to science, and attention to local context.The <a href="https://www.nepalitimes.com/editorial/this-is-war/" target="_blank" rel="noopener noreferrer">deadly surge in 2021</a> makes a regionally-coordinated, evidence-driven strategy even more critical. The virus continues to challenge us with its mutations and new lines of attack. If we are to move at the speed of the virus, it is necessary to construct multi-stakeholder regional coalitions to devise new solutions and frugal innovations that can be applied across South Asia.Given our shared and mostly similar social, economic and cultural contexts, local successes must find means to be amplified across the region.Is that even possible, given the troubled history South Asian countries share? The mutual mistrust appears to have hit a new low, as <a href="https://www.nepalitimes.com/editorial/shared-futures/" target="_blank" rel="noopener noreferrer">SAARC</a> has not even managed to hold its summit since 2014.But today we write a positive, hopeful story about a new consortium we are involved in, with core team members from India, Pakistan, Nepal, and Bangladesh jointly developing Covid prevention strategies. The emerging consortium provides an example of how neighbours can work together for mutual benefit, despite political differences.Every country in South Asia has struggled to ensure consistent <a href="https://www.nepalitimes.com/opinion/the-economics-of-masks/" target="_blank" rel="noopener noreferrer">mask-wearing</a> to stem the spread of Covid. Beliefs, priorities, traditions, and aversions to behaviour change are more similar across South Asia than we care to admit. These commonalities mean that interventions that are successful in changing behaviour in one place are likely applicable in other parts of the Subcontinent.We have experienced this with Community-Led Total Sanitation (CLTS) campaigns to solve the <a href="https://www.nepalitimes.com/here-now/nature-calls/" target="_blank" rel="noopener noreferrer">problem of open defecation</a> -- originally developed by Bangladeshi NGOs in partnership with an Indian consultant --- and now broadly applied across South Asia and beyond.The Grameen Bank microcredit model was an indigenous South Asian innovation that spread rapidly. BRAC’s recent ‘Graduation’ program targeting the ultra-poor in Bangladesh was replicated with success in India and Pakistan. India’s digitised social protection ecosystem with Aadhar IDs and Jan Dhan accounts serves as a model (albeit with cautionary notes) for other countries in the region. E-governance programs in Pakistan, like eVaccs and Citizen Feedback Model have been replicated and provide strong models ready to be deployed regionally and globally.The new pan-South Asian consortium in response to Covid-19 evolved out of an experiment conducted in Bangladesh, that successfully changes social norms around mask-wearing in rural communities. We observed that a combination of No-cost distribution, Offering information, Reinforcing the message in markets, mosques and other public spaces, and Modelling and endorsement by community leaders (NORM) leads to large, sustained increases in mask usage that persisted beyond the period of active intervention.This <a href="https://www.nepalitimes.com/here-now/3-pronged-strategy-to-save-nepal-from-covid-19/" target="_blank" rel="noopener noreferrer">four-part NORM intervention</a> was originally examined in a cohort of 350,000 individuals across 600 villages. BRAC is implementing the model to reach 81 million people across Bangladesh.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109121144/636b92f99c7e80680e06f17djpeg.jpg" alt="" width="1600" height="876">The team is now partnering with several organisations across Pakistan, India, Nepal, and Bangladesh to start adapting the model to fit each country’s context, and set up partnerships to pilot, implement, tinker, and learn.The Self Employed Women’s Association (SEWA) quickly implemented the model to reach over one million members in Gujarat. An additional 1.5 million masks were shipped from Bangladesh to support SEWA’s outreach to other states. Lahore’s Commissioner worked with our research team to adapt the NORM model to an urban setting, and devised new creative ideas to improve effectiveness.For example, it has prepared to deliver <a href="https://www.nepalitimes.com/opinion/masks-and-vaccines-to-stop-nepals-2nd-wave/" target="_blank" rel="noopener noreferrer">masks</a> at doorsteps using Pakistan’s postal service, and is targeting beneficiaries on the basis of billing information from utility companies. Philanthropists and private corporations are sponsoring the masks. We are re-importing some of these innovations back to Dhaka, inspiring further scale-ups in Dhaka, Chittagong, Rajshahi and Kathmandu.Effective mask promotion requires visits to thousands of remote villages, and those same visits can be used to prepare for more effective community-based healthcare responses. To that end, a host of physicians, scientists and community based organisations created the Swasth Community Science Alliance, committing to pragmatic, science-based protocols to manage mild and moderate cases of Covid-19 in rural India, where institutional health care access is limited.These guidelines (available at https://science.swasth.app) were translated to training tools for healthcare workers by digital health innovators like Noora Health, making them widely available across the region.NORM implementation teams based in Lahore, Ahmedabad, Peshawar, Hyderabad, Dhaka, Kathmandu, and Delhi are learning from each other’s successes and failures. The process usually starts with the original research team sharing evidence-based insights with implementing agencies, as the implementers adapt the design, co-create localised implementation protocols, and are threaded together in a collaborative environment across countries where each implementing team iterates while learning from others’ prior iterations, and all our sub-teams are connected in an active learning system that allows us to course-correct in real time. This coalition is poised to change mask-wearing norms amongst hundreds of millions of people across all of South Asia.The CSA is working with partners across rural, tribal belts around India. A team of physicians from India and the Indian diaspora work with local implementing partners to support design, implementation and monitoring of home-based programs and Covid-19 centres providing rigorously protocolised treatment for moderate cases, with oxygen, proning and steroids.Combining the NORM and CSA interventions, our Masking-Treatment-Vaccine Preparation (MTV) approach offers a sensible strategy to mitigate the pandemic until universal vaccination is achieved. These are regional solutions that thoughtfully apply scientifically sound interventions to the local context.The <a href="https://www.nepalitimes.com/editorial/nepals-humanitarian-emergency/" target="_blank" rel="noopener noreferrer">Covid-19 crisis</a> has increased policymakers’ appetite for evidence-informed policy measures that can be quickly implemented to stem transmission. This drive for quick action has created some unprecedented opportunities for enhanced cross-country collaborations that are normally hampered by politics and mistrust.We hope that the consortium that first formed around <a href="https://www.nepalitimes.com/opinion/how-nepal-can-survive-2nd-covid-wave/" target="_blank" rel="noopener noreferrer">mask-promotion</a>, and now around science-based treatment approaches, and that developed quickly and organically without regard to national boundaries, can serve as a model for a broader and deeper collaborative ecosystem that endures.We need to come together to solve problems that affect us all. Let the lasting legacy of this pandemic be a new era of partnership in social innovations that can benefit all South Asians.https://www.youtube.com/watch?v=d0hpuXRByic&amp;t=9sMushfiq Mobarak is Professor of Economics, Yale University, and Director of the Yale Research Initiative on Innovation and Scale. Twitter: @mushfiq_econ Maha Rehman is director of policy at the Mahbub-ul-Haq Research Centre at the Lahore University of Management Sciences. Twitter @MahaRehman1Satchit Balsari is assistant professor of emergency medicine, and of global health and population, at Harvard University. Twitter: @satchit_balsari

What can we do till vaccines arrive?

<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109121140/636b91c69c7e80680e06f10djpeg.jpg" alt="" width="1500" height="1000"/>Nepal will open its 2021 lockdown long before the country <a href="https://www.nepalitimes.com/here-now/aid-pours-into-nepal-but-where-be-vaccines/">has enough vaccines</a> to protect its citizens -- our aunts, uncles, and neighbours. We will not have substantial vaccine coverage for many months, if not longer.We will <a href="https://www.nepalitimes.com/here-now/its-an-emergency/">need more oxygen,</a> more testing, and better tracking and isolation procedures. Crucially, we will also have to maintain and strengthen our only effective tools: physical distancing and masks.Unfortunately, too many Nepalis are wearing low-quality masks, taking them off too often, touching them, and not washing them or replacing them often enough. More people should be wearing three-layer surgical masks, which, for only a few more rupees, offer greater protective power.The key problem Nepal faces has not changed: infected people do not know they have the virus and spread it around. And new variants make the virus even more easily transmissible. We need to behave not as if only a small number of people could have the virus, but as if everyone we encounter already has it. That includes the friendly neighbourhood fruit seller. That includes family members. That includes you.“Vaccinations will take a long time to arrive in South Asia to create a wall of immunity. Till then, masks are most essential,” says <a href="https://www.nepalitimes.com/here-now/3-pronged-strategy-to-save-nepal-from-covid-19/">Mushfiq Mobarak</a>, a Yale university professor who recently led a huge study of<a href="https://docs.google.com/forms/d/e/1FAIpQLSfMJkyBBtK74lqSsHZnx_8qb0_sJ0WaR7A7XA8IQHAobrBEQA/viewform"> mask-wearing in Bangladesh.</a>Many Nepalis wear cloth masks or one-layer surgical masks. These help, no question. But the 3-layer surgical masks and N95s offer more filtration efficiency and more protection, although they cost just a few rupees more. That is an investment well worth it to protect individuals, institutions, and governments.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109121140/636b91c99c7e80680e06f10ejpeg.jpg" alt="" width="2370" height="950"><figcaption>This projection by the Institute for Health Metrics and Evaluation (IHME) of the University of Washington School of Medicine in Seattle shows that in Nepal 1,000 fewer people will die by 1 September if 95% of people wore masks while outdoors. Source of all graphs: IHME University of Washington / Nepal Ministry of Health and Population</figcaption></figure>I asked Biraj Vajracharya, an epidemiologist at Dhulikhel hospital, what kind of mask people should be buying and wearing. "Surgical mask, or if possible, N95 mask," he replied.The Yale researchers recommend high quality 3-layer masks because they filter more efficiently. They can be washed and reused without losing much efficiency. For more on the study's recommendations about masks, see this excellent <a href="https://www.youtube.com/watch?v=ifiR_5DuyfA">video</a>."We need to change mask-wearing norms amongst hundreds of millions of South Asians to mitigate the spread of COVID," Mushfiq Mobarak told me via email. "High-quality washable, reusable surgical masks are much more cost-effective, and offer a feasible path to scalability across the region."The <a href="https://www.business-standard.com/article/current-affairs/covid-19-crisis-india-draws-lessons-from-bangladesh-s-mask-study-121051401341_1.html">Yale study in Bangladesh</a>, involving over 300,000 people in 600 villages, identified simple policies that led to much greater mask wearing. They found that when <a href="https://docs.google.com/document/d/1EUhdri6CST9uzw_myffNmyUVPt8_UMsM75NOt5Q-54o/edit">authorities do four things together</a>, mask wearing more than tripled:<ol><li>Offer free masks</li> <li>Provide clear information about mask wearing in videos and brochures</li> <li>Find community leaders to speak in support of mask wearing</li> <li>Reinforce the message with gentle questioning for those not wearing</li></ol>The fourth policy was the most important: special monitors to verbally poke people who were not wearing masks. Those monitors, the Yale study explains, ‘walk around and if somebody is not wearing a mask, they intercept them and politely say, “We distributed masks here—why aren’t you wearing one?” If the person didn’t have a mask or couldn’t get one, the monitor gives them one.’What this combo of four actions does is establish a community expectation, a clear norm or standard for the community to follow. The norm shows everybody that the community expects them to wear the masks, that it takes masks seriously. That makes a big difference.The researchers call their recommended program NORM:No-Cost masksOffering InformationReinforcement in public places by intercepting non-mask wearersModelling and endorsement by trusted leadersHere's some useful mask info:<ol><li>All masks help, but 3-layer surgical masks and N95 masks offer greater protection.</li> <li>Double masking is good, especially with low-quality surgical or cloth masks.</li> <li>Masks should cover the mouth and nose. A tight fit on all four sides is good.</li> <li>If you touch the mask, you should wash your hands.</li> <li>Masks should be washed and replaced regularly.</li> <li>In general, you should wash your hands with soap several times a day.</li></ol>A historical reminder might be relevant here: when we think about the Covid-19 vaccine, we often recall the <a href="https://www.nepalitimes.com/opinion/how-nepal-eradicated-the-smallpox-virus/">big health breakthroughs of the past</a>, such as the discovery of the polio vaccine in the 1950s, and penicillin in the 1940s.But long before these headline-stealing medical heroes arrived to save the day, death rates had already dropped dramatically in Western Europe and North America. This health revolution came because of much less glamorous innovations: clean drinking water, efficient waste disposal, increased bathing, and expanded soap use.These basic sanitary measures saved millions and millions of lives. In Nepal in 2021, basic preventative measures such as physical<a href="https://www.nepalitimes.com/latest/nepal-covid-19-impact-worse-than-official-figures/">l distancing and careful mask wearing </a>can save lives as well.One other reminder: last year, after we were released from Lockdown I in July, Covid-19 <a href="https://www.nepalitimes.com/latest/nepal-its-no-time-to-let-your-guard-down/">infections spiked</a>. After Lockdown II was lifted in September, infections spiked again, reaching their highest level yet. The end of Lockdown III will <a href="https://www.nepalitimes.com/latest/learning-to-live-with-covid/">likely bring new risks.</a><a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/how-chitwan-was-opened,4159">Tom Robertson</a>, PhD, is researching the environmental history of the Kathmandu Valley.

After lockdown, we will need masks more than ever

<figure><img width="2038" height="1356" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131128/636ceedd9c7e80680e09ae54jpeg.jpg" alt=""/><figcaption>Universal mask wearing could save 2,211 lives in Nepal in the next three months, according to a new study. Photo: AMIT Machamasi</figcaption></figure>In its daily briefing on Saturday, the Ministry of Health announced that 4,311 people had tested positive for Covid-19, and 116 more people had died in 24 hours from the pandemic.Experts were encouraged by these figures, and took it as a sign that the<a href="https://www.nepalitimes.com/opinion/how-nepal-can-survive-2nd-covid-wave/"> second wave</a> had peaked. Indeed, the daily confirmed cases had dropped to half the level a week ago, and so had the positivity rate. Fatalities were also down from nearly 200 a day earlier this month.However, a new study shows that pandemic statistics the world over are fraught with inaccuracies, and the <a href="https://www.nepalitimes.com/editorial/the-covid-tsunami/">Nepal figures</a> are also a gross underestimation. The calculations show that new daily infections were probably closer to 120,000 on Saturday, and there were more than 700 deaths from Covid-19 nationwide—more than 30 times higher than official figures. The study by the Institute for Health Metrics and Evaluation (IHME) of the University of Washington School of Medicine in Seattle goes beyond official confirmed figures to calculate <a href="http://www.healthdata.org/special-analysis/estimation-excess-mortality-due-covid-19-and-scalars-reported-covid-19-deaths" data-saferedirecturl="https://www.google.com/url?q=http://www.healthdata.org/special-analysis/estimation-excess-mortality-due-covid-19-and-scalars-reported-covid-19-deaths&amp;source=gmail&amp;ust=1622442215950000&amp;usg=AFQjCNGW9ufUy8M70_z6NyotWDzInxyG1A">‘excess mortality’</a> and undetected Covid-19 infections.  ‘As terrible as the COVID-19 pandemic appears, this analysis shows that the actual toll is significantly worse,” said <a href="http://www.healthdata.org/covid/video/insights-ihmes-latest-covid-19-model-run" data-saferedirecturl="https://www.google.com/url?q=http://www.healthdata.org/covid/video/insights-ihmes-latest-covid-19-model-run&amp;source=gmail&amp;ust=1622442215950000&amp;usg=AFQjCNE9LwJOecLypPgPl4neBePOrEG0gw">IHME Director Chris Murray</a>, revealing the results of the analysis this month. ‘Understanding the true number of Covid-19 deaths not only helps us appreciate the magnitude of this global crisis, but also provides valuable information to policymakers developing response and recovery plans.’The official figures for Nepal are frightening enough. The country has the world’s second-highest bi-weekly increase in deaths at 291%, and the highest national test positivity rate of 40%. Yet, Nepal conducts only 713 tests per million people, contact tracing is virtually non-existent, less than 2% of the 30 million population is fully vaccinated, and <a href="https://www.nepalitimes.com/opinion/masks-and-vaccines-to-stop-nepals-2nd-wave/">mask-wearing</a> is at less than 65%. IHME’s graphs for Nepal show that during the early May peak when new confirmed cases were above 9,000 every day, the actual daily number was probably closer to 350,000. Nepal’s Ministry of Health’s total tally of fatalities is now 7,163, but the modelling shows that the actually total is 28,256. <figure><img width="2370" height="1010" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131128/636ceee09c7e80680e09ae55jpeg.jpg" alt=""><figcaption>Cumulative deaths in Nepal by 1 September under pre-Covid mobility scenario, scaled top vaccination drive by then, and if 95% of people wore masks while outdoors. Source of all graphs: IHME University of Washington / Nepal Ministry of Health and Population</figcaption></figure>Epidemiologists warn that if the official figures are so wrong, then the planning to meet the requirements for everything from test kits, hospital beds, ICU, <a href="https://www.nepalitimes.com/here-now/its-an-emergency/">oxygen requirement,</a> ventilators, and even funerary planning would need to be re-evaluated and up-scaled.“We have known that under-reporting is widespread. The figures are underestimates, but the impact cannot be underestimated,” says virologist Sher Bahadur Pun at Teku Hospital. “For example, although we are just beginning to see a <a href="https://www.nepalitimes.com/latest/covid-19-numbers-slightly-down-in-nepal/">plateauing</a> of the second wave, the increase in new cases is constant and the strain on the health system remains the same.”The IHME uses the <a href="http://www.healthdata.org/special-analysis/estimation-excess-mortality-due-covid-19-and-scalars-reported-covid-19-deaths" data-saferedirecturl="https://www.google.com/url?q=http://www.healthdata.org/special-analysis/estimation-excess-mortality-due-covid-19-and-scalars-reported-covid-19-deaths&amp;source=gmail&amp;ust=1622442215950000&amp;usg=AFQjCNGW9ufUy8M70_z6NyotWDzInxyG1A">‘excess mortality’ model</a> to calculate a more accurate figure for the infection and death rate from Covid-19 by using data for previous years, and factoring in new variables to calculate how many more people are actually dying during the pandemic compared to pre-pandemic years.There are many factors affecting mortality during the pandemic: deaths directly due to Covid-19, increase in mortality because patients with pre-existing conditions are not getting the hospital care they need, or deaths due to mental disorders. However, there is also a reduction during the pandemic of deaths caused by high air pollution, fatalities from other air-borne infections like tuberculosis, measles or influenza, and even a drop in highway-traffic accidents. So, IHME modellers collected available data on excess mortality from Covid-19,  added an estimate the additional deaths that were not registered to came up with the total deaths from coronavirus. The results are shocking. The actual global death toll from Covid-19 is more than double the 3.5 million official figure. In India, the government’s figure for total fatalities till Saturday stood at 325,998, but the projections show that the actual deaths probably at more than 1 million. Although the death rate is going down, IHME says India’s cumulative deaths from Covid-19 could be 1.2 million by 1 September. In Nepal, even official data shows a steep spike during the whole of May as Nepali workers started arriving from India with the fast-spreading B.1.617 variant. But on 1 May when the confirmed daily Covid-19 deaths was showing only 32, the model shows that 117 people were already dying every day nationwide from the disease. Within two weeks, even when the official total had soared to 205, the graphs show that the excess daily mortality was already 742. The reason for the discrepancy was that mostly hospital deaths were being counted, and the death registration system is inaccurate and late.  <figure><img width="2350" height="1014" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131128/636ceee39c7e80680e09ae56jpeg.jpg" alt=""><figcaption>Daily deaths is the best indicator of the progression of the pandemic. This graph shows the discrepancy between official figures and total Covid-19 daily fatalities factoring in 'excess mortality'. There is usually a 3-week lag between infection and death.</figcaption></figure>Epidemiologist Lhamo Yangchen Sherpa says the graphs just prove what everyone knew all along: testing is inadequate and even the distribution of testing facilitates is lop-sided. For example, 29 of 42 labs with RT PCR testing capacity in Bagmati Province are clustered within Kathmandu Valley. The whole of Gandaki province is reliant on three labs in Pokhara.She adds: “People in<a href="https://www.nepalitimes.com/latest/in-nepal-virus-climbs-from-plains-to-mountains/"> remote parts of Nepal like Solukhumbu</a> have to walk for days to give their swab sample, which is then sent to a lab in Biratnagar. By the time result is back, a week has passed by and many of them are already sick.” Most of the returnees from India were never tested, and went straight home without quarantine, becoming data blind spots and skewing transmission numbers beyond Nepal’s limited testing capacity. Even though the national case numbers have gone down, experts say it is raging across rural Nepal—but there is no way to quantify it because of the lack of testing.Epidemiologist Sherpa recommends rapid turnaround of antigen tests to reduce time lost waiting for PCR results in <a href="https://www.nepalitimes.com/latest/rural-nepal-fights-back-covid-19/">rural Nepal</a>. She says, “Patients show symptoms in five days but are contagious from the third day onwards. To avoid further spread in that crucial 48 hours, we must increase access to tests but also bring down the time it takes to get the result.”But targeted testing of symptomatic patients in remote districts like Rolpa and Humla have shown a staggering 90% positivity rate. Because of the lack of hospital care and the absence of medical oxygen, many die at home and the numbers never feed into the daily count announced in Kathmandu every evening.Virologist Pun at the Teku Hospital says effective contact tracing would provide the most accurate situation report, but that is not happening. He says, “The 70-80 daily new cases during the first wave were mostly asymptomatic travellers needing mandatory checks and their traced contacts. But in the more severe second wave, there is no contact tracing at all.”  <figure><img width="2350" height="952" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131128/636ceee69c7e80680e09ae57jpeg.jpg" alt=""><figcaption>Estimated infections in Nepal, showing the first and second waves, and the impact of mask-wearing.</figcaption></figure>Experts like Moshfiq Mobarak of Yale University say that the most effective strategy for countries with fragile health systems like Nepal to reduce fatalities is a three-pronged approach that aggressively promotes mask-wearing, responds to localised surges, as well as last-mile vaccine delivery.Mask-wearing alone has been proven in a trial in Bangladesh to show that a vigorous campaign for no-cost mask distribution, aggressive awareness drive, and punishment for non-wearers tripled the number of people using masks properly.‘This is an extremely cost-effective way to reduce transmission risk and save lives,’ Mobarak said in an op-<a href="https://www.nepalitimes.com/here-now/3-pronged-strategy-to-save-nepal-from-covid-19/">ed he co-wrote for Nepali Times last week. </a>Indeed, the IHME model also proves that direct impact of mask wearing in Nepal. The modelling shows that the total coronavirus death toll in Nepal by 1 September will be at 44,711 if mobility went up to pre-Covid levels. However, if 95% of Nepalis wore masks in public at all times, the number of deaths would be reduced to 42,500. This means 2,211 lives would be saved just by universal mask-wearing in the next three months.Even though Nepal’s second wave may be susbsiding, experts say the country will take longer to come out of it than neighbours India or Bangladesh despite the lockdown. This is because of the lack of vaccines, mask-wearing at less than 65%, as well as lack of mass testing. Nepal’s seven-day decrease in new caseloads post-peak is estimated to be around 7.45% compared to India's 12.8%.

Nepal Covid-19 impact worse than official figures

<figure><img width="2038" height="1356" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111152/636b86d59c7e80680e067877jpeg.jpg" alt=""/><figcaption>Universal mask wearing could save 2,211 lives in Nepal in the next three months, according to a new study. Photo: AMIT Machamasi</figcaption></figure>In its daily briefing on Saturday, the Ministry of Health announced that 4,311 people had tested positive for Covid-19, and 116 more people had died in 24 hours from the pandemic.Experts were encouraged by these figures, and took it as a sign that the<a href="https://www.nepalitimes.com/opinion/how-nepal-can-survive-2nd-covid-wave/"> second wave</a> had peaked. Indeed, the daily confirmed cases had dropped to half the level a week ago, and so had the positivity rate. Fatalities were also down from nearly 200 a day earlier this month.However, a new study shows that pandemic statistics the world over are fraught with inaccuracies, and the <a href="https://www.nepalitimes.com/editorial/the-covid-tsunami/">Nepal figures</a> are also a gross underestimation. The calculations show that new daily infections were probably closer to 120,000 on Saturday, and there were more than 700 deaths from Covid-19 nationwide—more than 30 times higher than official figures. The study by the Institute for Health Metrics and Evaluation (IHME) of the University of Washington School of Medicine in Seattle goes beyond official confirmed figures to calculate <a href="http://www.healthdata.org/special-analysis/estimation-excess-mortality-due-covid-19-and-scalars-reported-covid-19-deaths" data-saferedirecturl="https://www.google.com/url?q=http://www.healthdata.org/special-analysis/estimation-excess-mortality-due-covid-19-and-scalars-reported-covid-19-deaths&amp;source=gmail&amp;ust=1622442215950000&amp;usg=AFQjCNGW9ufUy8M70_z6NyotWDzInxyG1A">‘excess mortality’</a> and undetected Covid-19 infections.  ‘As terrible as the COVID-19 pandemic appears, this analysis shows that the actual toll is significantly worse,” said <a href="http://www.healthdata.org/covid/video/insights-ihmes-latest-covid-19-model-run" data-saferedirecturl="https://www.google.com/url?q=http://www.healthdata.org/covid/video/insights-ihmes-latest-covid-19-model-run&amp;source=gmail&amp;ust=1622442215950000&amp;usg=AFQjCNE9LwJOecLypPgPl4neBePOrEG0gw">IHME Director Chris Murray</a>, revealing the results of the analysis this month. ‘Understanding the true number of Covid-19 deaths not only helps us appreciate the magnitude of this global crisis, but also provides valuable information to policymakers developing response and recovery plans.’The official figures for Nepal are frightening enough. The country has the world’s second-highest bi-weekly increase in deaths at 291%, and the highest national test positivity rate of 40%. Yet, Nepal conducts only 713 tests per million people, contact tracing is virtually non-existent, less than 2% of the 30 million population is fully vaccinated, and <a href="https://www.nepalitimes.com/opinion/masks-and-vaccines-to-stop-nepals-2nd-wave/">mask-wearing</a> is at less than 65%. IHME’s graphs for Nepal show that during the early May peak when new confirmed cases were above 9,000 every day, the actual daily number was probably closer to 350,000. Nepal’s Ministry of Health’s total tally of fatalities is now 7,163, but the modelling shows that the actually total is 28,256. <figure><img width="2370" height="1010" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111152/636b86da9c7e80680e067878jpeg.jpg" alt=""><figcaption> </figcaption></figure>Epidemiologists warn that if the official figures are so wrong, then the planning to meet the requirements for everything from test kits, hospital beds, ICU, <a href="https://www.nepalitimes.com/here-now/its-an-emergency/">oxygen requirement,</a> ventilators, and even funerary planning would need to be re-evaluated and up-scaled.“We have known that under-reporting is widespread. The figures are underestimates, but the impact cannot be underestimated,” says virologist Sher Bahadur Pun at Teku Hospital. “For example, although we are just beginning to see a <a href="https://www.nepalitimes.com/latest/covid-19-numbers-slightly-down-in-nepal/">plateauing</a> of the second wave, the increase in new cases is constant and the strain on the health system remains the same.”The IHME uses the <a href="http://www.healthdata.org/special-analysis/estimation-excess-mortality-due-covid-19-and-scalars-reported-covid-19-deaths" data-saferedirecturl="https://www.google.com/url?q=http://www.healthdata.org/special-analysis/estimation-excess-mortality-due-covid-19-and-scalars-reported-covid-19-deaths&amp;source=gmail&amp;ust=1622442215950000&amp;usg=AFQjCNGW9ufUy8M70_z6NyotWDzInxyG1A">‘excess mortality’ model</a> to calculate a more accurate figure for the infection and death rate from Covid-19 by using data for previous years, and factoring in new variables to calculate how many more people are actually dying during the pandemic compared to pre-pandemic years.There are many factors affecting mortality during the pandemic: deaths directly due to Covid-19, increase in mortality because patients with pre-existing conditions are not getting the hospital care they need, or deaths due to mental disorders. However, there is also a reduction during the pandemic of deaths caused by high air pollution, fatalities from other air-borne infections like tuberculosis, measles or influenza, and even a drop in highway-traffic accidents. So, IHME modellers collected available data on excess mortality from Covid-19,  added an estimate the additional deaths that were not registered to came up with the total deaths from coronavirus. The results are shocking. The actual global death toll from Covid-19 is more than double the 3.5 million official figure. In India, the government’s figure for total fatalities till Saturday stood at 325,998, but the projections show that the actual deaths probably at more than 1 million. Although the death rate is going down, IHME says India’s cumulative deaths from Covid-19 could be 1.2 million by 1 September. In Nepal, even official data shows a steep spike during the whole of May as Nepali workers started arriving from India with the fast-spreading B.1.617 variant. But on 1 May when the confirmed daily Covid-19 deaths was showing only 32, the model shows that 117 people were already dying every day nationwide from the disease. Within two weeks, even when the official total had soared to 205, the graphs show that the excess daily mortality was already 742. The reason for the discrepancy was that mostly hospital deaths were being counted, and the death registration system is inaccurate and late.  <figure><img width="2350" height="1014" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111152/636b86dc9c7e80680e067879jpeg.jpg" alt=""><figcaption> </figcaption></figure>Epidemiologist Lhamo Yangchen Sherpa says the graphs just prove what everyone knew all along: testing is inadequate and even the distribution of testing facilitates is lop-sided. For example, 29 of 42 labs with RT PCR testing capacity in Bagmati Province are clustered within Kathmandu Valley. The whole of Gandaki province is reliant on three labs in Pokhara.She adds: “People in<a href="https://www.nepalitimes.com/latest/in-nepal-virus-climbs-from-plains-to-mountains/"> remote parts of Nepal like Solukhumbu</a> have to walk for days to give their swab sample, which is then sent to a lab in Biratnagar. By the time result is back, a week has passed by and many of them are already sick.” Most of the returnees from India were never tested, and went straight home without quarantine, becoming data blind spots and skewing transmission numbers beyond Nepal’s limited testing capacity. Even though the national case numbers have gone down, experts say it is raging across rural Nepal—but there is no way to quantify it because of the lack of testing.Epidemiologist Sherpa recommends rapid turnaround of antigen tests to reduce time lost waiting for PCR results in <a href="https://www.nepalitimes.com/latest/rural-nepal-fights-back-covid-19/">rural Nepal</a>. She says, “Patients show symptoms in five days but are contagious from the third day onwards. To avoid further spread in that crucial 48 hours, we must increase access to tests but also bring down the time it takes to get the result.”But targeted testing of symptomatic patients in remote districts like Rolpa and Humla have shown a staggering 90% positivity rate. Because of the lack of hospital care and the absence of medical oxygen, many die at home and the numbers never feed into the daily count announced in Kathmandu every evening.Virologist Pun at the Teku Hospital says effective contact tracing would provide the most accurate situation report, but that is not happening. He says, “The 70-80 daily new cases during the first wave were mostly asymptomatic travellers needing mandatory checks and their traced contacts. But in the more severe second wave, there is no contact tracing at all.”  <figure><img width="2350" height="952" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111152/636b86df9c7e80680e06787ajpeg.jpg" alt=""><figcaption> </figcaption></figure>Experts like Moshfiq Mobarak of Yale University say that the most effective strategy for countries with fragile health systems like Nepal to reduce fatalities is a three-pronged approach that aggressively promotes mask-wearing, responds to localised surges, as well as last-mile vaccine delivery.Mask-wearing alone has been proven in a trial in Bangladesh to show that a vigorous campaign for no-cost mask distribution, aggressive awareness drive, and punishment for non-wearers tripled the number of people using masks properly.‘This is an extremely cost-effective way to reduce transmission risk and save lives,’ Mobarak said in an op-<a href="https://www.nepalitimes.com/here-now/3-pronged-strategy-to-save-nepal-from-covid-19/">ed he co-wrote for Nepali Times last week. </a>Indeed, the IHME model also proves that direct impact of mask wearing in Nepal. The modelling shows that the total coronavirus death toll in Nepal by 1 September will be at 44,711 if mobility went up to pre-Covid levels. However, if 95% of Nepalis wore masks in public at all times, the number of deaths would be reduced to 42,500. This means 2,211 lives would be saved just by universal mask-wearing in the next three months.Even though Nepal’s second wave may be susbsiding, experts say the country will take longer to come out of it than neighbours India or Bangladesh despite the lockdown. This is because of the lack of vaccines, mask-wearing at less than 65%, as well as lack of mass testing. Nepal’s seven-day decrease in new caseloads post-peak is estimated to be around 7.45% compared to India's 12.8%.

<figure><img width="933" height="622" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85d19c7e80680e067815jpeg.jpg" alt=""/><figcaption>Photo: AMIT MACHAMASI</figcaption></figure>The deadly COVID-19 surge that has engulfed neighbouring India appears to be spilling over into Nepal. <a href="https://covid19.healthdata.org/nepal?view=daily-deaths&amp;tab=trend" data-saferedirecturl="https://www.google.com/url?q=https://covid19.healthdata.org/nepal?view%3Ddaily-deaths%26tab%3Dtrend&amp;source=gmail&amp;ust=1621659959142000&amp;usg=AFQjCNGfuMEKH4nbyw3hcxqFK7i15jQZ4w">Daily deaths have been exploding</a>. The experience from India shows that fragile health systems can get overwhelmed quickly leading to needless suffering: <a href="https://www.nytimes.com/2021/04/23/world/asia/india-covid-oxygen-hospitals.html" data-saferedirecturl="https://www.google.com/url?q=https://www.nytimes.com/2021/04/23/world/asia/india-covid-oxygen-hospitals.html&amp;source=gmail&amp;ust=1621659959142000&amp;usg=AFQjCNENS9eia0jqVilkrcyyhhNE-jxYyw">citizens’ pleas for oxygen</a>, lack of ICU beds and medicines. Tackling this threat requires Nepal to adopt a three-pronged approach immediately: <ol><li>Promote consistent mask-wearing to contain the spread of disease, especially in rural areas where the healthcare infrastructure is even more deficient.</li><li>Prepare a healthcare response in the event of localised surges</li><li>Prepare for quick last-mile vaccination delivery, in anticipation of vaccine arrival. </li></ol>There are rigorous evidence-based strategies to implement such a response, as Nepal’s other South Asian neighbours are doing.  On mask-wearing, researchers at Yale University and Stanford University, together with the non-profits Innovations for Poverty Action and GreenVoice ran a large-scale (350,000 adults) randomised controlled trial to identify <a href="http://tinyurl.com/maskpromotion" data-saferedirecturl="https://www.google.com/url?q=http://tinyurl.com/maskpromotion&amp;source=gmail&amp;ust=1621659959142000&amp;usg=AFQjCNE53xG48uOd3u-buWDHQbA4AgkJ1Q">a precise combination of strategies</a> that are successful in changing <a href="http://tinyurl.com/maskpromotion" data-saferedirecturl="https://www.google.com/url?q=http://tinyurl.com/maskpromotion&amp;source=gmail&amp;ust=1621659959142000&amp;usg=AFQjCNE53xG48uOd3u-buWDHQbA4AgkJ1Q">mask-wearing norms</a>. Randomised controlled trials are the same techniques used to test vaccine efficacy. When the strategies were jointly implemented, they tripled mask-wearing in rural Bangladesh, and this effect was persistent over 10 weeks of observation, including after the intervention activities ended. These four strategies form the NORM model: No-Cost masks distributed at scaleOffering Information on mask-wearingReinforcement in public places by intercepting non-mask wearersModelling and endorsement by trusted leaders   <img width="1540" height="918" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85d49c7e80680e067816jpeg.jpg" alt="">The researchers tested a dozen other strategies like verbal commitments, text message reminders, social signaling, involving the village police in reinforcement, and even village-level monetary rewards, but none of these were successful in increasing mask-wearing rates any further. The basic NORM model without these unnecessary add-ons is an extremely cost-effective way to reduce transmission risk and save lives. Why do these strategies work?  Door-to-door distribution with messaging makes it public knowledge that everyone in the community was given a mask, and neighbors are aware of the public health threat of not wearing one. Public, in-person reinforcement creates some social shame from being confronted by a stranger and creates incentives for people to carry the mask to avoid the awkward confrontation. The endorsement from community leaders makes the program personal and credible. The Stanford engineers on the research team produced high-quality reusable, washable masks that can be procured very quickly and cheaply in South Asia. The research team also provides <a href="https://docs.google.com/document/u/0/d/1EUhdri6CST9uzw_myffNmyUVPt8_UMsM75NOt5Q-54o/edit" data-saferedirecturl="https://www.google.com/url?q=https://docs.google.com/document/u/0/d/1EUhdri6CST9uzw_myffNmyUVPt8_UMsM75NOt5Q-54o/edit&amp;source=gmail&amp;ust=1621659959142000&amp;usg=AFQjCNHmPxf6BzdhtcBRIRgO3QCt-_dj8g">detailed implementation protocols</a> for all project activities, to make each step <a href="http://tinyurl.com/maskprotocol" data-saferedirecturl="https://www.google.com/url?q=http://tinyurl.com/maskprotocol&amp;source=gmail&amp;ust=1621659959142000&amp;usg=AFQjCNFdN78xGI1kCVezL4844eoi9DjiIA">easily and quickly implementable</a> for governments.    The results of this study  were so compelling that state governments and groups in India, Pakistan and Bangladesh have quickly moved to implement the NORM model, and it has drawn headlines such as ‘<a href="https://www.business-standard.com/article/current-affairs/covid-19-crisis-india-draws-lessons-from-bangladesh-s-mask-study-121051401341_1.html" data-saferedirecturl="https://www.google.com/url?q=https://www.business-standard.com/article/current-affairs/covid-19-crisis-india-draws-lessons-from-bangladesh-s-mask-study-121051401341_1.html&amp;source=gmail&amp;ust=1621659959142000&amp;usg=AFQjCNFF_oND2c2C6cn24lnj8UqJQK1crQ">India draws lessons from Bangladesh’s mask study</a>’, in a leading newspaper in India. In India, SEWA (Self-Employed Women’s Association) is distributing 3-5 million masks and has implemented the model for 1 million people in Gujarat. The Mayor of Dhaka North quickly mobilised a consortium of partners within 48 hours to implement in crowded shopping malls and at transit hubs before the Eid travel rush.   <img width="640" height="634" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85d79c7e80680e067817jpeg.jpg" alt="">The commissioner of Lahore and the health minister of Khyber-Pakhtunkhwa Province in Pakistan have mobilised staff and resources to implement after Ramadan. BRAC, the world’s largest non-governmental organisation, is poised to reach 77 million people in Bangladesh with the NORM masking interventions, along with associated healthcare responses and vaccine preparation strategies. This model of community-level mask distribution, promotion, and reinforcement can serve as the anchor to cost-effectively deliver the other necessary components of an effective COVID response strategy: empowering community health workers to provide more accurate treatment options to those who fall ill, and undertaking the activities required to overcome vaccine hesitancy and facilitate vaccine registration.  In both India and Bangladesh, SEWA and BRAC are taking advantage of the economies of scale in mask delivery to also set up Covid care centres to take pressure off hospitals. Distinguishing effective from inaccurate treatment strategies requires medical expertise and clinical experience. We have partnered with the <a href="https://science.swasth.app/" data-saferedirecturl="https://www.google.com/url?q=https://science.swasth.app/&amp;source=gmail&amp;ust=1621659959142000&amp;usg=AFQjCNH_Trj1oFBrdZZoMibJpLTZTEhGVA">Swasth </a><a href="https://science.swasth.app/" data-saferedirecturl="https://www.google.com/url?q=https://science.swasth.app/&amp;source=gmail&amp;ust=1621659959142000&amp;usg=AFQjCNH_Trj1oFBrdZZoMibJpLTZTEhGVA">Alliance</a> convened by a professor at Harvard Medical School to create training manuals on effective Covid treatment plans for community health workers. We have also collected large-sample data to <a href="https://www.medrxiv.org/content/10.1101/2021.03.11.21253419v1" data-saferedirecturl="https://www.google.com/url?q=https://www.medrxiv.org/content/10.1101/2021.03.11.21253419v1&amp;source=gmail&amp;ust=1621659959142000&amp;usg=AFQjCNF7p-2nFnzjsaUPM_uK7qO3Db08rg">systematically understand the nature of vaccine hesitancy</a> in Nepal, and other low and middle-income countries, to inform the design of vaccine campaigns.   Quick implementation of the NORM model in Nepal is feasible with decisive leadership and political will, as other South Asian neighbours are doing. Our international research team stands ready to provide any necessary technical support to adapt the model, share all implementation protocols, and monitor results to aid further tinkering and any necessary course-correction, as we have done for our other partners in India, Pakistan, and Bangladesh. The team is not looking for any monetary or research rewards. The evidence is convincing that this is a cost-effective way to stem Covid transmission and save lives, and we would therefore like to facilitate implementation by the Nepali government or other local non-government actors.    Mushfiq Mobarak is Professor of Economics, Yale University, and Neela Saldanha has a PhD in marketing from the Wharton School of the University of Pennsylvania and an MBA from the Indian Institute of Management, Calcutta. To support:<a target="_blank" href="https://docs.google.com/forms/d/e/1FAIpQLSfMJkyBBtK74lqSsHZnx_8qb0_sJ0WaR7A7XA8IQHAobrBEQA/viewform" style="letter-spacing: normal; margin: 0px; padding: 0px; border: 0px; outline: 0px; font-size: 14px; font-family: Arial, Helvetica, sans-serif; vertical-align: baseline;" rel="noopener noreferrer">https://docs.google.com/forms/d/e/1FAIpQLSfMJkyBBtK74lqSsHZnx_8qb0_sJ0WaR7A7XA8IQHAobrBEQA/viewform</a> <table style="letter-spacing: normal; margin-bottom: 0px; padding: 0px; border-top-width: 0px; border-left-width: 0px; outline: 0px; font-size: 14px; font-family: Arial, Helvetica, sans-serif; vertical-align: baseline;"><tbody style="margin: 0px; padding: 0px; border: 0px; outline: 0px; font-style: inherit; font-size: 1em; font-family: inherit; vertical-align: baseline;"><tr style="margin: 0px; padding: 0px; border: 0px; outline: 0px; font-style: inherit; font-size: 1em; font-family: inherit; vertical-align: baseline;"><td style="margin: 0px; padding: 0px; border-right-width: 0px; border-bottom-width: 0px; outline: 0px; font-style: inherit; font-size: 1em; font-family: inherit; vertical-align: baseline;"> </td> </tr></tbody></table><img width="84" height="109" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85da9c7e80680e067818jpeg.jpg" alt=""><img width="82" height="109" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85db9c7e80680e067819jpeg.jpg" alt="">

3-pronged strategy to save Nepal from Covid-19

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111136/636b836a9c7e80680e067734jpeg.jpg" alt="" width="1050" height="1400"/><figcaption></figcaption></figure><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111136/636b836d9c7e80680e067735jpeg.jpg" alt="" width="1125" height="1500"><figcaption> </figcaption></figure>Nani pulls the elastic band tucked behind her ear and tugs off the mask from her face. It is pink. The mask. It is modelled after a surgical mask—the same flexile lining on one end with a bunch of pleats gathering at the centre, allowing the material to unfold over the face.But it isn’t a surgical mask. It is a copy. Nani squats by the public tap, reaches for the small piece of abandoned soap. The soap has degenerated from constantly lying by the tap and from being repeatedly grabbed by several pairs of hands. Now, Nani holds it too.The soap suds as she rubs it on her mask. The froth leaves a creamy feel on Nani’s palms, otherwise dry from all the washing and cleaning she does, day in and day out. Nani rinses the mask in running water, wrings it and then hangs it next to her kurta on the clothesline.This a daily ritual after she returns home from work. She washes the mask, first thing and leaves it to dry—it has to see her through another day.Read also: <a href="https://www.nepalitimes.com/opinion/how-nepal-can-survive-2nd-covid-wave/" target="_blank" rel="noopener noreferrer">How Nepal can survive 2nd wave</a>, Buddha BasnyatRita Didi, whose house Nani visits every day to clean and wash, had told her: “Nani, here is the money for you to buy masks. Buy a box of surgical masks from the pharmacist’s. Wear a new one every day when you come to work.”“Surgical,” Rita Didi had repeated and had placed a five hundred rupee note in her palm. And as Nani closed her fist to hold the money in, in her mind she immediately saw note books and pencils and a new water bottle that little Reshma had been asking for. So, on her way back home, Nani stopped at the local store.She spent two hundred rupees on a water bottle that had the image of a mouse with massive black ears, looking happy in a red frock with white dots. She spent another two hundred on a note book, pencils and a bunch of coloured chart papers.That was when she had spotted the pink mask, staring at her from a bunch of green, grey, blue masks stacked against a pail of daal. So, fifteen rupees was spent on a pink mask and the change, she thrust into her bag.Nani had finally acquired a mask! She unfurled the pleats of the mask like she were opening an umbrella before an impending storm and pressed it against her face, sliding the elastic bands behind her ears. She had felt safe.A week since, the little pink thing hung on the clothesline, frayed from daily washing. Thin sprays of material like the remnants of a broken spider’s web formed a bush over the front of the mask—the part that chaffed her nose.Tomorrow, Rita Didi would once again ask her why she wasn’t <a href="https://www.nepalitimes.com/opinion/masks-and-vaccines-to-stop-nepals-2nd-wave/" target="_blank" rel="noopener noreferrer">wearing a surgical mask</a>. Again, Nani would tell her that she had not spotted an open pharmacy yet. And Rita Didi would go into a rant about safety, all of it shouted through her white mask that looked like the snout of some animal.Rita Didi would say, “I’m only asking you to come to work because I know you need a salary. I’m trying to help you through this difficult time.” And Nani would nod and begin to do the math in her head, breaking her salary of seven thousand rupees into house rent, a bag of rice, Reshma’s school fees, a new pair of chappals, medicines for Ama, and an umbrella and, and……S walks up to an elderly man who’s pushing a bicycle, loaded down with big baskets carrying fruits.“Dai,” she interrupts him, as he turns around and smiles at her. “Tapai le mask kina nalagauna bhako?” Why aren’t you wearing a mask?The man laughs and pulls out a blue, crushed surgical mask from his front pocket and spreads it over his face. He explains that he had been sucking on some tobacco a while ago and had removed the mask so he could spit and that he had forgotten to wear it back on.S requests him to keep it on at all times and he laughs and say Huss, Huss.“See?” S turns to me. “We keep berating people for not <a href="https://www.nepalitimes.com/opinion/prevention-while-searching-for-a-cure/" target="_blank" rel="noopener noreferrer">wearing masks</a>, but we aren’t thinking of why they aren’t wearing them.” And as though to prove her point, a man walks past us, briefly stopping to spit a streak of paan into the gutter. His mask is dangling by his ear.“We need to think of individual needs, cultures and all kinds of things when talking about masks. It’s no use blaming people without trying to understand why. We need to set up mask banks across the country, so that people have access to masks!” S says excitedly.Past the narrow alleyway, we enter a store that sells branded clothing. There are sets of <a href="https://www.nepalitimes.com/banner/masks-unmasked/" target="_blank" rel="noopener noreferrer">colourful cloth masks</a> arranged in rows on the shelf. The masks have double layers—made from soft cotton that comes with the promise of not leaving marks on the ridge of your nose. They come with the promise of sitting snugly against your face. They come with the promise of colours that match your outfit.“I switched to cloth masks because I don’t want to be throwing surgical masks out everyday and add to the waste,” explains A. “Do they work?” we ask the guy at the counter. “Yes, yes,” he averts our eyes, quickly shoves the masks into tony pouches and pushes them at us across the counter.Suburban Tales is a monthly column in Nepali Times based on real people (with some names changed) in the author’s life.Photos: PRATIBHA TULADHAR

Pratibha Tuladhar

The economics of masks

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111136/636b83649c7e80680e067732jpeg.jpg" alt="" width="3563" height="2375"/><figcaption>Photo: AMIT MACHAMASI</figcaption></figure>Only a month ago, even prominent doctors in India were declaring that the country had defeated the <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/&amp;source=gmail&amp;ust=1620014851520000&amp;usg=AFQjCNH26pr4ATCusVi4rW_jCSccSqOyNw">novel coronavirus. </a>They felt that herd immunity in cities like Delhi would protect people from infection and death. Based on a few dubious studies, they conceded that a large proportion of Indians had acquired herd immunity through mild or asymptomatic Covid-19 infections.Just like the theory that a lifetime exposure to germs would protect South Asians, herd immunity also turned out not to be true.Here in Nepal we are seeing a surge that is proportionately similar to India. The exponential rise in the number of cases, infection of younger cohorts, and the severity of the disease, bear all the hallmarks of the contagion sweeping across India.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111136/636b83679c7e80680e067733jpeg.jpg" alt="" width="1390" height="584"><figcaption> </figcaption></figure>While we try to treat the sick by increasing hospital space and ensuring oxygen supply, we must also plan for an <a href="https://www.nepalitimes.com/opinion/a-covid-19-exit-strategy-for-nepal/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/a-covid-19-exit-strategy-for-nepal/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNGreS-S3470fwa9xi8chTwsApsL8Q">exit strategy</a> that entails acquiring more effective herd immunity through mass vaccination, and partial lockdowns enforced with all <a href="https://www.nepalitimes.com/opinion/prevention-while-searching-for-a-cure/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/prevention-while-searching-for-a-cure/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNEgv4bMUglLS5mZDf0VcnTA8rrcwA">precautionary measures</a>.<a href="https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNFOLiROFJhRqoWS8Lm4Rrizbt_w7w">Over-preparation rather than under-preparedness </a>needs to be our mantra. Widespread vaccination is the key to get us out of this pandemic, and we have lost precious time with the delays.This means our <a href="https://www.nepalitimes.com/latest/nepal-braces-for-new-wave-with-vaccine-drive/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-braces-for-new-wave-with-vaccine-drive/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNH7Un17CIezo7XVehWgZr4IVThqzQ">vaccine diplomacy</a> has to go into top gear. If <a href="https://www.nepalitimes.com/latest/jabs-and-jab-nots/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/jabs-and-jab-nots/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNEHISgu64T2PwpgpRFk_IklnxurbA">Covishield from India</a> is not available, we must lobby for as many dosages of vaccines from <a href="https://www.nepalitimes.com/latest/the-gift-of-the-jab/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/the-gift-of-the-jab/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNFYyDtUVRKNT2a92xdtV6IBpGmKNQ">Chin</a>a, <a href="https://www.nepalitimes.com/latest/sputnik-v-vaccine-mystery-in-nepal/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/sputnik-v-vaccine-mystery-in-nepal/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNGsbwsSUqjInkvevMv3Ycj6ryTa8w">Russia</a>, or the United States, and administer them urgently.All of these vaccines are in general at least 50% effective (the ‘pass mark’ for vaccine efficacy). None of the inoculations appear to have serious adverse effects, even though there are questions about whether they provide enough protection from the new strains, and duration of immunity.We are trying to immunise the population from SARS-CoV-2, which happens to be a wily killer that exploits the human need for social interaction and mobility. Analysing this sudden and rapid spread of the virus in the Subcontinent, it looks like South Asians are more vulnerable because of <a style="letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/nepals-virus-vortex/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/nepals-virus-vortex/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNFClAleG43b0LxtmN6SUTtqq0wUeA">our co-morbidities.</a>South Asians are known to be genetically more susceptible to diabetes and cardio-vascular diseases. The diet and lifestyle of people in the 40-70 age group increases the risk factor for obesity, diabetes and hypertension. Not unsurprisingly, the death toll due to Covid-19 is higher in this age cohort among South Asias than in Europe or the Americas.The other reason for the infection suddenly taking off again in our part of the world is that we let our guard down, attending festivals, religious ceremonies and political rallies.And then there is the presence in Nepal of both the UK variant of the virus ( B.1.1.7) and the B.1.617 (Indian variant) both of which are at least 20% more transmissible. The good news (at least so far) is that these variants may not be any more lethal than the standard virus. But even if they are not, we desperately need to stop transmission.And since this is a respiratory virus, the most effective way to do that is still to wear a mask, avoid crowds and use hand sanitiser.In a pandemic of this scale, the general public also needs to know what treatment works and does not. Oxygen, if available, is definitely helpful since it is a drop in oxygen level in the blood that leads to serious complications.A drug called dexamethasone saves lives, it is easily available and cheap. Tocilizumab, unavailable in Nepal, and expensive, can also be used to treat severely ill patients and should only be administered by a physician. There are web <a href="https://www.indiacovidsos.org/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.indiacovidsos.org/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNG9m03344ZEP5kR4-D9sw3xAz7ZjQ">links</a> with pragmatic tips that may come in handy if a hospital bed is not available, as we are now seeing in India and Nepal.There is a lot of fake news about the effectivity of treatment drugs. The following commonly used drugs for well-known illnesses do not work against Covid-19 although, even today, many are rampantly and unnecessarily prescribed in South Asia: Azithromycin, ivermectin, choloroquin, colchicine, convalescent plasma, vitamin D, zinc, lopinavir-ritonavir, favipiravir, and doxycycline.Even remdesivir, the drug that many desperate families try to acquire for their hospitalised relatives, does not save lives even though it is known to reduce hospital stay.Many of these drugs were studied for their efficacy by carrying out large randomised controlled trials by the biggest, adaptive Covid-19 tests undertaken by Oxford University’s <a href="https://www.recoverytrial.net/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.recoverytrial.net/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNFWVQpxuWW8Bb9WDrI4MR584LIUww">Recovery Trial</a>.The Nepal Health Research Council was the first country set-up outside the UK that recently started collaboration with Recovery Trial as part of a global effort to in order to help find a treatment drug against Covid-19.This tragedy has exposed the inadequacy and inequity in the health care system of Nepal and South Asia. The dominant method of health care delivery in the region, especially for curative services, are private enterprises that follow the corporate health care model patterned after the United States.Nepal has also increasingly gravitated towards this system of health care, with many new private hospitals all over the country. The pandemic will force us to question this model, and ask if alternatives like the UK National Health Service would be more suitable.Despite the vested interests behind the <a href="https://www.nepalitimes.com/here-now/kcs-fast-highlights-nepals-covid-19-failure/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/kcs-fast-highlights-nepals-covid-19-failure/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNGPAmj-NNRDt3JI_--ydl8p8gFc_A">medical-industrial complex</a> in Nepal, we need to plan for <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNGNZppXCvCMgFPm4GVAEVi5e8MJRg">universal health care (UHC)</a>, and even consider universal basic income (UBI), if we are going to improve health care to the vast majority of Nepali people.Even President Joe Biden is trying to reform US health care with a stimulus package that has clear aspects of UBI. We need to look at a combination of UHC and UBI in Nepal because even if we survive this pandemic, there is certain to be another one sooner or later.The international media has only taken notice of the second wave in Nepal after reports of infections at <a href="https://www.nepalitimes.com/banner/mt-everest-city/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/mt-everest-city/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNEXmV4I4K_YnFSjorLfpqWrs5_c0g">Mt Everest Base Camp</a> last week. But it is reassuring to know that even up there at 5,364m, Nepali specialists are doing their best to follow protocols to deal with suspected Covid-19 among climbers and support staff.This work is critical because the ubiquitous ‘Khumbu cough’ and even the life-threatening high altitude pulmonary edema (<a href="https://www.nepalitimes.com/latest/high-alert/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/high-alert/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNHi0ktDBncK6SypHGzDbi44cBgObw">HAPE</a>) simulate the symptoms of Covid-19, and it can be difficult to tell them apart.Buddha Basnyat, MD, is a clinical researcher at the Patan Academy of Health Sciences and an <a href="https://www.nepalitimes.com/latest/sherpa-genes-for-covid-19-treatment/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/sherpa-genes-for-covid-19-treatment/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNEJKfShTwfhNqAdP0GvlMmh5-IMfQ">expert in high altitude medicine</a>. He is also a <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNF_WOWRO49qKaxdIzZ6QpXh6cnQpA">frequent health columnist</a> for Nepali Times.

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