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 width="1236" height="856" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85a09c7e80680e067804jpeg.jpg" alt=""/><figcaption>Photo: AMIT MACHAMASI</figcaption></figure><h2>1. Oxygen</h2> To save lives, Nepal’s most urgent need now is oxygen. Not just cylinders, but oxygen generators, concentrators and liquid oxygen. Most infected people are not succumbing to Covid-19, they are <a href="https://www.nepalitimes.com/here-now/helping-nepalis-breathe-again/" target="_blank" rel="noopener noreferrer">dying because of low oxygen saturation</a> in the blood, and lack of hospital beds -- patients who need not have died of coronavirus. Dire as the situation is in the cities, Nepal’s pandemic has now <a href="https://www.nepalitimes.com/editorial/nepals-humanitarian-emergency/" target="_blank" rel="noopener noreferrer">infiltrated the remotest villages</a> where there is no hospital care and no oxygen. The virus is preying on people already suffering malnutrition, previous ailments, and decades of structural state neglect. In Rolpa, Humla and other remote districts, between 80-90% of PCR tests are coming back positive, and it takes a week to get results. Patients are either not isolating, or not following precautions.Kathmandu's doctor-to-patient ratio is 1:850, but in rural Nepal it is one doctor for every 15,000 people, and hospitals and medical staff there <a href="https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/" target="_blank" rel="noopener noreferrer">are already overstretched</a>.Close to 60% of all swabs collected nationwide are from Bagmati Province, with nearly half of them in Kathmandu Valley, says epidemiologist Lhamu Yangchen Sherpa. She adds: “There just aren’t enough tests and contact tracing is minimal, official total cases and fatalities are grossly underestimated.” <figure><img width="1497" height="746" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85a39c7e80680e067805jpeg.jpg" alt=""><figcaption> </figcaption></figure><figure><img width="984" height="519" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85a69c7e80680e067806jpeg.jpg" alt=""><figcaption> </figcaption></figure>Hospitals in Kathmandu Valley with roof helipads have multiple daily rescue flights, but even these facilities are <a href="https://www.nepalitimes.com/banner/we-knew-the-tsunami-was-approaching/" target="_blank" rel="noopener noreferrer">at breaking point</a> with patients being turned away. Understaffed and under-equipped hospitals in the districts do not stand a chance. Even where hospitals exist, many families avoid them for fear of being infected and take wrong medication from pharmacies.Case in point are recent deaths due to misdiagnosis across the country. <a href="https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/" target="_blank" rel="noopener noreferrer">Typhoid disease</a> simulates Covid-19 with similar symptoms, and the widespread Widal test is known to give false positives.“Covid patients are being prescribed antibiotics to fight typhoid, only to turn critically ill in a few days’ time,” says Buddha Basnyat of Patan Academy of Health Sciences. “This is the reason behind some of the latest Covid fatalities.” <figure><img width="1280" height="720" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85a89c7e80680e067807jpeg.jpg" alt=""><figcaption> </figcaption></figure>As in India, Nepal is beginning to see a slight bending of the curve for new infections, but health experts expect the fatality rate to remain high for some more time.  There were 190 Covid deaths in the past 24 hours and 6,543 recoveries. Of the total 8,305 new cases on Thursday, Kathmandu Valley accounts for 3,232 infections. 7,814 people are undergoing treatment in hospitals with 1,748 in ICU and 492 in ventilator support. “After the relentless patient pressure of the past month, we have seen a decline in those requiring admissions,” says virologist at Teku hospital Sher Bahadur Pun. “The virus has now infected a majority of people in the cities, and this combined with the lockdown means we may be getting to the halfway mark of the second wave.” <h2>2. Vaccines</h2> A prolonged lockdown is not the answer. If it was, the <a href="https://www.nepalitimes.com/latest/covid-19-numbers-slightly-down-in-nepal/" target="_blank" rel="noopener noreferrer">reduction in the number of cases and the positivity rate</a> this week would have been steeper. Even while the government tries to increase oxygen supply to hospitals, the only long-term strategy is to vaccinate at least 70% of Nepal’s eligible population.Doctors report a marked difference between the recovery of people who are vaccinated against those who are not. Says virologist Pun at Teku Hospital: “Except for a few rare cases, all patients in critical condition and those dying are the ones who for one reason or another had not been vaccinated.”But Nepal has run out of its vaccine stock, leaving 1.4 million people still waiting for their second dose of AstraZeneca Covishield in a lurch, after India banned its export, and the COVAX Facility could not supply its remaining 1.8 million vaccines to Nepal because of the global supply bottleneck.  <figure><img width="1440" height="1080" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85ac9c7e80680e067808jpeg.jpg" alt=""><figcaption> </figcaption></figure>The Nepal government and pressure groups in Nepal and the United States <a href="https://www.nepalitimes.com/here-now/nepal-needs-urgent-american-vaccine-support/" target="_blank" rel="noopener noreferrer">have strongly urged the Biden administration</a> to immediately rush some of its AstraZeneca doses to Nepal.Meanwhile, the UK, the US and Canada have authorised vaccines for use in children and adolescents, sparking outrage in the global public health community for prioritising an age group that is rarely critically affected by Covid-19. The World Health Organisation’s director-general Tedros Adhanom Ghebreyesus has urged rich countries to instead donate doses to the <a href="https://www.nepalitimes.com/latest/unicef-urges-g7-to-dispatch-vaccines/" target="_blank" rel="noopener noreferrer">COVAX Facility</a> for poorer states that have barely covered health workers and the most vulnerable groups. Speaking at the British Parliament last week, noted vaccinologist and the principal researcher of Oxford University’s AstraZeneca vaccine, Andrew Pollard, called the decision to inoculate children in wealthy nations ahead of high-risk groups in poorer countries “morally wrong.” Pollard has worked extensively in the region, leading research into the burden and transmission of typhoid in Nepal, Bangladesh and Malawi, and the impact of typhoid vaccine in these areas. He also runs surveillance for invasive bacterial diseases, and studies the impact of pneumococcal vaccines in children in Nepal.In Nepal, vaccination will grind to a halt this week after the current campaign to inoculate 300,000 people in the 18-59 age group with their second dose of the Chinese VeroCell ends.  <figure><img width="960" height="640" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85af9c7e80680e067809jpeg.jpg" alt=""><figcaption> </figcaption></figure><img width="960" height="640" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85b29c7e80680e06780ajpeg.jpg" alt=""><img width="960" height="639" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85b49c7e80680e06780bjpeg.jpg" alt="">Although <a href="https://www.nepalitimes.com/here-now/nepal-is-a-priority-for-vaccine-shipments/" target="_blank" rel="noopener noreferrer">Foreign Minister Pradeep Gyawali says</a> the government is in “final negotiations” for 2 million doses of Sinopharm VeroCell vaccines by June, there is no movement at the Ministry of Health. Ongoing talks to procure 8 million doses of <a href="https://www.nepalitimes.com/opinion/vaccine-geo-politics-and-sputnik-v/" target="_blank" rel="noopener noreferrer">the Sputnik V</a> have hit a production capacity snag in Russia. “We can implement lockdowns only for so long, the only exit strategy is vaccines. Science delivered, now our politicians must do the same,” says Buddha Basnyat, a physical at the Patan Academy of Health Sciences. “The Nepal government must procure vaccines using every diplomatic channel possible, and rich countries must realise that they are not safe until countries like Nepal are also vaccinated.” Activists have been trying to convince <a href="https://www.nepalitimes.com/latest/leading-public-figures-call-on-uk-government-for-oxygen-for-nepal/" target="_blank" rel="noopener noreferrer">the US government and Europeans</a> that Nepal has a lot of experience in successful vaccination campaigns against polio, smallpox, measles. It has over 50,000 female community health volunteers (FCHVs) reaching children with vaccines every year.  <figure><img width="1024" height="768" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85b79c7e80680e06780cjpeg.jpg" alt=""><figcaption> </figcaption></figure><img width="2048" height="943" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85ba9c7e80680e06780djpeg.jpg" alt=""><img width="1920" height="864" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85bd9c7e80680e06780ejpeg.jpg" alt="">Similarly, Nepal’s health system has amassed vast experience in maintaining the vaccine cold chain even in the remote mountains. It also has trained human resource overseeing DOTS (Directly Observed Therapy, Short-course) for tuberculosis management all over the country who can lend a hand in equitable distribution of vaccines in <a href="https://www.nepalitimes.com/latest/rural-nepal-fights-back-covid-19/" target="_blank" rel="noopener noreferrer">rural Nepal</a>.Says epidemiologist Lhamo Yangchen Sherpa: “It’s not too late, we can still use existing resources like FCHVs to better mobilise vaccination, conduct contact tracing, dispel any remaining vaccine hesitancy, and use public health professionals in prevention.”

It’s an Emergency

<figure><img width="1400" height="933" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110111156/636cd9779c7e80680e092ea0jpeg.jpg" alt=""/><figcaption>Photo: SONIA AWALE</figcaption></figure>Sabina Magar lost her job at a brick kiln during the Covid-19 lockdown. The 28-year-old, a single mother raising two young children, was faced with uncertainty. To make matters worse, she had a fever, began to lose weight rapidly and found herself constantly bed-ridden, without an appetite. When she started to cough up blood, she dragged herself to a hospital in her village in Piuthan. She was diagnosed with tuberculosis.Tuberculosis (TB) is a common ailment in Nepal. This perfectly curable medieval disease, still kills at least 6,000 Nepalis a year. TB is in fact the biggest infectious disease worldwide, with 10 million new cases and causing 1.5 million deaths annually.TB has been traditionally difficult to diagnose. Despite free screening and medications, poor people in rural parts cannot afford to visit health centres and hospitals in district headquarters, leading to gross underestimation of TB cases in Nepal.A 2018 survey by the National Tuberculosis Control Center revealed that close to 70,000 Nepalis contract the infection every year, much higher than previously estimated.The Covid-19 pandemic has further exacerbated the situation. Nationwide lockdowns and restricted mobility meant that in lack of screening, many people went undiagnosed and patients like Magar had harder time accessing free medications.Delayed diagnosis and subsequent treatment of TB translates into enduring health impact from permanently damaged lungs. This in turn increases their risk of contracting the coronavirus.On the flipside, safety measures taken to contain the spread of Covid-19 such as wearing masks and handwashing can significantly reduce tuberculosis infection as every other Nepali is a carrier.<a href="https://www.nepalitimes.com/banner/tb/">TB</a>, Sonia AwaleMagar could not take nutritious food to regain her health because of the lack of income, making her recovery difficult.On the other hand, the standard Observed Treatment, Short-course (DOTS) requires medical supervision of the administration of antibiotic treatment to patients. This is fraught with challenges because it means travelling long distance to the health centres during which patients can continue to spread the disease. People are also worried about being stigmatised as TB patients and hence visit distant hospitals, walking for hours along the abandoned forest trails.TB and Covid-19 also have a synergistic impact on economic conditions, mental health and social life. While the coronavirus is a new disease and spread rapidly by a virus, TB is one of the oldest diseases known to mankind and a ‘slow’ pandemic caused by a bacillus.TB and Covid-19 disproportionately affect women, children, elderly and people living below the poverty line.At the same time, the response to the pandemic has overloaded Nepal's under-resourced health system. It has set back years of hard-earned gains against other infections. So how do we guarantee free and easy access to TB services during a time of crisis?The national TB program aims to diagnose all people with TB and leave no one behind. The right to free TB treatment should not be compromised at any cost, as the early diagnosis and treatment of every TB case, protects us all.Understanding the multitude of ways in which the pandemic has affected TB diagnosis and treatment in Nepal is essential to repair the damage, bring services within the reach of all the citizens and rebuild a resilient health service for the future.The lessons that we are learning from the Covid-19 response, including monitoring and the surveillance system, is an important opportunity for TB programs to develop innovative technologies for socio-culturally appropriate and people-centric care.Nepal might be a role model in the community-based DOTS, but a more active case detection method is now required. Employing GeneXpert, a more accurate diagnostic tool and introducing drones as a form of TB telemedicine might be a start.TB, is often called a medical poverty trap or disease of poverty and is a life-threatening disease for people living below the poverty line like Sabina. Due to the difficulties in completing the minimum six months of daily drugs, people also have a higher risk of incomplete treatment that allows the disease to take severe forms.Sabina, fought with the disease for her two children and trusted the benefits of taking medicines which helped to regain her damaged health. Her case is a reminder to us that health needs of people is a priority of the community.The slogan of this year’s World TB Day on 24 March ‘The clock is ticking’ prompts us to act in solidarity to take for TB prevention, diagnosis and treatment. Each one of us is responsible to achieve a TB-free future for our children.<a href="https://www.nepalitimes.com/latest/tb-patients-in-limbo-due-to-covid-19/">TB patients in limbo due to COVID-19</a>, Devika AgarwalKritika Dixit is a researcher with Britain Nepal Medical Trust (BNMT) and a doctoral student at Karolinska Institutet, Sweden. <img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110111156/636cd97a9c7e80680e092ea1jpeg.jpg" alt="" width="115" height="113">

Tackling TB amidst a pandemic

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181152/636be9a79c7e80680e0878d1jpeg.jpg" alt="" width="995" height="659"/><figcaption>Photo: NEWS MEDICAL LIFE SCIENCES</figcaption></figure>As a physician, I am at the receiving end of a lot of questions from friends and relatives about the pandemic. While some want to know about their symptoms, most questions are about <a href="https://www.nepalitimes.com/here-now/why-nepals-covid-19-figures-are-deceptive/" target="_blank" rel="noopener noreferrer">whether the number of cases in Nepal is actually going down</a>.It is hard to tell. There a lack of tracing, testing is inadequate, and record keeping is unreliable. The media carries a daily tally that is based on government figures, and they show confirmed cases have now dipped to below 1,000 per day, almost half of them in Kathmandu Valley.The Ministry of Health statistics also show that there are about 250 patients in critical care, and some 50 of them require ventilator support. If these figures are to be believed, the death rate from Covid-19 does not seem to have decreased.More worrying are reports that <a href="https://www.nepalitimes.com/banner/bala-chaturdashi-and-covid/" target="_blank" rel="noopener noreferrer">Pashupatinath now sees 80 cremations daily</a> as opposed to 30 per day at this time last year. Are some of these unidentified Covid-19 ‘excess mortality’? It is all guess work, but this more than double increase in funerals needs to be accounted for.It is indeed possible that although some of the excess mortality is due to undiagnosed Covid-19, it could very well be that the <a href="https://www.nepalitimes.com/latest/covid-19-will-get-worse-before-it-gets-better/" target="_blank" rel="noopener noreferrer">winter death rate</a> has gone up this year because people with other pre-existing conditions like cancer, cardio-vascular diseases, diabetes or kidney patients needing dialysis are not visiting hospitals for treatment. These ‘indirect’ Covid-19 deaths could be a useful research project.Despite this, there are indications that young urban Nepalis are letting their guard down. The parties during the <a href="https://www.nepalitimes.com/here-now/tying-the-knot-during-covid-19/" target="_blank" rel="noopener noreferrer">wedding season</a>, unmasked crowds at Thamel’s indoor nightclubs and concerts and the throngs in Pokhara Lakeside and Sauraha show a <a href="https://www.nepalitimes.com/banner/concerts-rallies-and-crowded-malls/" target="_blank" rel="noopener noreferrer">‘what will be will be’ attitude</a>.An affordable and effective vaccine is still some way off. Wearing a mask, preferably a N95, which serves the dual purpose of protection from SARS-CoV-2 as well as Kathmandu’s air pollution, maintaining safe distance and frequent had washing with soap and water are our ‘vaccines’ for now.Japan has important lessons for us. So far, it has kept Covid-19 death rate at the lowest by far among G7 countries by strictly following guidelines including avoiding the ‘san-mitsu’ or the 3Cs: closed spaces, crowded spaces and close contact settings.<a href="https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/">We in Nepal will be lucky</a> if a <a href="https://www.nepalitimes.com/here-now/when-will-nepals-covid-vaccine-turn-come/">vaccination</a> arrives by mid-2021. Current vaccines like Pfizer and Moderna are out of the question because of their cost and the lack of capacity to maintain the very cold storage that they require.The <a href="https://www.nepalitimes.com/opinion/glimmers-of-hope-for-nepal-on-vaccine/">Oxford University Astra Zeneca vaccine</a> that the <a href="https://www.deccanherald.com/national/serum-institute-of-indias-covid-19-vaccine-not-to-get-nod-till-uk-authorises-astrazeneca-shot-931200.html">Serum Institute of India</a> is manufacturing appears to be our best bet because it is relatively inexpensive and only requires the regular 3-6o Celsius cold chain. The good news is that the Serum Institute of India is also studying other vaccines such as an <a href="https://www.livemint.com/companies/people/intra-nasal-covid-19-vaccines-will-be-far-easier-to-deliver-kiran-mazumdar-shaw-11603681291099.html">intra-nasal vaccine</a>, which can be stored at room temperature. If effective, this would be the answer for countries like Nepal.We are awaiting published results of trials of the <a href="https://www.nepalitimes.com/latest/nepal-to-test-covid-19-test-kits-from-china/">Chinese</a> vaccine, and that could also be the answer for developing countries like <a href="https://www.nepalitimes.com/latest/90-in-poor-countries-will-miss-covid-vaccinations/">like Nepal</a>. The Chinese have an impressive track record of making vaccines, and to combat infectious diseases. For example, the inexpensive <a href="https://www.nepalitimes.com/banner/mosquitoes-move-up-mountains-as-the-earth-warms/">Japanese Encephalitis</a> vaccine made in Chengdu helped control the deadly disease in rural communities throughout Asia.This Chengdu vaccine cost less than $5, in contrast to the $100 per shot encephalitis vaccines made by Western pharmaceutical companies. The Chinese <a href="https://archive.nepalitimes.com/news.php?id=18079">Hepatitis E vaccine</a> could prevent infection and save lives of pregnant women in the Subcontinent where the virus is a scourge due to poor hygiene.TherapiesAside from vaccines, research into treatment of Covid-19 is also making progress. For example, the Recovery Trial in the UK has convincingly showed that dexamethasone, a readily available and inexpensive steroid saves lives in the treatment of moderate to severe Covid-19 patients.In all this confusion regarding treatment, however, it is equally important to note what does not work. Drugs like hydroxychloroquin do not work in the treatment of this disease, despite its false efficacy touted by Donald Trump. The <a href="https://www.who.int/nepal">World Health Organisation</a>’s Solidarity research also showed that the expensive remdesivir drug that our government was at one time handing out freely to Covid-19 patients is not very helpful, either.Reliable diagnosis of Covid-19 is important, especially in countries like Nepal as there are many other infectious diseases that may at first present with fever and cough, like tuberculosis. The PCR (polymerase chain reaction) test still remains the gold standard for Covid-19, but they are expensive and may take a day or two for the results.Antigen tests are being carried out in Nepal and can give a quick diagnosis in symptomatic individuals within 30 minutes. But they are not as accurate as the PCRs. There are other commercial brands, and some may not be as accurate as others.New variantNews of the new variant of Covid-19 reported in England and South Africa and now spreading across the globe, sound alarming. It is interesting that this new variant was discovered in the UK where a great emphasis is given to finding its chemical constituents.One of UK’s prime institutions for this is the Sanger Centre near Cambridge, with whom we at Patan Hospital also collaborated to delineate a variant of typhoid organism mutation, helping establish a new treatment strategy for typhoid in the Subcontinent in 2016.The best way to handle the new Covid-19 variant is <a href="https://www.nepalitimes.com/opinion/a-covid-19-exit-strategy-for-nepal/">continued vigilance</a> about preventive measures, especially since the mutation gives the virus the ability to spread faster. It is best to be over-prepared than under-prepared to fight this wily virus.Masking up, safe distance and hand washing are our best course of action for us to stop the pandemic in 2021 and beyond.<a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/">Buddha Basnyat</a> is a clinical researcher at Patan Academy of Health Sciences and writes Dhanvantari, a <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/">frequent health column</a> for Nepali Times.

Buddha Basnyat

Staying safe in 2021 and beyond

<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.”

Nepal anti-TB drone project awarded

<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.”

<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/20221109121116/636b8c4d9c7e80680e06b2efjpeg.jpg" alt="" width="4096" height="2730"/><figcaption>Photo: BIKRAM RAI</figcaption></figure>With no proven <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNFhARSUb8HMQP_ZJgsaTmPoQDLWvA">cure or vaccine available yet for COVID-19</a>, various treatments with no proven benefits and potential deadly side-effects are being tried out on patients.One example of a desperate treatment measure is a New York City doctor carelessly declaring on primetime tv recently that COVID-19 pneumonia was similar to <a href="https://www.nepalitimes.com/latest/high-alert/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/high-alert/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNGuDq-Ti_uWGlw-rY-q1PpyQQO54g">high altitude pulmonary edema (HAPE)</a>, and he recommended high altitude drugs like Diamox for the treatment of Covid-19.Trekkers in Nepal are familiar with <a href="http://archive.nepalitimes.com/news.php?id=19693#.Xp-oJy8w0Wo" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/news.php?id%3D19693%23.Xp-oJy8w0Wo&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNGSLnJg3LMR2gIcZz9LMdKOvruqJA">Diamox</a>, a pill they take to acclimatise better when hiking at higher altitudes. There is no scientific basis that the drug will work, but this idea of very low oxygen (hypoxia) and pneumonia in both afflictions was appealing.To counter this some of us in Nepal and other countries have a forthcoming Opinion in the British Medical Journalcautioning against this rash treatment strategy using high altitude medicines. In medicine, doctors have to remember the maxim, Primum non nocere (‘above all do no harm’).But there are some silver linings <a href="https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNGtTkAInA3D5xIkzd65kTSfDvYESg">if Nepal escapes the worst of COVID-19</a>. <a href="https://www.nepalitimes.com/banner/tb/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/tb/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNGbOqrkOzN3uP_va7u0F-uhlxipaQ">Tuberculosis</a> rates, which are very high in South Asia (more than 400 per 100,000) could go down if people continue to use the masks since it will also mean that a tuberculosis patient will not spread the bacteria, not to mention other respiratory infections.Similarly, as more people get into the habit of washing hands with soap and water where available, the rates of diseases like typhoid and hepatitis A and E, caused by fecal oral transmission, will certainly be reduced.An average of <a href="https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNHn0HGje-Tq3pDeekYbQAbhZxJOwg">230 people used to be killed every month</a> on Nepal’s highways and streets. The lockdown has now lasted a month, and that is approximately the number of lives saved due to vehicles being off the roads.The importance of public health for both the rich and poor countries has been highlighted by the pandemic. Industrialised countries had thought they had been done with infectious diseases, except perhaps the odd HIV patient. This pandemic has given great pause to that argument. Developing countries which having tried to come to grips with pre-existing epidemics have used lessons learnt in dealing with coronavirus in prevention.The Indian state of Kerala for example, has done relatively better in dealing with COVID-19 partly because it utilised prior lessons from the Nipah outbreak a year ago. Other South Asian countries with robust public health infrastructure like Sri Lanka also have a better handle on the disease.They strengthened their public health system, and it has paid rich dividends. South Korea too had an outbreak of MERS Coronavirus in 2015 which was brought by a South Korean returning from Kuwait, but they were able to effectively control the spread, and have been dealing successfully (so far) with the novel coronavirus. Singapore had been doing well, but discovered last week that it had a blind spot in the migrant workers’ dormitories. It has now announced a ‘circuit breaker’ lockdown till 1 June.South Asian countries have had more time in preparing for the contagion, while they wait for a vaccine or drugs to treat COVID-19. Treatment trials are happening all over the world even as the patients and doctors await with bated breath (pardon the pun). In all likelihood, we will soon know if chloroquin works or not before we have a vaccine.Vaccines will be a game-changer against Covid-19, and competition is heating up because whoever makes this vaccine first will be the knight-in-shining armour. China, USA, UK are probably a few of the countries engaged in developing a vaccine, and among them are researchers at Oxford University Clinical Research Unit who <a href="https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNHKJgZ_d-vQIhZ5sdehQmMT7iWvHQ">collaborated closely with Patan Academy of Health Science</a> in a recent successful typhoid vaccine study.This Oxford University group lead by Professors Sarah Gilbert and Andrew Pollard are optimistic about producing a million doses of the vaccine by autumn. The vaccine will be eventually required not in the millions, but in billions of dosages. It also has to be affordable for countries like ours.For making vaccines promptly for neglected tropical illnesses, it is hard to beat the Chinese. When <a href="http://archive.nepalitimes.com/news.php?id=19220#.Xp-nMS8w0Wo" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/news.php?id%3D19220%23.Xp-nMS8w0Wo&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNEw-YGKhD3XomMEP736r5ileoWJ3g">Japanese Encephalitis (JE)</a> was raging in China and South Asia, it was the Chinese who tested, developed and made available the ‘Chengdu vaccine’ that revolutionised the prevention of the mosquito-borne disease. The earlier vaccine was expensive and only tourists in Nepal could afford it.Similarly, when <a href="http://archive.nepalitimes.com/news.php?id=18079#.Xp-m3S8w0Wo" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/news.php?id%3D18079%23.Xp-m3S8w0Wo&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNEndZvjwlu6D0uMBXFMGO9OgvSoXg">hepatitis E</a> was a scourge in China, the Xiamen Innovax Biotech came up with a vaccine in 2012 to protect vulnerable populations. Because there is no other commercial vaccine available against hepatitis E, it will be valuable in South Asia if the virus is rampant again and affect pregnant women with a fatal outcome.Nepal clearly needs to have a strong public health infrastructure in collaboration with a prestigious institute abroad to be able to tackle COVID-19 and other infections. Just like earthquakes, there will be more pandemics in future. Humanity needs to up its game in the control of emergent infectious diseases, and Nepal can make a small contribution by helping itself, especially by strengthening public health.Buddha Basnyat is a clinical researcher at Patan Academy of Health Sciences and a <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNFhARSUb8HMQP_ZJgsaTmPoQDLWvA">frequent health columnist</a> for Nepali Times.Prevention while searching for a cur

Prevention while searching for a cure

<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109121112/636b8bc79c7e80680e06b2c0jpeg.jpg" alt="" width="2000" height="896"/>Governments in industrialised countries must not ignore the plight of poorer nations facing the coronavirus pandemic, or the disease will not be brought under control.African nations report growing numbers of cases, and more and more infections are being detected in countries with endemic poverty in Asia as testing picks. There are growing fears that developing countries could soon see major outbreaks they will not be able to cope with.A potential paralysis of <a href="https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/" target="_blank" rel="noopener">already vulnerable healthcare systems</a> would not only have a drastic impact on public health, but could also push people further into poverty and deprivation. If developed countries in Europe and North America bring COVID-19 under control, there is a threat that the disease would rage on in developing countries, with the danger that it could spread back into places like North America and Europe.<a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/" target="_blank" rel="noopener">Nepal must hope for the best, prepare for the worst</a>, Buddha Basnyat and Sudeep AdhikariRich states must keep a focus on helping other countries with weak healthcare systems, despite the fact they are fighting their own battle with the disease.“High income countries are completely consumed with what is happening in their own states, but it would be good if they could give at least some focus to poorer countries,” Amanda Glassman of the Washington-based Global Centre for Development think-tank. “If things are not brought under control in less developed countries, it could come back to hurt developed countries later on.”But while there have been <a href="https://www.nepalitimes.com/latest/could-an-anti-tb-vaccine-be-protecting-nepalis/" target="_blank" rel="noopener">far fewer registered cases of the disease</a> in Africa, Asia and South America, many health experts believe that those numbers could very quickly rise dramatically. Some countries also face extra burdens of other endemic diseases, <a href="https://www.nepalitimes.com/here-now/epicentre-of-two-disasters-in-west-nepal/" target="_blank" rel="noopener">recent natural disasters</a>  or coping with large-scale refugee influxes.“Sub-Saharan Africa is already struggling with the Ebola virus and the locust invasion and associated famines. It now faces a third war against the coronavirus. In many countries, resources are stretched thin,” said Dan Steinbock of the Difference Group advisory organisation.South Africa has the world’s worst HIV/AIDS epidemic and it is not known how a major coronavirus outbreak may affect treatment for those with HIV/AIDS or outcomes if they are infected with COVID-19. In Latin America, where more than two thirds of people live in extreme poverty, doctors have already warned of the strain widespread coronavirus infections could put on hospitals and health workers.Any major COVID-19 outbreak could affect incidence, and treatment of other diseases in some African states, says Ambrose Talisuna at the WHO Regional Office for Africa. “We saw this with Ebola outbreaks in some African countries. There was a diversion of resources to the disease and the healthcare system couldn’t deal with the shock of the outbreak. People died of malaria, people couldn’t get treatment for tuberculosis.”There would also be serious economic problems. Not only would massive financial resources have to go into healthcare rapidly, but measures implemented to contain the virus’s spread, such as travel restrictions, business closures, quarantines, would very soon affect people’s incomes.<a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/here-now/ke-garne-attitude-kills-people/" target="_blank" rel="noopener">Ke garne attitude kills people</a>, Laxmi BasnetOne potential advantage some less developed countries may have in dealing with an initial outbreak is their experience with other deadly infectious diseases. In the Democratic Republic of Congo, a devastating Ebola outbreak has just been brought under control. Tests for COVID-19 could simply be added to existing Ebola screening on entry into the country.Some of the poorest in the world in Asia, Latin America and Africa, have begun introducing strict measures to try and halt the spread of the disease. These have included closing borders and lockdowns. While WHO has supported the use of such measures, they have been shown to have had an enormous economic toll with sectors such as travel, transportation, tourism and retail, among others, all seriously affected.“The <a href="https://www.nepalitimes.com/latest/what-nepal-can-learn-from-china-about-covid-19/" target="_blank" rel="noopener">draconian measures that China opted for</a> have been very costly. But all alternatives would have been much worse. The Chinese leadership had to choose between extensive economic damage in one to two quarters with probable virus containment, or far greater economic devastation coupled with drastic increases in cases and deaths,” explained Steinbock.But the costs cannot, and should not, be borne by developing nations alone, development experts say. While local governments can help businesses and individuals with measures such as tax relief, providing financial support through loans, and exemptions from health and social security payments, other countries have a role to play.This month the World Bank made $12 billion available in immediate support to help countries coping with the health and economic impacts of the global outbreak. The International Monetary Fund has said $10 billion could be mobilised in loans to low-income countries tackling the virus. On March 13 WHO and its partners launched the <a href="https://www.who.int/news-room/detail/13-03-2020-who-un-foundation-and-partners-launch-first-of-its-kind-covid-19-solidarity-response-fund" data-saferedirecturl="https://www.google.com/url?q=https://www.who.int/news-room/detail/13-03-2020-who-un-foundation-and-partners-launch-first-of-its-kind-covid-19-solidarity-response-fund&amp;source=gmail&amp;ust=1587206340290000&amp;usg=AFQjCNEFMIPH219XuGD5cfiwkL2SpBnokg">COVID-19 Solidarity Response Fund</a> which aims to raise funds from private and corporate individuals to contribute to global response efforts. Meanwhile, the Global Fund for HIV, TB and malaria is to allow some funds to be used for the virus response while the United Nations’ Central Emergency Response Fund global emergency response fund has made $15 million available.Over a month ago, WHO chief Tedros Adhanom Ghebreyesus launched a $675 million preparedness plan hoping to contain the crisis and pave the way to deter future crises. But that is less than 1% of the US 2020 military budget. In late February, the European Commission earmarked $124 million for the WHO response plan, but others have not proved as generous.Added Steinbock: “No matter how it is funded, experts agree that developing countries must be given whatever help is needed to contain the disease. If cases escape detection in poor countries, then it is more likely than not that weak healthcare systems, coupled with endemic poverty and social instability could result in a secondary epidemic with potential global impact.”IPS

A COVID-19 third wave in the Third World?

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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