One in every three Nepalis carries the <a href="https://nepalitimes.com/editorial/tb-or-not-tb">tuberculosis</a> bacillus. There may be no active symptoms, but they can at any point progree into a full blown infection. TB kills up to 47 Nepalis daily. If so many people died every day in road traffic accidents, it would make headlines every day. But they do not because tuberculosis afflicts the poorest people in the poorest parts of Nepal.&nbsp; The annual 17,000 fatalities from <a href="https://nepalitimes.com/banner/for-nepal-a-game-changer-in-tb-control">tuberculosis in Nepal</a> are preventable with cost-effective treatment. A new pilot study in Chitwan and Piuthan in the past two years showed that of the 1,173 people given a Tuberculin Skin Test (Mantoux Test), 1,127 were positive. Following a Mantoux test and chest x-ray, 509 were diagnosed with latent TB of whom 95% were willing to take preventive therapy.&nbsp; Researchers were pleasantly surprised. As in other countries in the region, they were expecting very few to agree to take preventive therapy medicines because they did not have TB symptoms, so a 95% agreeing to the treatment was exceptionally high. “People in Chitwan and Piuthan who participated in the study were not sick, they were just carrying the TB bacteria, but they agreed to take the preventive drugs because they have all known of relatives who had died of TB,” explains Buddha Basnyat, a physician who advised the Birat Nepal Medical Trust (BNMT) that conducted the research.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240325030340_43b4bc93b22c3964ee021a9dc9df40f9da783917b2ebfbe798a03a82276421a7.jpg" data-media-id="editor_2" data-image-id="20240325030340_43b4bc93b22c3964ee021a9dc9df40f9da783917b2ebfbe798a03a82276421a7" data-rendition-name="original" width="1500" height="1125" loading="lazy" alt="Tuberculosis preventive therapy in Nepal"> <figcaption>Health care volunteers during an outreach screening program in Dhanusha as part of active case-finding for tuberculosis in local communities.</figcaption> </figure>  BNMT is now extending the study to Nawalparasi and Rupandehi with the National Tuberculosis Control Centre. Latent TB is more prevalent in the Tarai districts because of their higher population density. With Nepal suffering such an <a href="https://nepalitimes.com/here-now/nepal-tb-cases-grossly-underestimated">enormous disease burden from tuberculosis</a>, one would have thought World TB Day on Sunday 25 March would have got more attention. But it was overshadowed by Holi celebrations. It would have been interesting to see how many in the crowds attending the concert at Darbar Marg would test positive. Scientists worry that the World Health Organisation’s END TB strategy of reducing global tuberculosis incidence by 90% and deaths by 95% in the next ten years is too ambitious unless latent tuberculosis cases are also treated.&nbsp; What makes this failure all the more tragic is that tuberculosis is a completely preventable and treatable infection. Every $1 invested in TB gives a $39 return, yet there is little investment and advocacy to combat this biblical illness. South Asia accounts for some 40% of all TB cases and 38% of all TB deaths — most of them occurring in the thickly-populated states across the Nepal border in India. The region also has a high burden of multi-drug resistant TB, one-third of global cases. In the past, Directly Observed Therapy Short Course (DOTS) drug therapy in which patients were administered medicines at health posts was considered a cure-all for tuberculosis. <a href="https://archive.nepalitimes.com/news.php?id=294">Nepal had a high success rate for DOTS</a>, but there were loopholes in the program: latent cases remained hidden and only the cases that came to the health system were treated. DOTS also added to the pre-existing stigma so that patients travelling to the health posts would be identified as having tuberculosis. In one instance, a patient in Bardia chose to take a dangerous tiger-infested jungle route to reach the health post. &nbsp; Meanwhile, BNMT had been setting up a strong community network of health volunteers, and was <a href="https://nepalitimes.com/banner/nepal-tests-and-treats-tb-with-a-flying-pharmacy">tracking active TB cases</a>. Unlike DOTS, it involved meeting family and friends of patients, allowing more case detection and treatment. Even so, they were not looking for latent infections.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240325030340_39b79cbd0799bee83a8ae67fd8016d9c75b539d89679e5a4328a7b8540bbca01.jpg" data-media-id="editor_6" data-image-id="20240325030340_39b79cbd0799bee83a8ae67fd8016d9c75b539d89679e5a4328a7b8540bbca01" data-rendition-name="original" width="1687" height="1125" loading="lazy" alt="Tuberculosis preventive therapy in Nepal"> <figcaption>Female Community Health Volunteers (FCHVs) have played a significant role in active case finding.</figcaption> </figure>  Latent cases can progress to active tuberculosis especially when a patient's immune system is weak because of malnutrition, illnesses like HIV, or age. In fact, half of TB worldwide can be attributed to undernourishment. Latent TB can be confirmed in two simple steps: a Mantoux test with an above 10 score and a clear chest x-ray. If positive, the patient is given the 3HP preventive therapy — a once-weekly treatment with isoniazid-rifapentine for 12 weeks. This treatment can prevent reinfection for as long as six years, and is not to be confused with the one for active cases which requires daily treatment for six months. “On an individual level, you can still get reinfected if you are living in a house with active cases. But if you treat the community at large with preventive therapy, you drive down the prevalence of TB and in turn, people won't get reinfected,” explains Maxine Caws of BNMT. She adds: “If we can use preventive therapy to push down the reservoirs of infection then we extend the amount of time people are protected as is the case in Europe for example where people don't get TB anymore because they are not exposed to the bacteria at all. We have to eradicate that reservoir.” The traditional BCG vaccine given within 28 days of birth is effective against childhood tuberculous meningitis and miliary disease, but does not prevent TB in adults. Efforts are underway to develop a new effective vaccine but there are many challenges.&nbsp; TB vaccine development is difficult because exposure to the tuberculosis bacillus does not seem to induce sufficient protective immunity. A new viable vaccine could take a decade, but in that time 13 million more people would die.&nbsp; “We cannot wait and do nothing until a new effective vaccine is developed. Preventive therapy is a vaccine until we have one,” adds Basnyat. Indeed, the 3HP preventive therapy after diagnosis costs only $5 per regimen. So, Nepal’s strategy should be a simultaneous focus on 3HP preventive therapy and case finding.&nbsp; The problem has been a lack of priority for preventive therapy at national and international levels because it does not involve costly research and interventions, and the patients are poor. Explains Caws: “On paper, we have very strong policies but the commitment in terms of funding from the governments has not materialised, essentially because it is not affecting the rich unlike with Covid when we threw everything at it to have a vaccine developed in a year.” TB’s main problem, <a href="https://nepalitimes.com/opinion/comment/pandemic-eclipses-nepals-tb-epidemic">unlike Covid</a> and HIV/AIDS is that it is a disease of the poor.&nbsp;

Sonia Awale

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Ending TB is possible, and cost-effective

<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

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181148/636be7f69c7e80680e087831jpeg.jpg" alt="" width="1500" height="1125"/><figcaption>Photos: BNMT</figcaption></figure>Drone therapy for tuberculosis diagnosis in Nepal’s remote and hard to reach mountains has won at the <a href="https://tiaca.org/tiaca-press-release/pelican-biothermal-and-nepal-flying-labs-win-2020-tiaca-air-cargo-sustainability-awards/" target="_blank" rel="noopener noreferrer">2020 International Air Cargo Association (TIACA)</a> Sustainability Awards and will receive $10,000 in prize money as a start-up category winner.The winning project, <a href="https://www.nepalitimes.com/banner/nepal-tests-and-treats-tb-with-a-flying-pharmacy/" target="_blank" rel="noopener noreferrer">Drone Optimised Therapy System</a> (DrOTS) by Nepal Flying Labs links rural health posts with high-end diagnostic tool via drones to improve the accessibility of tuberculosis diagnostic tests.“In a year marked by a global pandemic which disrupted our industry, problem solving and forward-thinking companies like Nepal Flying Labs bring hope that air cargo can come out of this crisis stronger and more resilient,” says Céline Hourcade of TIACA, which celebrates and encourages outstanding industry initiatives driving sustainability in air cargo.Under DrOTS, drones fly from a central district hospital to health posts in the mountains to collect sputum samples and deliver both diagnoses and treatment to patients living in up-country villages. The samples are tested using a <a href="https://www.nepalitimes.com/banner/for-nepal-a-game-changer-in-tb-control/" target="_blank" rel="noopener noreferrer">high-end GenExpert kit</a>.If they are positive, patients are given DOTS (directly observed treatment short course) treatment using smart pill boxes, which keep electronic records of whether or not patients have taken the antibiotics regularly.The highly competitive award evaluated humanitarian projects based on three aspects of sustainability -- economic social and environmental -- as well as innovation and practicality of the applied solution. The winners were announced online on 10 December.The project had also won the prestigious industry award from the <a href="https://www.auvsi.org/industry-news/winners-2020-xcellence-awards" target="_blank" rel="noopener noreferrer">Association for Unmanned Aerial Vehicles</a> – the AUVSI XCELLENCE Award 2020 in Humanitarian and Public Safety category in October.The goal of this project is to assist Nepal’s Ministry of Health in generating data on <a href="https://www.nepalitimes.com/banner/tb/" target="_blank" rel="noopener noreferrer">tuberculosis</a> and support it in its efforts to reduce the prevalence of the infection. This perfectly curable medieval disease is the biggest infectious killer in the world today, more than HIV or malaria.https://www.youtube.com/watch?v=Xf4OpwoblRc&amp;feature=emb_logoWhile Nepal is a role model in the community-based DOTS treatment, which ensures index patients are taking their medicines, this alone will not suffice in the battle against TB, since a patient would often have already infected others in the household and workplace. Which is why active case finding and early treatment is the key.The first comprehensive national TB prevalence survey 2018-19 in Nepal showed that the burden of TB in Nepal is much higher than previously estimated. There are now known to be 245 TB cases per 100,000 people – which means there are 69,000 new cases each year. Some 6,000 people in Nepal die every year because of the infection while every other Nepali is a carrier of TB.“Tragically over 35,000 cases of TB are not due to difficulties reaching the basic health services. To accelerate progress towards the end of TB in Nepal we must increase efforts to reach remote and disadvantaged populations with high quality TB services,” says Maxine Caws, epidemiologist with BNMT. “The drone project project represents one such approach to solve this problem, and also has the potential to address many other health challenges facing rural populations of Nepal.”The DrOTS test flight was conducted successfully in Piuthan district in western Nepal last year. Since then, over 106 flights have been carried out, collecting and delivering more than 742 sputum samples, with a result of 26 positive cases from eight remote health facilities. The technology has also been used for TB control in Zimbabwe and Papua New Guinea.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181148/636be7fa9c7e80680e087832jpeg.jpg" alt="" width="1500" height="1125"><figcaption>Locals wait for drone to arrive.</figcaption></figure><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181148/636be7fe9c7e80680e087833jpeg.jpg" alt="" width="1500" height="1125"><figcaption>Using the drone interface.</figcaption></figure>The drones weigh 9kg when empty and can carry another 7kg in a cargo hold designed to protect against biohazards; they can be airborne for 30 minutes. The craft flies at speeds of up to 1km per minute, and is controlled by a pilot at the take-off point who coordinates with a health worker at the destination.The DrOTS project is a multidisciplinary consortium of Birat Nepal Medical Trust (BNMT Nepal), DroNepal, Nepal Flying Labs, Liverpool School of Tropical Medicine, UK and WeRobotics, Switzerland working in partnership with the Nick Simons Institute, National Tuberculosis Centre, and Stony Brook University, USA.Says Biplav Pageni of Nepal Flying Labs: “We hope to scale our drone cargo technology to other rural locations and establish networks of medical cargo drones to help more people in the coming days. Drones are said to be the future of air cargo but I believe they are the present and we are using it to save lives in Nepal.”

Nepal anti-TB drone project awarded

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109191116/636beef44b0ad905ca02ef7ajpeg.jpg" alt="" width="1500" height="1125"/><figcaption>Photos: BNMT</figcaption></figure>Drone therapy for tuberculosis diagnosis in Nepal’s remote and hard to reach mountains has won at the <a href="https://tiaca.org/tiaca-press-release/pelican-biothermal-and-nepal-flying-labs-win-2020-tiaca-air-cargo-sustainability-awards/" target="_blank" rel="noopener noreferrer">2020 International Air Cargo Association (TIACA)</a> Sustainability Awards and will receive $10,000 in prize money as a start-up category winner.The winning project, <a href="https://www.nepalitimes.com/banner/nepal-tests-and-treats-tb-with-a-flying-pharmacy/" target="_blank" rel="noopener noreferrer">Drone Optimised Therapy System</a> (DrOTS) by Nepal Flying Labs links rural health posts with high-end diagnostic tool via drones to improve the accessibility of tuberculosis diagnostic tests.“In a year marked by a global pandemic which disrupted our industry, problem solving and forward-thinking companies like Nepal Flying Labs bring hope that air cargo can come out of this crisis stronger and more resilient,” says Céline Hourcade of TIACA, which celebrates and encourages outstanding industry initiatives driving sustainability in air cargo.Under DrOTS, drones fly from a central district hospital to health posts in the mountains to collect sputum samples and deliver both diagnoses and treatment to patients living in up-country villages. The samples are tested using a <a href="https://www.nepalitimes.com/banner/for-nepal-a-game-changer-in-tb-control/" target="_blank" rel="noopener noreferrer">high-end GenExpert kit</a>.If they are positive, patients are given DOTS (directly observed treatment short course) treatment using smart pill boxes, which keep electronic records of whether or not patients have taken the antibiotics regularly.The highly competitive award evaluated humanitarian projects based on three aspects of sustainability -- economic social and environmental -- as well as innovation and practicality of the applied solution. The winners were announced online on 10 December.The project had also won the prestigious industry award from the <a href="https://www.auvsi.org/industry-news/winners-2020-xcellence-awards" target="_blank" rel="noopener noreferrer">Association for Unmanned Aerial Vehicles</a> – the AUVSI XCELLENCE Award 2020 in Humanitarian and Public Safety category in October.The goal of this project is to assist Nepal’s Ministry of Health in generating data on <a href="https://www.nepalitimes.com/banner/tb/" target="_blank" rel="noopener noreferrer">tuberculosis</a> and support it in its efforts to reduce the prevalence of the infection. This perfectly curable medieval disease is the biggest infectious killer in the world today, more than HIV or malaria.https://www.youtube.com/watch?v=Xf4OpwoblRc&amp;feature=emb_logoWhile Nepal is a role model in the community-based DOTS treatment, which ensures index patients are taking their medicines, this alone will not suffice in the battle against TB, since a patient would often have already infected others in the household and workplace. Which is why active case finding and early treatment is the key.The first comprehensive national TB prevalence survey 2018-19 in Nepal showed that the burden of TB in Nepal is much higher than previously estimated. There are now known to be 245 TB cases per 100,000 people – which means there are 69,000 new cases each year. Some 6,000 people in Nepal die every year because of the infection while every other Nepali is a carrier of TB.“Tragically over 35,000 cases of TB are not due to difficulties reaching the basic health services. To accelerate progress towards the end of TB in Nepal we must increase efforts to reach remote and disadvantaged populations with high quality TB services,” says Maxine Caws, epidemiologist with BNMT. “The drone project project represents one such approach to solve this problem, and also has the potential to address many other health challenges facing rural populations of Nepal.”The DrOTS test flight was conducted successfully in Piuthan district in western Nepal last year. Since then, over 106 flights have been carried out, collecting and delivering more than 742 sputum samples, with a result of 26 positive cases from eight remote health facilities. The technology has also been used for TB control in Zimbabwe and Papua New Guinea.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109191116/636beef84b0ad905ca02ef7bjpeg.jpg" alt="" width="1500" height="1125"><figcaption>Locals wait for drone to arrive.</figcaption></figure><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109191116/636beefb4b0ad905ca02ef7cjpeg.jpg" alt="" width="1500" height="1125"><figcaption>Using the drone interface.</figcaption></figure>The drones weigh 9kg when empty and can carry another 7kg in a cargo hold designed to protect against biohazards; they can be airborne for 30 minutes. The craft flies at speeds of up to 1km per minute, and is controlled by a pilot at the take-off point who coordinates with a health worker at the destination.The DrOTS project is a multidisciplinary consortium of Birat Nepal Medical Trust (BNMT Nepal), DroNepal, Nepal Flying Labs, Liverpool School of Tropical Medicine, UK and WeRobotics, Switzerland working in partnership with the Nick Simons Institute, National Tuberculosis Centre, and Stony Brook University, USA.Says Biplav Pageni of Nepal Flying Labs: “We hope to scale our drone cargo technology to other rural locations and establish networks of medical cargo drones to help more people in the coming days. Drones are said to be the future of air cargo but I believe they are the present and we are using it to save lives in Nepal.”

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109141132/636babf89c7e80680e077f08jpeg.jpg" alt="" width="1400" height="933"/><figcaption>Photo: NEPALI TIMES ARCHIVE</figcaption></figure>COVID-19 has made headlines every day over the past two months, but tuberculosis (TB) patients across South Asia have their treatment interrupted due to the lockdown.South Asia is a vast hub for TB. India alone had 2.7 million new cases and 440,000 deaths due to TB in 2018 — the highest in the world. Every year, tuberculosis kills at least 6,000 people in Nepal and every other person is a carrier of the microbe.The WHO has set <a href="https://www.who.int/tb/End_TB_brochure.pdf?ua=1" data-saferedirecturl="https://www.google.com/url?q=https://www.who.int/tb/End_TB_brochure.pdf?ua%3D1&amp;source=gmail&amp;ust=1593695520550000&amp;usg=AFQjCNHVd_kVz8K7Q1LZxUa_CWkwSdG7Vg">global targets</a> to reduce new cases of TB by 90% and deaths by 95% between 2015 and 2035. However, the fight against TB faces a setback of an estimated 5-8 years globally, due to COVID-19.The COVID-19 crisis has uncovered gaps in the present healthcare system in the Subcontinent. There is now a shortage of functioning sputum testing centres as well as DOT (Directly Observed Treatment Short-course) centres. Healthcare workers are also wary of going on-ground and carrying out tests and diagnoses.Migrant workers with TB, who are travelling away from their workplaces, are at risk of treatment interruption, which may lead to <a href="https://en.wikipedia.org/wiki/Multi-drug-resistant_tuberculosis#:~:text=Infectious%20disease,drugs)%2C%20isoniazid%20and%20rifampin." data-saferedirecturl="https://www.google.com/url?q=https://en.wikipedia.org/wiki/Multi-drug-resistant_tuberculosis%23:~:text%3DInfectious%2520disease,drugs)%252C%2520isoniazid%2520and%2520rifampin.&amp;source=gmail&amp;ust=1593695520550000&amp;usg=AFQjCNEkqQ32ZjQluu9UU_sZ8EeTipApXQ">multi-drug-resistant (MDR) TB</a>. Additionally, due to the stigma attached with the symptoms of COVID-19, people are now afraid to get tested for TB, which has symptoms similar to those of COVID-19.This can exacerbate the problem, as undiagnosed patients can infect many more. Those with lung injuries due to TB may be <a href="https://www.thetruthabouttb.org/coronavirus/" data-saferedirecturl="https://www.google.com/url?q=https://www.thetruthabouttb.org/coronavirus/&amp;source=gmail&amp;ust=1593695520550000&amp;usg=AFQjCNHh8d8TmjVl40wPRPytgXeQDPsiww">prone to more severe outcomes</a> if infected with COVID-19.“In India, health-seeking behaviour has completely changed after COVID-19. People think twice before seeking a doctor,” says Khasim Sayyed of TB Alert India. “We are expecting a very high number of patients across all DOT centres and outpatient departments once the lockdown is lifted, because the patients are afraid to get diagnosed right now.”A combination of strategies will be required to restore normal TB services, with the objective to reduce the accumulated pool of undetected TB patients. Here are some other steps that can be taken to strengthen both diagnosis and treatment:Diagnosis<ul><li>Governments should collaborate with non-profits and use technology to ramp-up active case-finding and contact tracing.</li> 	<li>Community health workers should conduct door-to-door sample collection.</li> 	<li>Health system should ensure diagnostic services for TB. Currently, most labs are being used for COVID-19 testing only.</li> 	<li><a href="https://www.nepalitimes.com/here-now/a-covid-19-game-changer-for-nepal/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/a-covid-19-game-changer-for-nepal/&amp;source=gmail&amp;ust=1593695520550000&amp;usg=AFQjCNEqv3e5bpooFbMQx594hHcms3j7uA">GeneXpert</a> test should be enabled for MDR TB cases as they are quicker and can identify if a person has resistance to the drug.</li></ul>Treatment<ul><li>Healthcare workers and non-profits should facilitate tele-counselling to sensitise family members about the possible side effects and severe symptoms of TB.</li> 	<li>The government, in collaboration with non-profits, should run a helpline so that TB patients can better manage severe symptoms or side effects.</li> 	<li>Health practitioners should leverage digital tools to diagnose patients and prescribe first-line treatment.</li></ul>Additionally, institutions must also work to safeguard healthcare workers from tuberculosis, as well as COVID-19, during any intervention. And as more private practitioners turn to digital facilities for diagnosis and consulting, there is a need to design solutions for marginalised communities.The projected numbers for TB highlight the urgency for a better intervention strategy. While the COVID-19 pandemic deserves attention and intervention, the response to it should not come at the cost of another disease. (IPS)Devika Agarwal has worked with TB Alert India, Ministry of Health and Family Welfare, Government of Delhi, and the non-profit Aaroogya. This story was <a href="https://idronline.org/managing-an-epidemic-within-a-pandemic/" data-saferedirecturl="https://www.google.com/url?q=https://idronline.org/managing-an-epidemic-within-a-pandemic/&amp;source=gmail&amp;ust=1593695520550000&amp;usg=AFQjCNGlN78X8O31tWoB2VkPn1rFIadjaA">originally published</a> by India Development Review (IDR) and has been reprinted under an arrangement with Inter Press Service (IPS).

TB patients in limbo due to COVID-19

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a66739c7e80680e059980jpeg.jpg" alt="" width="1500" height="1000"/><figcaption>Photo : BIKRAM RAI</figcaption></figure>There used to be a time when the main public health threat in Nepal was from infectious diseases like <a href="https://www.nepalitimes.com/here-now/the-mosquito-that-changed-nepals-history/" target="_blank" rel="noopener">malaria</a>, encephalitis, <a href="https://www.nepalitimes.com/banner/tb/" target="_blank" rel="noopener">TB</a> and typhoid. Whether vector-borne or transmitted through contaminated air or water, the most cost-effective way to address them was through prevention. Communication was the first line of defence against communicable diseases.Things have changed. Awareness has grown because literacy rates are up. Most Nepalis now suffer from non-communicable ailments like cardiovascular diseases, <a href="https://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018">diabetes</a>, <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/A-mysterious-rash-of-kidney-failures,3639" target="_blank" rel="noopener">renal failure</a> and malignancies. These need treatment in medical facilities at a time when the over-commercialisation of hospitals has made healthcare unaffordable for a majority of the population. In fact, <a href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">poor health</a> is making Nepalis poorer.Read also:<a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">Is free health care possible in Nepal?</a>, S P Kalaunee<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/?p=37821&amp;preview_nonce=9ce6a7c55d&amp;preview=true" target="_blank" rel="noopener">Federalism leaves Nepal’s medical sector ailing,</a> Sewa BhattaraiAlso, communicable diseases have not been completely overcome. Diarrhoeal dehydration and other water-carried infections are still major killers. One of the reasons Nepal’s progress in reducing child mortality has stalled is because of the state’s failure to ensure adequate and safe drinking water in remote regions. In this paper we have also reported on <a href="https://www.nepalitimes.com/banner/nearly-half-of-nepali-children-still-malnourished/" target="_blank" rel="noopener">stunting and wasting among children</a> due to malnutrition.In addition, <a href="https://www.nepalitimes.com/here-now/air-pollution-is-more-dangerous-than-smoking/" target="_blank" rel="noopener">worsening air pollution</a> has caused an epidemic of chronic obstructive pulmonary disease (COPD), which has led to lung infections in all age brackets and causing terminal pneumonia and other complications in the elderly. At current levels of PM2.5 concentration in the air, studies show, the average lifespan of city dwellers in Nepal could be reduced by up to four years.Read also:<a href="https://www.nepalitimes.com/here-now/nepal-is-a-microcosm-of-all-of-the-changes-in-world-health/" target="_blank" rel="noopener">"Nepal is a microcosm of all of the change in world health"</a><a href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">Poor health</a>, EditorialNepal’s burden of non-communicable diseases and injuries has doubled in the last 25 years, with nearly 15% caused by <a href="https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/" target="_blank" rel="noopener">road traffic accidents</a> or natural disasters. Traffic accidents are now the second biggest killer of young Nepalis. Just in the past three weeks, 90 people have been killed on highways due to poor road condition or carelessness.A vivid indication of the threat of non-communicable diseases is today’s prevalence of diabetes. South Asians are genetically more susceptible to cardiovascular diseases and diabetes, but there are now new risk factors caused by increasing rural to urban migration. While the world prevalence average for both types of diabetes is 8%, research has shown that 14% of people in Dharan suffer from the disease. Taplejung, from where many have migrated to Dharan, has a rate of only 1%. The reason is clear: increased intake of carbohydrates and a more sedentary lifestyle when people move to cities.To meet these challenges, Nepal desperately needs <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">affordable and accessible medical care</a>. At the moment, hospital treatment is neither. The poor in remote, underserved areas of the country are disproportionately vulnerable. As our report from Bajura shows, the problem is further complicated because confusion over federalism, budget and jurisdiction has left most rural government hospitals underfunded and underserved. It is imperative that the government act quickly to resolve the retention crisis caused by medical staff getting themselves transferred out of their jobs in remote areas.Read also: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">A national health insurance is not as easy as it looks</a>, Sonia Awale<a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" target="_blank" rel="noopener">This is how to upgrade Nepal's rural health</a>, Sewa BhattaraiA survey last year showed that half of all <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">medical expenditure of Nepalis families</a> is out-of-pocket, and 60% of that is for treatment of non-communicable diseases and injuries. The federal government allocates only about 10% of its budget to health care, and the focus is still on communicable diseases. Donor priority is also not on non-communicable diseases and injuries. A study of government hospitals by the Nick Simons Institute shows a huge unmet need in remote areas for basic surgery like caesarean sections and orthopaedics.One bright spot ahead is the success of pilot insurance schemes being tried out in various parts of the country. In a <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">commentary this week</a>, S P Kalaunee of Nyaya Health, an NGO that helps the government manage hospitals in Achham and Dolakha, presents a proven 60:25:15 formula of health insurance. In this arrangement, non-profits, the private sector and all three levels of government can make medical care affordable to all Nepalis, if upscaled. Under the scheme, 60% of the cost of care comes from insurance, provincial governments pay 25% and municipalities take care of the remaining 15%.Parts of the scheme are being tried out in <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" target="_blank" rel="noopener">Bayalpata Hospital in Achham</a> (which last week <a href="https://www.nepalitimes.com/banner/bayalpata-hospital-in-nepal-wins-global-design-award/" target="_blank" rel="noopener">won the Global Architecture Festival award</a> in Amsterdam for its design). Insurance reimbursement covers the cost of insurance-covered care, the local government allocates funds required for basic and emergency healthcare, and the provincial government pays for managing the cost of referrals beyond insurance coverage. Internationally, this has become an issue with 12 December marked as Universal Health Coverage Day.Nepal’s constitution now guarantees basic and emergency healthcare as fundamental rights of citizens, and puts the responsibility on to the state. The government  can no longer keep passing the buck on providing universal insurance for its citizens.<h2>10 years ago this week</h2>Nepali Times <a href="http://archive.nepalitimes.com/issue/480" target="_blank" rel="noopener">issue #480 of 11-17 December 2009</a> carried an <a href="http://archive.nepalitimes.com/news.php?id=16572#.XfId7ZMzaUk" target="_blank" rel="noopener">interview on page 1 with Baburam Bhattarai</a>, who was then vice-chair of the Maoist party.  Excerpts:‘From the very beginning, we have said that the basis of the federal system should be nationality. In Marxist terms, nationality means a common language, geography, economy and psychological make-up. A group of people that shares these qualities is called a nationality.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a66769c7e80680e059981jpeg.jpg" alt="" width="392" height="600">On this basis we have proposed to constitute federal autonomous units in Nepal and we also practised this during the People’s War. Since the very beginning we have been consistent that federalism should be along the lines of nationality.’

POOR HEALTH MAKES NEPALIS POORER

https://www.youtube.com/watch?v=qYrj1Et-9PkSir Jeremy Farrar is a British medical doctor and researcher with 30 years of experience in tropical and infectious diseases. In 2013, he was appointed director of the Wellcome Trust, one of the biggest global charities working in medical research. Nepali Times caught up with Farrar this week in Kathmandu, a place he visits often. Excerpts from the conversation:Nepali Times: What explains your interest in Nepal?Jeremy Farrar: I first came to Nepal in about 1989 or 1990. Since then, I have been working mostly on infectious diseases but increasingly on non-infectious diseases. I spent 18 years in Vietnam and moved back to London 6 years ago. I'm interested in where there are inequitable challenges of health, which I can see getting worse than better, and I think science as part of society can make a difference, and all of that is true in Nepal.You were with Oxford University collaborating with Patan Hospital.Most of my work was based on typhoid in Vietnam and Dr Buddha Basnyat of Patan Hospital quite rightly termed South Asia as the ‘capital of typhoid’. The burden of typhoid in this part of the world is massive. So in 2004 I came here and started a partnership that has been ongoing for the last 15 years. It started with typhoid, but now it has branched out to include other infections particularly important in Nepal.Since you started coming to Nepal how has the health situation here changed?In some ways Nepal is a microcosm of all of the changes that are happening in low and low-middle-income countries. <a href="http://archive.nepalitimes.com/news.php?id=12158#.Xa_yEZIzbIU" target="_blank" rel="noopener">Nepal is still struggling with the burden of infectious diseases </a>but it is now also having to deal with the double whammy of infectious diseases that have not disappeared and the increasing burden posed by non-communicable diseases. The real problem for countries such as Nepal is dealing with both at the same time, and those require quite different public health measures, and require governments to make informed, evidence-based policy decisions.Read also:  <a href="http://archive.nepalitimes.com/news.php?id=17306#.Xa_yFZIzbIU" target="_blank" rel="noopener">Myadhe joro aka typhoid fever</a>, Buddha Basnyat<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108141156/636a60b19c7e80680e056e92jpeg.jpg" alt="" width="1500" height="1000"/><figcaption>Photo: Sonia Awale</figcaption></figure>We just suffered an unprecedented dengue epidemic in Kathmandu.  Dengue is the infectious disease of the 21st century because it is driven by all of the changes we are going to see: environment change, climate change, urbanisation, travel and movement of people and therefore vectors. <a href="https://www.nepalitimes.com/banner/mosquitoes-move-up-mountains-as-the-earth-warms/" target="_blank" rel="noopener">Cities like Kathmandu are perfect breeding grounds</a> for the Aedes mosquito. Kathmandu's climate is changing, the city is growing exponentially in a haphazard way and the mosquito loves highly dense populations of people. If you put together environmental and climate change and the mosquitoes gradually spreading further north from India into the Tarai and increasingly into Nepal, it's inevitable that Kathmandu and the lower lands of Nepal will suffer from dengue outbreaks.Read also: <a href="https://www.nepalitimes.com/here-now/climate-health-emergency/" target="_blank" rel="noopener">Climate-health emergency,</a> Sonia AwaleOn top of these, we still have TB and leprosy.In my professional career of 35 years I have never been more optimistic about <a href="https://www.nepalitimes.com/banner/nepal-tb-cases-grossly-underestimated/" target="_blank" rel="noopener">tuberculosis</a>. If you take the big three infectious diseases of the world (TB, HIV, malaria), in 30 years HIV has gone from being a death sentence in a few week after diagnosis to a difficult disease but one you can manage long term. In the last 20 years there has been amazing progress in malaria with insecticide-laced bed nets and the Chinese herbal drug called Artimisinin, the most important malaria drug ever invented.TB has not made that much progress. We are still using a diagnostic test invented in the 19th century. There has been no new tuberculosis drug since the last 40 years. We have not really understood how it transfers from one person to another. But that is being transformed. With the coming of a new pipeline of drugs that are now being used in South Asia and sub-Saharan Africa, the treatment period will shorten, making it much easier. But perhaps more important than that, for the first time there is the possibility of a tuberculosis vaccine that will prevent infection and disease. We have to make sure that it gets developed properly, then manufactured and made accessible in an equitable way at a price that is affordable for everybody.Read also: <a href="https://www.nepalitimes.com/banner/tb/" target="_blank" rel="noopener">TB</a>, Sonia Awale<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/for-nepal-a-game-changer-in-tb-control/" target="_blank" rel="noopener">For Nepal, a game-changer in TB control</a>, Buddha Basnyat and Maxine CawsWellcome Trust is also involved with snakebite research. What are the real problems tackling this?Snakebite is the biggest disease nobody has heard of. It affects mostly impoverished people in rural communities who have no political voice. <a href="https://www.nepalitimes.com/here-now/snakebite-is-treatable-no-one-need-die-from-it/" target="_blank" rel="noopener">Snakebite treatment</a> is still using 19th century or early 20th century interventions, which are expensive to produce, difficult to access and not available to those who really need them. If people are bitten in low or low-middle income countries, chances are they will never get treated. We are interested in bringing in technologies that have been used in cancer and infectious diseases to produce a treatment that counteracts the snake venom.Read also: <a href="https://www.nepalitimes.com/banner/hisss/" target="_blank" rel="noopener">Hiss</a>, Sonia AwaleIs mental health an area you are working on?In addition to funding discovery science, we have a small number of focused areas, where there has been little progress in the past. Mental health is the next one we are launching. Mental health has not attracted much investment or young people interested in working on it, and it's often placed into different parts of the health system with separate hospitals. Mental health still caries enormous stigma everywhere in the world. So we've not had the investment in science, public health and in clinical care of people, and we haven't had the advances in prevention and treatment. This is not only a health issue but also of social justice and economy. Working in collaboration with various partners we are trying to transform mental health from being an issue of stigma and no progress to one that people are willing to talk about, that becomes a normal part of society and where we make scientific and health progress that will reduce the burden of this massive problem.

“Nepal is a microcosm of all of the changes in world health”

Paul Nunn and Bhim Singh Thakuri<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110814110/636a52f19c7e80680e052324jpeg.jpg" alt="" width="1400" height="933"/><figcaption>Pic: NT ARCHIVE</figcaption></figure>Tuberculosis remains <a href="https://www.nepalitimes.com/editorial/tb-or-not-tb/" target="_blank" rel="noopener">a major public health problem in Nepal</a>, with over 32,000 notified cases and an estimated 7,000 deaths per year.Nepal participated at the United Nations High Level Meeting on TB in September 2018 and, with all the other nations of the world, committed to end TB as a public health problem by 2035.In June, a team of international TB experts reviewed the country’s progress against the disease, visiting five provinces. Their findings: Nepal is not on track to meet the 2035 commitment.  What is more, cases of TB in the country are much higher than we previously estimated.There had been concern that notified cases were just the tip of the iceberg, as there was evidence that many TB cases were being missed.  The Ministry of Health and Population (MOHP) supported by the Global Fund against AIDS, TB and Malaria and the World Health Organisation, conducted a survey to measure for the first time the amount of <a href="https://www.nepalitimes.com/banner/tb/" target="_blank" rel="noopener">TB in Nepal</a>.Read also:<a href="https://www.nepalitimes.com/banner/nepal-tests-and-treats-tb-with-a-flying-pharmacy/" target="_blank" rel="noopener">Nepal tests and treats TB with a flying pharmacy</a>, Ramu Sapkota<a href="https://www.nepalitimes.com/banner/tb/" target="_blank" rel="noopener">TB</a>, Sonia AwaleDespite the terrain, this was one of the most thorough surveys ever done. Final results will be published at the end of the year, but preliminary findings show there is about two-thirds more TB than was previously estimated.How could this be? For over 20 years, Nepal has had a National TB Programme (NTP), which provided nationwide coverage of basic services for drug sensitive TB and, more recently, for drug resistant TB. Treatment results compare favourably with other countries.The NTP has successfully introduced modern rapid diagnostic technology (GeneXpert) and electronic reporting of cases, started a collaboration with the private sector to ensure proper management of patients, and begun a program to find and treat children with TB.Read also: <a href="https://www.nepalitimes.com/banner/for-nepal-a-game-changer-in-tb-control/" target="_blank" rel="noopener">For Nepal, a game-changer in TB control</a>, Buddha Basnyat and Maxine Caws<a href="https://www.nepalitimes.com/editorial/tb-or-not-tb/" target="_blank" rel="noopener">TB or not TB</a>, Editorial<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110814110/636a52f59c7e80680e052325jpeg.jpg" alt="" width="1000" height="639"><figcaption>A lab technician at National Tuberculosis Centre in Thimi, Bhaktapur. Photo: NATIONAL TUBERCULOSIS CENTRE</figcaption></figure>But long-standing weaknesses in management and organisation, compounded now by the federalisation process, have allowed some of the essential functions of the NTP to disintegrate, and others are at serious risk. The laboratory network for diagnosing TB and the system of supportive supervision that ensures standards are maintained through all levels of government should be restored immediately.This is because district centres, key to TB control strategies, were abolished — and then reinstated — but with far fewer staff than previously.Accurate surveillance of the cases notified and the flow of information to the centre is endangered. Federalisation has so far not created clear mechanisms that will ensure these essential functions continue. If decentralised procurement of drugs continues, it will increase procurement costs significantly and risk the purchase of poor quality drugs.Successive governments have allowed the technical staff of the National TB Centre to be hollowed out, eroding its capacity to develop policies and lead their implementation. The National Strategic Plan, written three years ago, is underfunded and only partially implemented. Most staff responsible for TB activities are now not trained to carry out the work.Diagnosis is mostly by outdated and insensitive sputum microscopy.  <a href="https://www.nepalitimes.com/banner/nepal-tests-and-treats-tb-with-a-flying-pharmacy/" target="_blank" rel="noopener">Transport of specimens to laboratories</a> is still inadequate. Consequently, GeneXpert utilisation has been slow to increase.The private health sector is massive and growing. Over 70% of people with TB first go to private clinics, yet diagnosis and treatment are of variable quality, leading to drug resistance.The joint monitoring mission recommended the following:Stop the collapse of the NTP by engaging the MOHP in discussions on federalisation to ensure that the essential functions of TB control are preserved, with clear roles and responsibilities for the newly appointed staff.Increase investment to provide technical support to all levels of the NTP through teams of staff at central and provincial levels. Let a partner employ these staff if the government cannot do so immediately.Use these teams to address the massive training gap that hypermobility of staff and federalisation have created.Phase out sputum microscopy for diagnosis and move to GeneXpert testing, and make sure contracted organisations achieve case-finding targets. If they do not, stop the activities and redirect the resources to more effective areas.Fully engage with the private sector to ensure patients there are diagnosed and treated according to national guidelines.Similarly engage with community-based organisations to help find cases and ensure they finish treatment.Nepal must act on all these recommendations without delay to get back on track to meet its commitments.Paul Nunn was Team Leader of the international mission and Bhim Singh Tinkari is a recent Director of the National Tuberculosis Centre<h2>Communities against a communicable disease</h2>TB testing by and for communities can free Nepal from its biggest infectious killerOlivia Biermann<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110814110/636a52f79c7e80680e052326jpeg.jpg" alt="" width="1400" height="1194"><figcaption>Photos: Birat Nepal Medical Trust</figcaption></figure>Ram, 65, from Makwanpur was nothing but skin and bones. He had lost his appetite and was coughing. His back pain made it difficult for him to walk and care for his chickens and buffalos, which were his main source of income. Ram was very sick, but his disease remained undiagnosed.Over the course of a year, he had visited several private and public health facilities, and spent over Rs69,000 for different treatments. Nothing helped. Ram had given up hope of being healthy.A partner organisation of the national TB program was targeting high-risk areas like Makwanpur for the disease by setting up neighbourhood camps to test people. Ram met volunteer Sangita, who collected his sputum sample and tested it. Ram had TB. He started treatment immediately. Six months later, the treatment completed, he was cured.There are about 10,000 Nepalis like Ram, sick with TB but never diagnosed and treated. They continue to unknowingly transmit the disease to their families, friends and colleagues — fuelling the epidemic. Poverty increases the likelihood that a person will get sick with TB. In turn, TB can make people and their families a lot poorer.Worldwide, TB is the number one infectious killer. The World Health Organization (WHO) estimates 3.7 million people have TB, but do not even know it.One strategy to find these ‘missing’ TB patients is community-based screening (active case-finding). Setting up a camp, as in Ram’s neighbourhood, is only one of many examples of how this type of outreach screening can be done. It could also mean testing friends and family members of a TB patient or offering screening to high-risk groups, such as persons with HIV or diabetes, or people living in a homeless shelter.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110814110/636a52fb9c7e80680e052327jpeg.jpg" alt="" width="1400" height="1116"><figcaption>PROACTIVE MEASURES: Health care volunteers during an outreach screening program in Dhanusha as part of active case-finding for tuberculosis in local communities.</figcaption></figure><a href="https://www.nepalitimes.com/banner/for-nepal-a-game-changer-in-tb-control/" target="_blank" rel="noopener">Active case-finding</a> is not a silver bullet to end TB. There are no silver bullets, in fact. Consequently, in countries with many TB patients like Nepal, community-based TB screening is a necessary but potentially double-edged sword in the global TB emergency.Community screening can waste resources or increase stigma, but it can also decrease suffering and transmission – it all depends on how it has been tailored and put into practice. That is to say that this ‘sword’ should be used carefully, and by those who know when, where and how to mobilise the community.Tailoring outreach screening approaches means considering a) global and local data and evidence, which are limited but steadily growing, and b) using the most accurate diagnostic tools, such as the molecular <a href="http://archive.nepalitimes.com/news.php?id=17747#.XUwPT_IzaUl" target="_blank" rel="noopener">GeneXpert test</a> not widely available in Nepal yet. (See article above)Active case-finding is a balancing act. Tailoring and integrating outreach screening approaches implies that we must consider and strike a balance between:Focusing on transmission versus individual health outcomesPublic health versus risk of harm for individualsEmploying the necessary human resources versus relying on volunteersAchieving long-term success versus containing costs in the short-termProactive prevention versus reactive medical interventions.What Nepal needs to meet its 2030 TB target, contained in the Sustainable Development Goals, is a person-centred public health and sustainability mindset. This is not an oxymoron. We need to keep the big picture in mind so that the 10,000 missing Nepali TB patients like Ram can be identified and treated. Only then can we work towards ending the TB epidemic.Olivia Biermann of the Karolinska Institutet in Stockholm used to work for the WHO and is researching health systems and policy in low- and middle-income countries.  Read also:<a href="http://archive.nepalitimes.com/news.php?id=17747#.XUwP8_IzaUl" target="_blank" rel="noopener">Game change in Tuberculosis</a>, Buddha Basnyat<a href="https://archive.nepalitimes.com/page/resistance-to-live-saving-drugs-threatens-to-set-back-progress-in-nepal" target="_blank" rel="noopener">The return of microbes</a>, Sunir Pandey

Nepal TB cases grossly underestimated

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110811118/636a2ab39c7e80680e04592fjpeg.jpg" alt="" width="1400" height="933"/><figcaption>TB OR NOT TB: Birat Nepal Medical Trust team in Hetauda on Wednesdady used the Holi festival to raise awareness about tuberculosis in Nepal. Photo: Antonio Beltrán Rodríguez</figcaption></figure>Tuberculosis killed 33 million people worldwide between 2000-2015, more than the entire population of Nepal. The infection still kills three people every minute all over the world, and 11 Nepalis a day. This perfectly curable medieval disease is the <a href="https://www.nepalitimes.com/banner/tb/" target="_blank" rel="noopener">biggest infectious killer</a> in the world today, more than HIV or malaria. In sharp contrast, <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/ebola-in-asia,1764" target="_blank" rel="noopener">Ebola</a>, which receives far more media coverage, killed only four people in 2017.Read also:<a href="https://www.nepalitimes.com/editorial/tb-or-not-tb/" target="_blank" rel="noopener">TB or not TB</a>, Editorial<a href="https://www.nepalitimes.com/banner/tb/" target="_blank" rel="noopener">TB</a>, Sonia Awale<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110811118/636a2ab69c7e80680e045930jpeg.jpg" alt="" width="800" height="702">World Tuberculosis Day on 24 March is an opportunity for governments to renew efforts to control this devastating disease. More than 40% of the world’s TB cases occur in South Asia. While much research and funding focuses on HIV-associated TB and <a href="https://archive.nepalitimes.com/page/resistance-to-live-saving-drugs-threatens-to-set-back-progress-in-nepal" target="_blank" rel="noopener">multi-drug resistant (MDR) TB</a> in sub-Saharan Africa, HIV infected individuals make up only 9% of global TB cases and less than 1% had MDR TB in 2017. Despite a huge sample size, there is a lack of research on TB in South Asia, particularly India, and on cases not associated with HIV. If nothing is done, TB will cost another 28 million lives in the next 10 years.These shocking figures may seem like numbing statistics, but at an emotional level in Nepal, we all know people, including many family members, who have suffered and died of TB. Many readers also may have suffered from TB, and fortunately have been cured. <a href="https://www.nepalitimes.com/editorial/tb-or-not-tb/" target="_blank" rel="noopener">Tuberculosis</a> is so rampant in South Asia that every working day, clinicians struggle with the question in any random patient: Is this TB? This is in sharp contrast to the western world where TB is essentially a biblical disease.While Nepal is a role model in the community-based DOTS (directly observed treatment short course) treatment, which ensures index patients are taking their medicines, this alone will not suffice in the battle against TB, since a patient would often have already infected others in the household and workplace. Which is why active case finding and early treatment is the key. But tragically there is massive under-reporting -- Nepal gets over 40,000 new cases of TB a year with over 4,000 deaths, but many do not get diagnosis and treatment due to lack of resources for TB control.The first ever prevalence survey for TB in Nepal is currently underway, and preliminary findings show a substantial increase in the estimate of total TB cases in the country. This would be consistent with the results of other prevalence surveys in the region, which have all demonstrated that the burden of TB has been substantially underestimated in South Asia. For example, evaluation of data from multiple sources in India showed an increase of more than 80% in the estimated incident TB cases from 1.6 million to 2.9 million in 2014. Although better than DOTS, just active case finding and treatment will not be enough to bring TB under control.This is where George Comstock’s work becomes relevant in Nepal and South Asia. In the 1950-60s this epidemiologist worked with the largely Inuit population in the town of Bethel in Alaska. He determined that, although patients and their household contacts were being treated properly, the rates of TB in the community was not declining as predicted. He felt that unless latent TB infection was treated, the TB organism ‘pool’ would continue to perpetuate the disease. Many people who are exposed to the tuberculosis organism will just have an infection, that is latent TB, without any symptoms.Comstock started treating latent TB infections with one drug (isoniazid) which, sure enough, brought down TB cases in Bethel. Since then, multiple studies all over the world have shown that treating latent TB infection this way helps substantially decrease the TB pool in the community and make a resounding impact in the control of TB. Indeed, this is how TB has been nearly removed from many poor communities in the West. For many reasons, including financial and perceived concerns of isoniazid’s liver toxicity, Comstock’s game plan has never been taken seriously in South Asia. It is time we change this and replicated the strategy.In 2018, the World Health Organization (WHO) emphasised treatment of latent TB in high incidence countries. This will be a game-changer in Nepal, besides the <a href="http://archive.nepalitimes.com/news.php?id=17747#.XJN9YyIzaUk" target="_blank" rel="noopener">highly efficient Gene Xpert machine</a> used for active case finding. By decreasing the pool of tuberculosis patients, we have a chance to meet the lofty <a href="https://www.who.int/tb/post2015_strategy/en/" target="_blank" rel="noopener">WHO END TB strategy</a> of reducing global incidence by 90% and deaths from TB by 95% by 2035. But even these targets only represent a reduction in TB to the levels seen in developed western nations today, not elimination.These targets are not achievable unless there is a dramatic escalation in TB control efforts and a significant paradigm shift in our approach. To attain the target, the annual decline in global TB incidence rates must accelerate from 2% per year in 2015 to approximately 17%  per year by 2025. This requires the deployment of George Comstock’s strategy to act now, and to observe this year’s TB Day slogan ‘It is time for action’.Buddha Basnyat is a physician at Patan Hospital and Max Caws is with the Britain Nepal Medical Trust in Kathmandu.

For Nepal, a game-changer in TB control

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107171136/636934889c7e80680e03dfffjpeg.jpg" alt="" width="1400" height="700"/><figcaption>Photo: UNICEF</figcaption></figure>Polio eradication is one of the most ambitious public health initiatives undertaken in human history. Launched in 1988 by the World Health Organization (WHO) the campaign aimed to rid the world of the virus by 2000. But 30 years on and $15 billion later, even though polio cases worldwide have been reduced by 99%, there are still isolated pockets of the disease. And unless every last case is removed, there will always a chance that the infection will come back.Encouraged by the eradication of small pox, WHO launched the campaign in 1988. The organisation debated the wisdom of spending so much time and money to exterminate a disease when there were many other more pressing health concerns like <a href="http://malaria https://www.nepalitimes.com/here-now/the-mosquito-that-changed-nepals-history/" target="_blank" rel="noopener">malaria</a>, <a href="https://www.nepalitimes.com/banner/tb/ or diarrhoea" target="_blank" rel="noopener">TB</a> or diarrhoea that kill many more people.https://www.youtube.com/watch?v=KQd_-6W_9Gg&amp;feature=youtu.beThomas Abraham, a journalist who taught health reporting at the University of Hong Kong, has tried to answer this and other questions in his new book <a href="https://www.amazon.co.uk/Polio-Odyssey-Eradication-Thomas-Abraham/dp/1849049564" target="_blank" rel="noopener">Polio: The Odyssey of Eradication</a>. He says polio was held hostage by geopolitics, and traces the reason why countries opted for a weak vaccine against a strong virus. The author concludes that future global campaigns that zero in on just one disease must be weighed against the necessity of upgrading public health, especially in poorer countries.In Nepal, indigenous <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/Bouncing-back-higher-wheelchair-basketball,3802" target="_blank" rel="noopener">polio</a> was eliminated in 2000 after the country responded to WHO’s eradication goal by adding polio to its successful campaign of vaccination against other diseases. However, there were still polio cases in Nepal brought over the border from India. The last case of polio was detected in Rautahat district in 2010, and <a href="http://archive.nepalitimes.com/blogs/thebrief/2014/03/28/polio-free-nepal/" target="_blank" rel="noopener">Nepal was finally declared polio free</a> four years later.In response to a query from Nepali Times this week, however, Abraham said Nepal is not out of the woods yet. “If polio re-emerges in India, particularly UP and Bihar, this would be a major challenge to Nepal,” he said. “Also, if levels of routine childhood immunisation fall in Nepal there is a danger of outbreaks of vaccine derived polio, as we are seeing in a number of countries.”Even though polio has been largely removed, there are still cases in Pakistan, Afghanistan and Nigeria where vaccination campaigns have been thwarted by religious extremists. Ironically, enmity between India and Pakistan and the heavily guarded border between the two countries has minimised the risk of polio spreading via India to Nepal.Polio derived from oral vaccines has emerged as a new threat to the eradication campaign. By 2016, WHO deployed a combination of Inactivated Polio Virus (Salk vaccine) and bivalent oral vaccine to prevent further outbreaks.“Routine immunisation levels need to remain high in order to maintain Nepal’s polio-free status. Luckily, we have a strong disease surveillance system to detect any new polio cases,” said Jhalak Sharma Gautam of the Department of Health Services.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107171136/6369348b9c7e80680e03e000jpeg.jpg" alt="" width="640" height="869"><figcaption> </figcaption></figure><a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="http://archive.nepalitimes.com/news.php?id=16116#.W_aWJTgzaUk" target="_blank" rel="noopener">Polio</a> is one of the oldest diseases to afflict humans, but it wasn’t until the beginning of 20thcentury that there were outbreaks in Europe, North America and Australia. US President Franklin D Roosevelt was paralysed by poliomyelitis, and because of this the US threw considerable political influence and funds to back polio vaccine research.The first was the Salk vaccine that used inactivated poliovirus, and protected individuals injected with right dose, but it did not stop the transfer of the disease. The Sabin vaccine in 1961 employed a weakened poliovirus to be administered orally. It was cheaper and easier to use and protected individuals from paralysis as well as stopped polio transmission, which eventually led to it being chosen as a tool of eradication.Despite its success, the Global Polio Eradication campaign has been criticised for its huge cost and for widening the gap between local health needs and global health programs. In his book, Abraham puts his experience as a foreign correspondent to good use by visiting the frontlines of the battle against polio in Pakistan, India and Nigeria. He writes about the <a href="https://www.nytimes.com/2018/01/22/health/polio-pakistan-killing.html" target="_blank" rel="noopener">assassinations of polio vaccinators in Pakistan</a> and Afghanistan by the Taliban.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107171136/6369348e9c7e80680e03e001jpeg.jpg" alt="" width="1250" height="441">A considerable portion of the book deals with a long-standing debate about whether targeting a single disease for eradication should take precedence over strengthening national health systems. This resonates with WHO’s own reluctance to endorse polio eradication for a long time in favour of a strong primary health care system.This book is a recommended read for public health professionals, but it has lessons for anyone who wants to better understand the inner workings of health systems, donor agency priorities, and what goes on behind the scenes in Geneva.Abraham is neither an epidemiologist nor a medical practitioner, he is a journalist with over 25 years of experience covering conflict, politics and health. Maybe that is why the book reads more like a thriller with an engaging real-life account of what goes right (and what can go wrong) in the fight against a disease-causing pathogen.Read also:<a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/Bouncing-back-higher-wheelchair-basketball,3802" target="_blank" rel="noopener">Bouncing back</a>, Shreejana Shrestha<a href="http://archive.nepalitimes.com/news.php?id=16116#.W_aWJTgzaUk" target="_blank" rel="noopener">Laxmi dreams of flying</a>, Rupa Joshi

Polio hunt

Born in Khandbari in eastern Nepal, Parashuram Pathak helped his family around the farm, sold what they grew in the market and lent a hand in the kitchen.&nbsp; After working as a chef in Dubai, San Francisco, Denmark, Australia, and on cruise ships, Pathak has now brought back what he has learnt to the Tusa Restaurant in Bhaktapur that opened on Nepali New Year on 13 April. Tusa uses fresh indigenous ingredients from various parts of Nepal, and fuses them with international methods to produce unique dishes. Pathak is a global Nepali, and is introducing global Nepali cuisine to his homeland. Pathak left an executive chef job to intern at three-Michelin-starred Noma in Denmark, named the best restaurant in the world five times. Noma runs on a philosophy of foraging to rediscover wild local ingredients, and Tusa’s mission is similarly noble: preparing dishes with Nepali ingredients using modern techniques and equipment. “We are taking Nepali food beyond dal-bhat and momo, we are taking it international,” Pathak said on the phone from Sydney. Read also: <a href="https://nepalitimes.com/here-now/nepali-baker-rises-to-the-top-in-denmark">Denmark’s best baker is a Nepali</a>, Vishad Onta  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240419180424_1312bc016cbb2fe59c6d4a78d1f8b463af4a10b3f79559a2405fd54ea5b3197a.jpg" data-media-id="editor_1" data-image-id="20240419180424_1312bc016cbb2fe59c6d4a78d1f8b463af4a10b3f79559a2405fd54ea5b3197a" data-rendition-name="original" width="801" height="802" loading="lazy" alt="The return of the natives Page 12 NT #1208"> <figcaption>Photo: PARASHURAM PATHAK/FACEBOOK</figcaption> </figure>  Pathak’s team in Nepal includes chefs Rupesh Bohara and Sagar Shrestha who have also worked extensively in Dubai and Australia, and share his vision. The three realised they shared the same dream, and over the past five years have travelled across Nepal to research their menu, collecting ingredients and ideas from homestays, food carts, and nature. The team then scouted for Nepal’s best architect, and zeroed in on Bhaktapur-based heritage conservationist Rabindra Puri who designed the Malla-era house for Tusa in the Nag Pokhari neighbourhood. Bohara and Shrestha have moved back to Nepal for good, and Pathak arrives in September. “I made dishes from all over the world, but when someone asked what Nepali food was like, I had no answer,” says Bohara, “I came back to find out.” &nbsp;“You can get citizenship, a green card, big houses and cars, but where is the self-satisfaction?” asks Shrestha, who has a red-and-blue chef’s knife with the sun and moon of the Nepali flag tattooed on his right forearm.&nbsp; Read also:<a href="https://nepalitimes.com/diaspora-diaries/the-return-of-a-master-baker"> The return of a master baker</a>, Raju Pakhrin  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240419180424_c601264463e5a28d4e71a46781f340a53619a08d00949a7aaebfef84e75a319d.jpg" data-media-id="editor_3" data-image-id="20240419180424_c601264463e5a28d4e71a46781f340a53619a08d00949a7aaebfef84e75a319d" data-rendition-name="original" width="6000" height="4000" loading="lazy" alt="The return of the natives Page 12 NT #1208"> <figcaption>Photos: TUSA</figcaption> </figure>  Bohara and Shrestha passionately recount stories of their trips across Nepal, speaking of generous lodge owners who introduced them to local ingredients. Tusa can seat 28, and dining here is a sensory experience with a live kitchen. The chefs cook and place dishes on a large granite countertop with induction sections built in. Behind the counter is a grill on an indoor fire with pulley control to adjust the fire. Everything that can be made in Nepal — chairs and tables, ceramic dishes, the grill — is locally sourced. The executive kitchen/laboratory is downstairs. It is spacious, spotless, and contains appliances rarely seen in restaurants here: a sous vide machine that cooks vacuum-sealed packets at consistent temperatures, and a dehydrator for sisnu nettles. A fresh batch of deep purple kimbu (mulberry) muffins has just come out of the oven. Fridges have dry-aged fish and marigold kombucha. Fermentation seems to be the theme at Tusa, and Pathak explained: “Fermentation takes away the natural sugars in food, leaving behind a true, umami taste.”&nbsp; Read also: <a href="https://nepalitimes.com/here-now/vikings-khukri-passion">Viking's khukri passion</a>, Alisha Sijapati  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240419180424_c59e2b4230864f646bc36108adb951e95ec85da6156740294b1ec715b86acf89.jpg" data-media-id="editor_5" data-image-id="20240419180424_c59e2b4230864f646bc36108adb951e95ec85da6156740294b1ec715b86acf89" data-rendition-name="original" width="5895" height="3930" loading="lazy" alt="The return of the natives Page 12 NT #1208"> </figure>  Tusa itself means ‘shoot’ in Nepali, and can be a dish of fermented bamboo shoots. The restaurant serves a tasting menu with six courses, plus surprises. It starts with a fermented potato and millet roti with charred green garlic and tomato chutney. The bread tastes like a mix of alu paratha and kodoko roti with a satisfying, mild flavour. The chefs do not show off, and overdo it. Dishes are tastefully simple and faithful, a theme that runs through the meal. The second course is a filet of fish charred on one side and placed in a broth. It is delicate and smokey, and does not mask the character of the fish.&nbsp; The next is Batuk Chukauni, a Magar dish with a lentil snack and a yoghurt-based potato achar. The batuk, made of lentil batter, is light and the chukauni has potatoes and peas. Read also: <a href="https://nepalitimes.com/here-now/money-is-not-everything-but-you-need-money-for-everything">"Money is not everything, but you need money for everything"</a>, Rohit Shrestha  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240419180424_e3f51228ff792e8d4297f81f8e67d138584e922ae035d131977494219e5e85c5.jpg" data-media-id="editor_7" data-image-id="20240419180424_e3f51228ff792e8d4297f81f8e67d138584e922ae035d131977494219e5e85c5" data-rendition-name="original" width="1333" height="1000" loading="lazy" alt="The return of the natives Page 12 NT #1208"> <figcaption>Batuk Chukauni. Photo: VISHAD ONTA</figcaption> </figure>  Next is a skewer of jackfruit with a tamarind and mustard glaze that has the texture of a slice of sausage and melts in the mouth. Then comes the first off-menu item: a steak of watermelon, glazed and grilled, tasting sweet, sour and smokey. After that a palate cleanser sorbet made with laligurans syrup adorned with a frozen candied rhododendron petal. Finally the main course: barbeque chicken and chyakla coarse corn grits. The chicken has been brined, marinated, cooked sous-vide and seared on the grill. The delicate consistency of the chicken stands out. Desert is a smooth, creamy cheesecake that uses the local juju-dhau yoghurt. And the last course is a moist, moss-green sisnu cake laced with mulberry jam and cream.&nbsp; There is nothing gimmicky about Tusa. It is the coming together of skilled Nepalis with international exposure who have mixed what they have learnt abroad with the flavours of home.&nbsp; The tasting menu is Rs3,500, and it may take some time before Nepalis develop a predilection for some of its items. The chefs are excited, vindicated, and relieved. Coming back to Nepal, uprooting successful careers abroad to take a chance on Nepal must not have been easy.&nbsp; Tusa had a soft launch on New Year’s day with Kathmandu-based diplomats. Australian Ambassador Felicity Volk was one of them, and wrote on a Facebook post: ‘Chefs who honed their skills in Australia and returned to Nepal to give back. We call it fine dining, they call it #cominghome.’ Read also: <a href="https://nepalitimes.com/multimedia/the-baker-of-barpak">The baker of Barpak</a>, Tara Aryal Pandey

The return of the natives

For a year or two after the 25 April 2015 earthquake, the residents of Kathmandu were too terrified to return to their high-rise apartments. None of them collapsed in the 7.8 disaster, but many sustained serious structural damage. &nbsp;
Fast forward nine years, and they have all but forgotten that frightful day. Kathmandu is back to building substandard structures, even as land prices drive developers to build taller.&nbsp;
With no more space to spread horizontally, Kathmandu is going vertical. But structural engineers say most of the high rises do not take into account seismicity, soil condition, construction methods, quality of raw materials, fire hazard, and search and rescue in collapsed concrete structures.
“Much of our focus since the 2015 earthquake has been on building and construction, but not as much on where we are building,” warns Sangeeta Singh, Professor of Urban Planning and Deputy Director of Centre for Disaster Studies at the Institute of Engineering.
Read also: <a href="https://nepalitimes.com/banner/in-a-disastrous-state">In a disastrous state</a>, Sonia Awale
She adds: “Kathmandu is not really suited for high-rises. We have to first test the condition of the soil, but building permits are being issued without this fundamental step.”
Kathmandu Valley is a former lakebed with soft topsoil prone to liquefaction and excessive shaking, as seen during the 1934 megaquake. Many ruptures tore up the surface in 2015. &nbsp;
During an earthquake, the rock layers below Kathmandu ring like a bell and the vibrations on the surface take between 0.5 to 2 seconds for one oscillation. Buildings also vibrate, but at different frequencies depending on their height, construction material, and arrangement of their structural components.
At five floors, the vibration period of a building is 0.5 seconds, which is the same as that for Kathmandu Valley, and this could cause more damage, says structural engineer Surya Narayan Shrestha at the National Society for Earthquake Technology - Nepal (NSET).
“Building anything that is five storeys or higher in Kathmandu needs special design and structural considerations,” says Shrestha.
Read also: <a href="https://nepalitimes.com/editorial/shaking-things-up">Shaking things up</a>, Editorial
Technologies exist to reduce seismic risk in high-rises, and these are used in earthquake-prone cities like Tokyo, Los Angeles, Jakarta or Mexico City.&nbsp;
Base isolation, for example, separates the vibration of the land and the building, reducing damage from soil-building resonance. Base isolators move and stretch under pressure, absorbing much of an earthquake's impact by reducing swaying and shaking. &nbsp;
Seismic dampers change the pattern of vibration altogether, dissipating energy as vibrations move across a structure. But these are all expensive technologies, and none of the high-rises in Kathmandu use them.
However, Nepali engineers who can help with technology transfer are working in the field in Nepal and overseas. Kathmandu’s high-rises are already very expensive, and making them seismic-resistant would be an incremental cost.
Read also: <a href="https://nepalitimes.com/opinion/comment/learning-from-jajarkot-what-we-didnt-after-2015-695vpzle">Learning from Jajarkot what we didn't after 2015</a>, Sushil Gyewali
The shape of high-rises also matters. Reinforced concrete buildings with asymmetric designs of the kind that are seen in newer structures in Kathmandu experience more torsion and shear during quakes. High-rises with regular geometry are stronger. &nbsp;&nbsp;
An even bigger concern is that of emergency evacuation and rescue in case of fire or earthquake. Kathmandu fire services do not have ladders that reach the higher floors of most new structures.
“High-rises mean more people and potentially higher casualties,” explains Shrestha. “We need immediate evacuation routes, fire escapes, emergency ladders, and fire trucks that can reach higher. Right now, safety features are voluntary and not mandatory.”
The street access, shelters, open spaces, and evacuation routes are integral to disaster preparedness and the safety of neighbourhoods and not just buildings. Most new high-rises in Kathmandu have narrow access roads.
Read also: <a href="https://nepalitimes.com/opinion/rebuilding-resilience-7-years-later">Rebuilding resilience 7 years later</a>, Anil Pokhrel
Since most of the buildings that survived the 2015 disaster were reinforced concrete structures, it fed the misconception that they are safer. But Himalayan seismologists say that if the intensity and duration of the shaking had been just a little higher, many substandard concrete structures would have collapsed.&nbsp;
And that is the final gap: Nepal’s limited expertise and equipment for search and rescue inside collapsed concrete structures. Kathmandu’s high-rises need to be better prepared for the next Big One.
“Structural safety and design were at the front and the centre after the 2015 earthquake, we also revised some building codes but we are back to square one with contractor-driven construction, especially in peri-urban areas,” says Sangeeta Singh, who is also with the National Planning Commission. “We need to monitor construction as much as design.”&nbsp;
Shrestha at NSET agrees there have been improvements in building practices in the past nine years, but adds, “We have both learnt and unlearnt lessons from 2015. The awareness hasn’t yet translated into action on safety.”
Read also: <a href="https://nepalitimes.com/here-now/lessons-not-learned-from-2015-o2etq6zu">Lessons not learned from 2015</a>, Sonia Awale

The rise of high-rises

Midway along the stretch of the ancient trade route between Tibet and India lies the Kel Tol neighbourhood. The name is derived from the original Koligrām, and it is believed the Koli people, who were originally from Rāmagrām in present-day southern Nepal near the Indian border, settled here. The Koli were the maternal ancestors of none other than the Buddha. Kel Tol is famous for the Buddhist monastic complex of Kanak Chaitya Mahāvihar, featuring the majestic two-tiered gilded temple of the white god Karunāmaya.&nbsp; This elaborately decorated courtyard is a bustling centre of the Vajrayāna sect of Buddhism, practised widely by the indigenous Newā people of Kathmandu Valley. Karunāmaya, also known as Ārya Avalokiteshwor, is defined in great detail in the 1st century CE Buddhist text Sadharmapundarikā where he liberates all sentient beings from suffering. He helps rid the eight external fears metaphorically equated with their equivalent internal states of mind: lions (pride), wild elephants (ignorance), fire (anger), snakes (jealousy), floods (attachment), imprisonment (miserliness), thieves (wrong views) and cannibals (doubt).  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240418130432_fe370cbee75003cd3eb5dccc7c3b2671630da193b0744db2aeac1bab3ff4a85c.jpg" data-media-id="editor_0" data-image-id="20240418130432_fe370cbee75003cd3eb5dccc7c3b2671630da193b0744db2aeac1bab3ff4a85c" data-rendition-name="original" width="1338" height="2000" loading="lazy" alt="Seto Machhindranath"> </figure>  In the Pancha Rakshyā Sutra, a Buddhist scripture from 200 CE, Ārya Avalokiteshwor was counted among the eight major deities. Followers of the Brāhminical god Shiva worship Ārya Avalokiteshwor as Seto Machhindranāth. For Shaivites, Machhindranāth is the Indian saint who founded the Nāth cult in the 10th century CE. He is the guru of saint Gorakhnāth. During the reign of Yakshya Malla (1428–1482 CE), a beautiful image of Ārya Avalokiteshwor was dug up by a farmer in present-day Jamal, which was then a cultivated area outside the city. The farmer, known as a Jamami (meaning the one from Jamal) took the image home for safekeeping. That night, Ārya Avalokiteshwor appeared in the farmer’s dream and told him that the proper place for him to reside is at the confluence of two rivers. The nearest confluence was at present-day Wongha (Indrachok) and the image was installed in the Kanak Chaitya Mahāvihar complex in Kel Tol near Wongha. This made it easier for city residents to pay homage to Ārya Avalokiteshwor and spread compassion. Soon, the deity came to be revered highly as Jamaleshwor, the one found in Jamal. Eventually, the name got corrupted, as happens often in Nepāl Bhāsā, to Janabahā Dyo. The courtyard where his temple is located is now popularly known as Janabahā.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240418130432_5c9b219530e400445ef4e7f64856b43e7cdb756be26d9ed4565c84044c178a7e.jpg" data-media-id="editor_1" data-image-id="20240418130432_5c9b219530e400445ef4e7f64856b43e7cdb756be26d9ed4565c84044c178a7e" data-rendition-name="original" width="2500" height="1668" loading="lazy" alt="Seto Machhindranath"> </figure>  The gilded temple of Janabahā Dyo, first built in the early 16th century CE, is adorned with wooden and metal artefacts that symbolise 108 forms of Ārya Avalokiteshwor. It stands out as the most decorated temple of its kind in Kathmandu. Today, Janabahā is a living heritage site where many ancient customs and rituals are widely practised as per Vajrayāna Buddhist tradition. Devotees throng the Janabahā Dyo shrine for daily worship and to receive Karunāmaya’s blessings. Being the compassionate one, Ārya Avalokiteshwor goes around town every year in his tall wooden chariot to allow sick and physically disabled devotees to pay homage to him from the comfort of their homes. One could say it is a door-to-door visit by the Compassionate One.&nbsp; For the pragmatic minded, the chariot festival is an annual renewal of communal harmony, validation of our ancient mathematical supremacy and demonstration of the need to keep practical skills alive, including the craft of building earthquake resilient houses.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240418130432_fc8b234ceca87dee4b99e897a485cef121fb953857fb61492a413fbfcc48360c.jpg" data-media-id="editor_2" data-image-id="20240418130432_fc8b234ceca87dee4b99e897a485cef121fb953857fb61492a413fbfcc48360c" data-rendition-name="original" width="2500" height="1667" loading="lazy" alt="Seto Machhindranath"> </figure>  The Janabahā Dyo chariot is pulled from Jamal, where his image was found by the farmer, through the historic heart of Kathmandu in a gala parade every year. The procession, accompanied by folk music ensembles and revellers, starts on the eighth day of the bright half of the month of Chaitra, and lasts up to a week (ending on Saturday this year). Hundreds of devotees pull the chariot along the streets as a way of expressing their gratitude to lord Karunāmaya for blessing them with compassion and well-being. Purna Ratna Vajrāchārya is an ordained priest who belongs to the clan responsible for taking care of Janabahā Dyo. He has been studying the design and architecture of the chariot for the past 40 years, and overseeing its construction for the past 15. He has learnt that the engineering principles of building the chariot are based on the mathematical system in which Buddhism is taught. For example, 365 pieces of wood are used in the chariot, each representing a day of the year. Each of the four wheels consist of 25 pieces of wood, totalling 100, representing completeness or fulfilment. The chariot is vertically divided into 13 sections, a parallel to the Buddhist concept of Trayodashi Bhuvana that describes the 13 steps that one must take to achieve the state of Nirvana.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240418130432_36d9964c9845f6d9a074786361fc5ab7d49138503ad162086998b731349b0ec0.jpg" data-media-id="editor_3" data-image-id="20240418130432_36d9964c9845f6d9a074786361fc5ab7d49138503ad162086998b731349b0ec0" data-rendition-name="original" width="2500" height="1668" loading="lazy" alt="Seto Machhindranath"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240418130432_2662753a9514a682ccdfd17bf05e2be3771183a68dc86b717ab67d9aad894563.jpg" data-media-id="editor_4" data-image-id="20240418130432_2662753a9514a682ccdfd17bf05e2be3771183a68dc86b717ab67d9aad894563" data-rendition-name="original" width="1668" height="2500" loading="lazy" alt="Seto Machhindranath"> </figure>  &nbsp;Exactly nine types of wood are used, which is the sum of the four base elements that make up the universe (earth, water, fire and air) and the five human senses. The height and length of the chariot is 32 arm’s length (hāt in Sanskrit), 14.8m. The number 32 represents the maximum number of auspicious and physical qualities one could possess to be considered an outstanding human being.&nbsp; Says Vajrācharya, “Observing how the chariot is built helps one learn the fundamental pillars of the Buddha’s teachings, and find an easier path to Nirvana.” The structural design of the nearly 15m wooden chariot is not only awe-inspiring but also gravity-defying. It leverages the pliancy of the materials used in its construction -- flexible joints tied with cane soaked in water for several days. The precise proportions of the chariot ensure great manoeuverability in the narrow streets along the route of the chariot procession that include some 90° bends, without colliding into houses.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240418130432_9f5c2943f5d6b3f0010d3d5213697549945e87a6f7d3d8cbadd69f0dea6c6e2c.jpg" data-media-id="editor_5" data-image-id="20240418130432_9f5c2943f5d6b3f0010d3d5213697549945e87a6f7d3d8cbadd69f0dea6c6e2c" data-rendition-name="original" width="2500" height="3750" loading="lazy" alt="Seto Machhindranath"> </figure>  Driving and steering the chariot with brute muscle power of the mirthful crowd is a seemingly impossible task. But this has been achieved year after year, despite the fact that the devotees who tug wildly at the ropes lassoed to the two front wheels, are most likely in high-spirits (pun intended). Sanjay Manandhar, a US-based technology entrepreneur, recounts how his high school physics teacher from Canada asked his students to go observe the locals build the chariots of Karunāmaya if they were interested in becoming engineers in the future.&nbsp; “That made no sense to me then, but, after all these decades, I now see clearly how the structural design of the chariot, adopted early on by our ancestors is full of earthquake-resilient properties that need to be applied in building houses in an earthquake-prone zone like Nepal,” says Manandhar. A highlight of the chariot festival is that human goddess Kumari makes an appearance at the final destination in Lagan, usually on the third day. This is only one of the 13 times that people get to see the Kumari outside her temple abode.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240418130432_08aa39f3f004a212b33c60a2840d6013110de15dd34a0288f699dd5fda8957ab.jpg" data-media-id="editor_6" data-image-id="20240418130432_08aa39f3f004a212b33c60a2840d6013110de15dd34a0288f699dd5fda8957ab" data-rendition-name="original" width="2500" height="1667" loading="lazy" alt="Seto Machhindranath"> </figure>  On the last day of the festival (Saturday), the image of lord Karunāmaya is carried on a palanquin by priests from Janabahā in a gala procession and brought back to his permanent residence at the temple in Kel Tol.&nbsp; The chariot festival is thought to have started during the reign of King Pratap Malla of Kantipur in the 17th century CE. For close to four centuries, the construction of the chariot and its operation has proven to be a phenomenal engineering feat, and the people’s faith in divinity means the tradition is alive.&nbsp; The essence of the colourful rituals and the religious beliefs of this ancient chariot festival is now all but lost. The logic, technology and practicality must be brought back to light, as they reflect the high civilisation and wisdom of our ancestors that we can leverage in modern times and into the future. &nbsp; Alok Tuladhar is a culture and heritage documentarian.

Kathmandu’s gravity-defying chariot festival

In the run-up to the third Nepal Investment Summit this weekend, there have been seminars, conferences and workshops where the discourse has revolved around the economy and the investment climate.
The consensus that Nepal needs foreign direct investments (FDI) to grow was repeated, and the familiar litany of reasons about why it has not been able to was discussed.&nbsp;
Policy advocates and regulators have understood that the lack of urgency is compounded by procedural inconsistencies, on top of the already deficient investment environment in the country.
It is a welcome change from what used to be flippantly accepting matters as given. There now seems to be a sense of urgency, with procedural inconsistencies and lack of harmonisation between various Acts and regulations openly discussed.&nbsp;
Government stakeholders also appear more willing to learn and attempt to be part of the solution. Whatever policy changes have been introduced in the past have been piecemeal and address the few rather than the entire industry. This left dual regulatory approaches aimed at similar players.&nbsp;
Read also: <a href="https://nepalitimes.com/opinion/killing-investment-in-nepal-in-10-easy-steps">Killing investment in Nepal in 10 easy steps</a>, Dibesh Karmacharya
This time, unlike in the past two Summits, the government seems to be committed to amending 9 Acts, a positive step towards showing commitment to change. However, the deadline to do so during the winter session of Parliament is over. The option mooted has been to have it passed through ordinance, a lesser appealing step; albeit, a positive one moving forward.&nbsp;
To attract FDI in a competitive global market means that Nepal has to demonstrate that it is serious about bringing in investments with a more consultative and collaborative approach with investors. A departure from procedural to a result-oriented focus is needed.&nbsp;
To put issues in perspective, Nepal needs US$20 billion in investments to meet the UN’s Sustainable Development Goals (SDG) targets by 2030. If net-zero decarbonisation targets are to be met by 2045, another US$7 billion will be required annually.&nbsp;
Looking at our investment history and poor government capital expenditure, the gap is long and wide. In fiscal year 2022-23 Nepal booked a lamentable ~$59 million in FDI (equity). Nepal is in fact the lowest market in South Asia for FDI with 0.3% of the regional average.&nbsp;
What is it that we can do to fill the gap?&nbsp;
First, we need to move away from the notion that Nepal only needs large investments. This has proven to be a mistake, and time series data have proven that smaller investments, in aggregate, make a larger impact on economies.&nbsp;
Read also: <a href="https://nepalitimes.com/news/poor-cash-rich-nepal">Poor cash-rich Nepal</a>, Sonia Awale
We talk about an ‘enabling environment’ but without the right tools. We place restrictions on interest on debt ceiling (SOFR +5.5), without risk premium adjustments, we do not have an active secondary market for bond trading, nor do we have a yield curve, an integral part of the bond market, which is inhibiting us from tapping into the trillion dollar green bond market.&nbsp;
In order to attract green financing, Nepal needs to develop its bond market. Sovereign risk rating has been mooted and was expected to be operationalised before the Investment Summit.&nbsp;
However, to be rated in an adverse economic environment could further deteriorate investment potential due to a lesser-than-expected rating.&nbsp;
Hedging is another instrument that needs further research on. A commercial bank last year showcased the first risk-hedging mechanism for an investment of $8 million. This can be the beginning to expand on its modality. &nbsp;
Subordinated debt instruments have been introduced, but on a special nod basis, this now needs to be institutionalised as it is the most applicable form of investment after equity in a market that has volatile forex reserves.&nbsp;
Read also: <a href="https://nepalitimes.com/editorial/invest-in-investment">Invest in investment</a>, Nepali Times
Viability Gap Funding has been introduced by multilateral development agencies implemented in solar installations. It is a tool to incentivise the private sector to invest in projects that are not financially lucrative initially, but have potential for profitability in the long run. This needs to be scaled up and replicated in sectors like infrastructure, where returns may not be immediate.
Moving forward, to attract FDI, Nepal needs to tap into the funds that are available for the growth of small and medium enterprises (SMEs) and climate change. Alternative investments such as Private Equity Venture Capital (PEVC) have been around in a structured manner in Nepal for nearly a decade now.
These funds have blended finance components and have attracted climate funding as well. PEVC is a new asset class and can address the issues of penetrating into SME financing by incorporating environment, social and governance issues into their investment process.&nbsp;
SMEs are the backbone of any economy, PEVC comes with the ability not only to scale up the enterprise with risk capital, but with the ability to bring technical knowhow to enhance not only the enterprise but also the entrepreneur.&nbsp;
Read also: <a href="https://nepalitimes.com/opinion/success-in-nepal-means-not-having-to-work">Success in Nepal means not having to work</a>, Anil Chitrakar
A differentiator from all other forms of financing available till date in Nepal. Blended finance is a way of de-risking investments, especially in frontier markets. Business Oxygen (BO2) is an example of blended finance with subordinated debt investments of IFC (World Bank Group) taking the lead and Climate Investment Funds along with FCDO as co-investors.&nbsp;
On a larger scale, the 216MW Upper Trisuli 1 is another example of blended finance with IFC, a Korean consortium and local investments. So far, we see that development finance Institutions have been taking the lead in Nepal as their risk appetite is greater than commercial investors and they are eager to help develop the financial markets.&nbsp;
In order to be sustainable, we need to step on this and attract commercial capital from all over the world. To do this there has to be political will to make that pivot.&nbsp;
Instead of being a means to an end, the two previous Investment Summits turned out to be intermittent and cosmetic, providing hardly any results. The third one’s success will depend on how the event will be implemented as a platform for continuous marketing for the country and facilitation for investors in future.&nbsp;
Nepal has outdone many countries in its macro-economic indicators, with sound forex reserves and a stellar history of debt payments to its creditors. This story needs to be propagated along with the drive for change to attract potential investors.
Read also: <a href="https://nepalitimes.com/opinion/comment/alternative-investments-to-attract-fdi">Alternative investments to attract FDI</a>, Siddhant Raj Pandey

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