Nepal’s humanitarian emergency

If there is just one deed Prime Minister K P Oli’s reincarnated government should perform in the month it has to try to prove it has the confidence of Parliament, it is to make up for the time it wasted in handling the pandemic so far.

The inexcusable negligence of the past year has added to decades of neglect so that the country’s second Covid-19 spike has overwhelmed the underprepared health system.

To be sure, surges elsewhere have left countries with much better medical care struggling to cope. Still, last year’s first wave had exposed gaps, especially in border testing, quarantine centres, hospital beds, oxygen, medical personnel, and drugs. It gave us enough time to prepare.

A large part of the problem is structural: political leaders lacking accountability, a lethargic state, the corruption and greed that drives the private medical-industrial complex. We do not even have a reactive government, we have a government that does not react at all.

Much before the pandemic was on the horizon, Govinda KC had been on serial hunger strikes pressing for reforms that would make healthcare more affordable and accessible to more Nepalis. Many called him “mad”.

Hospital tycoons continued to work hand-in-glove with a rent-seeking state. Politicians have stakes in medical colleges and institutions, so there is little incentive to upgrade quality of care in government hospitals. The sicker the country, healthier the  medical business.

The result was seen during last year’s pandemic, and in the collapse of Nepal’s health system during this second wave. The one advantage Nepal has is that India serves as an early warning system of what is to come 2-3 weeks later.

The curve is flattening in north Indian cities, but we have advance warning to prepare for the second wave now ravaging rural India. Many of these villages are just across the border from Nepal.

The virus has infiltrated nearly every family in even remote hamlets in this country. The health care system there is not just rudimentary, it is non-existent. No one is testing, and when people die it will not even register in the Ministry of Health’s official daily Covid-19 count. A village in Rolpa this week tested 43 people, the PCR results came back a week later with 42 positives. Left to fend for themselves, local governments are struggling to cope.

By now we know what the problems are, and where the solutions lie. The challenge for the government, as always, is to set priorities and deliver results. At Monday’s Cabinet meeting, Prime Minister Oli made a call to arms to wage war on the virus. The Health Ministry will now lead a ‘Unified Command’ to coordinate response. What happened to the CCMC?

The first order of business is to manage the supply chain for medical oxygen. Most patients in hospitals now can be saved if they get oxygen, but demand has outstripped supply. Kathmandu Valley alone produces 12,000 cylinders a day, but hospitals need 22,000. Cylinders are being flown in from China, Oman and elsewhere, but the bottleneck now is gas production.

There is a lot of quackery on social media. The MoH needs to push strong evidence-based guidelines: Remdesivir and plasma therapy are over-hyped, expensive steroids are unproven. Physicians advocate Paracetamol for early fever, oxygen when saturation drops below 92, and the cheap and easily available steroid Dexamethasone which is shown to significantly decrease mortality in patients requiring oxygen.

Public service announcements on proper masking, distancing and being careful must go beyond mobile ringtones, and better social enforcement is needed.

A lockdown is not the cure-all. It just buys us time to conduct mass testing and vaccination. Tests have gone up, and the high positivity rate reflects targeted testing mostly of people with symptoms. Random testing of the general population, then tracing and isolation of those infected, is recommended.

Nepal started out well with vaccines in March, but it ground to a halt after the Indian ban on Covishield export. India has reportedly assured us that Nepal is ‘priority’ when shipments resume. The least Delhi can do is allow Serum Institute of India to send the 1 million doses Nepal already paid for, so that those waiting for their second doses, and others left out in the 59-65 age cohort can get their shots. However, that prospect receded further on Tuesday after Serum Institute said in a statement it was not in a position to resume export of Covishield till end-2021.

Foreign Minister Pradeep Gyawali says talks are in the final stages with China for the supply of 2 million doses of Sinopharm VeroCell by June. Supply constraints and pricing appear to have delayed negotiations on the delivery of 8 million doses of Sputnik V.

US President Biden has promised to supply 80 million vaccines in the next six weeks to countries around the world, but it is not clear if the list includes Nepal. Meanwhile, the French dump AstraZeneca doses people are refusing to take. Canada is reportedly sitting on a stockpile of AZ that is reaching its expiration date.  On Monday, Unicef made an urgent appeal to G7 leaders to protect themselves by vaccinating the world.

Nepal, has a robust vaccination infrastructure, with decades of experience in polio, measles, and in maintaining the cold chain even to the remotest parts of the country. Supported by a nationwide network of Community Female Health Volunteers, Nepal's vaccination rate is regarded as a model for other developing countries.

However, this time, Nepal’s health crisis is a humanitarian emergency. Together with rapid international response, Nepal’s leaders have to demonstrate the same acumen they have shown at fighting each other to fight the virus.