Nepal’s doctors are like soldiers fighting a war

Prashuma Malla had never felt so helpless as a physician. Her patient, a man in his 40s, was suffocating, incapable of drawing in breath.

But the hospital ventilators were all occupied, and the central supply of oxygen was very low. She pronated her patient while his wife sobbed near him.

“With no oxygen, we can do nothing,” said the 28-year-old second year medical resident specialising in anaesthesia at Bir Hospital in Kathmandu. “It is scary. It is non-stop. I try to tell myself everything is OK. But what can we do? Eight people have already died on my watch.”

Malla and her colleagues are on the Covid frontlines in Nepal. Her world is a haze of 36-hour intense, and often terrifying shifts, at Nepal’s oldest and best-known public hospital.

As in many government hospitals in Nepal, relatives follow patients in the wards, providing food and running to pharmacies to purchase medicine. Bir Hospital is overwhelmed. People are sleeping in hallways, stairways, curled up on patients’ beds, pacing from room to room.

Doctors believe many relatives are sick as well, but the hospital does not have enough PPEs for them, and there is a serious shortage of oxygen.

“We are exposed to the virus all the time,” Malla said of her shifts with the sickest of patients. “Everywhere you go is a Covid ward.”

Malla and her colleagues have also become counsellors. But with every patient, her job gets harder because most are in their 30s and 40s, and increasingly some in their 20s are being brought in.

In the chaos, it calms her to explain every detail to relatives. What does it mean to be intubated? Why once intubated it is hard to take patients off, and they usually die if they are taken out. No, they cannot take the body to be cremated: only police or soldiers can remove it from the hospital.

“They are confused, they have never seen someone come off an intubator. I remind them: there is no guarantee,” Malla said.

Every move Malla makes, every decision she takes, she reports to her superior. And every day at the shift handover, she has to be careful with the safety precautions.

At the end of her shift that lasts more than 24 hours, Malla heads home on her scooter through light traffic because of the lockdown. She lives in a tiny two-room apartment with her two brothers, and is terrified of infecting them.

She washes immediately, including her mask and face shield. Masks are always on, they cook together. Briefly unmasked, she eats alone on a miniature terrace. She talks on Viber with her parents in central Nepal.

Every day, sometimes every hour, they remind each other to stay safe. She tries to focus on her online medical classes. She doesn’t want to fall behind. But always that nagging fear. Death is lurking. Near her. Floating and invisible.

Although Nepal’s second wave appears to have peaked, and the official number of Covid-19 cases and mortality is down, there are doubts about how accurate the figures are.

The number of daily recoveries is now higher than new infections, and the official death toll is hovering around 100 every day, which is half what it was three weeks ago. The number of active cases fell below 100,000 for the first time in more than one month on Saturday. But there are still more than 1,500 patients in ICUs nationwide, with 450 of them needing ventilator support.

More and more cases in city and district hospitals now are from the hinterland, and there are indications that the virus has spread to the remotest communities in the mountains where there is no hospital care. And no supplemental oxygen.

In rural Nepal, there is now hope from ground-breaking tele-health that is transforming medical care.

Hari Neupane is fighting Covid-19 with his cell phone. He is simultaneously a doctor, nurse and mental health expert, and works with Health Foundation Nepal, a Kathmandu-based volunteer-staffed telemedicine service that reaches out to patients across 35 districts in Nepal via its Kathmandu hotline.

Neupane leads a team of seven doctors in Dang Valley in mid-western Nepal. Because of the large numbers of workers returning from India and its rudimentary medical facilities, Dang bore the brunt of the pandemic in both the first and second waves.

As the monsoon approaches, it is soon rice planting season but a national lockdown has left fields, streets and roads empty, void of the everyday crowds and cacophony of passing trucks.

In Dang in western Nepal, the highways are empty because of the lockdown, while farmers are busy preparing for rice-planting. Photos: HARI NEUPANE

Telemedicine is new in Nepal, and medical teams in the field in Nepal are supervised by Ashok Devkota, a doctor of internal medicine in Providence, Rhode Island, in the United States The organisation’s seven full-time workers and 50 part-time physicians are all volunteers.

Most of Neupane’s patients across Nepal have Covid symptoms, but most have not been tested. Working closely with local health posts, Neupane’s team identifies symptoms, using cell phones – voice, photos and videos – as medical communicators.

They connect patients via cell phone with pharmacies and if necessary source portable oxygen. The very sick are referred to the hospital.

“We focus on people in home isolation and counsel them on the medicines they need and how to get them. We prescribe steroids and do follow-ups and notify local government officials,” Neupane explained.

In Dang, cell phones have become transformative lifelines at many levels. They are a critical means of money transfers from relatives working abroad, so that families can pay school fees, medical bills and food.

This year’s lockdown has made day-long walks to access medical care virtually impossible. Even if patients can get to a hospital, chances of a bed are slim. In Dang, there are only 155 intensive care beds and 15 ventilators, most of them occupied.

Health Foundation Nepal advertises its telemedicine counselling through social media and newspapers. It cannot take blood tests, but with the help of local health workers can monitor oxygen saturation, blood pressure and temperature and can gauge the condition of the patients to recommend a solution.

“Telemedicine existed in Nepal before but before Covid people did not accept it much, but now it is helping save lives,” said Ashok Devkota, the Nepali doctor in the US who supervises medical staff like Neupane half-way around the world Nepal. And as long as Neupane’s cell phone stays charged, he is on duty.

The pandemic and political crisis in Nepal have increased the risk of Nepal becoming an imploding catastrophe. The country was just beginning to recover from the 2015 earthquake, and was struggling with pre-existing health challenges, and earlier this year was beginning to think the worst was over when the second Covid-19 wave struck.

The health and economic crises threaten the gains Nepal has made in the past years in fighting malnutrition, immunisation against other infectious diseases, child labour, early marriage and women’s rights.

But if Nepal is a petri dish of disasters, it is also one of innovation and individual dedication. This pandemic once again is a place where despair is often met by individual and community fortitude by medical workers like Prashuma Malla and Hari Neupane.

Donatella Lorch is a former New York Times foreign correspondent who lived three years in Nepal. She blogs at: tangledjourneys