The long journey back to Nepal

After the COVID-19 pandemic struck in early 2020, it was not immediately apparent that the world would turn upside down like it did. As February came and went, people’s plans all over the world would take a tumultuous turn for the worse, including ours.

The two of us had been in the United States to pursue graduate degrees, and were scheduled to return to Nepal on 19 May. But the flights had been grounded with Nepal in lockdown, and there was no word about when airports would reopen for regular flights.

Finally, Nepal started repatriation flights for its nationals on 15 June and Fulbright Nepal supported us to fly back from JFK in New York on a Turkish Airlines charter flight to Kathmandu via Istanbul on 23 June.

We were at the Johns Hopkins University in Baltimore of Maryland, and although the United States has the highest number of cases and fatalities in the world today, the pandemic did not have the same degree of intensity all over the country.

Maryland state, in fact, was praised for being one of the first off the mark in COVID-19 response and for handling the pandemic as it evolved and spread on the east coast. Governor Larry Hogan, for instance, constantly took suggestions from experts from Johns Hopkins University.

In fact, the Johns Hopkins Coronavirus Resource Centre is regarded as the most credible global resource on the spread of the pandemic, and the figures in its live interactive website is quoted by academics and the media all over the world.

Maryland detected its first case in Maryland on 5 March, but within four days the state had passed an emergency legislation to shut down public schools, restaurants, bars, casinos, betting facilities, and other non-essential businesses.

Alongside that, the focus was primarily on contact tracing, and steps were taken to boost the health care work force. Hospital bed capacity was increased by 60,000, the authorities allowed interstate practice, and even let clinicians to practice without reinstating their inactive license.

The federal government was also aware of the financial fallout of the lockdown on individuals and businesses. It provided a $1,200 cheque to all tax-paying residents, and gave unemployment benefits for those who lost jobs in proportion to income. The governor ordered that tenants would be supported if unable to pay rent, and he ordered a ban on evictions by landlords and utility shutoffs for non-payment of bills.

By 30 March, as the cases multiplied, the governor issued a stay-at-home order, as well as a $175 million economic relief package for workers and small businesses. Essential functions like picking food, seeking urgent medical care, reporting to an essential job or engaging in outdoor recreation within a safe distance from others, were allowed.

Ridesharing services continued because the system is digitised and requires no touching or direct interaction. Some Uber drivers even put a plastic screen between the front and the back seats. Restaurants were open for take-out and contactless delivery. These measures ensured that people had essential supplies.

Himalayan New Yorkers tell stories of COVID-19

More importantly, the use of cloth face coverings over nose and mouth in public places like grocery stores, pharmacies and ride shares were enforced. Stores followed guidelines like maintaining physical distancing, limiting the number of people and sanitising shopping carts.

On 8 May, the seven-day average cases reached a peak with 1,090 cases, and after that steadily decreased for a week reaching 950 cases on 13 May. The stay-at-home order was changed to a safer-at-home suggestion, with gradual reopening of retail, manufacturing, worship houses, outdoor dining and outdoor activities like sports and camps.

One remarkable action alongside the easing of lockdown was to focus on testing asymptomatic cases. Free PCR testing sites were established, and by 3 June the positivity rate (7-day average reported) dropped to 9.5% for the first time since late March.

Those who watch general headline on the news about the worrying trends in the United States, will be surprised to note that in June Maryland was gradually reopening indoor dining, outdoor amusement parks, workplaces and businesses. For frontline health care workers in the long-term care management, weekly PCR tests were enforced. At present,  Maryland is one of the states that has met the positivity rate recommendations of 5% or below by the World Health Organization (WHO).

What worked was the focus on stringent testing, strict contact tracing, boosting healthcare personnel, and assistance to families with cash allowances. Later, as things improved, the restrictions were eased and the focus shifted to testing asymptomatic cases and enforcing precautionary measures.

As the day approached for our flight back to Nepal, we had been told that we need PCR tests before boarding to avoid a 14 day quarantine in Kathmandu on arrival, and would be eligible to go to home quarantine without having to stay in a holding centre or hotel.

Again, things were so well organised that we got free PCR tests from the state of Maryland, and had negative certificates before boarding. Those without either PCR or RDT tests were required to present a certificate from a doctor that they were symptoms free. Although we had been told that we needed to present these at check-in, however, no one asked us for them before flying.

JFK airport was not as crowded as it is normally, and passengers all wore masks and maintained physical separation. Some were even wearing face shields and gloves, and were constantly using hand sanitisers. Passengers were very disciplined and keeping 6 feet distance even though there were no floor markers with circles.

The flight from JFK to Istanbul was full of mostly elderly Nepalis, and we assumed they were parents who had been stranded in the US while visiting their families. Contrary to our expectations middle seats were not kept vacant to maintain distance, and all seats were occupied.  All passengers kept their masks on and seemed to be aware of the need to minimise touching.

Prior to being seated, airline staff sanitised our hands, provided a packet including a sanitiser bottle, mask and wipes. All meals were provided with both a mask and sanitised ware, although they were not provided as in regular commercial flights. Every meal was the same (cheese/vegetable sandwich) even though we had been asked about our meal preference (veg/non-veg) while purchasing our tickets.

This food was fine for us, but we observed that many elderly passengers  did not eat and probably went hungry throughout the long flight back to Nepal. There was no refilling of glasses or additional servings of fluids, and water was only provided to those who had their own bottles.

All public surfaces, door knobs and restrooms were cleaned frequently by cabin crew wearing personal protective equipment, masks and gowns. As with most flights in and out of Nepal, infrequent fliers looked lost and were not accustomed to using the lavatories. Even when the cabin crew tried to help, there would be a language barrier among some elderly Nepalis.

There was a two-hour layover at Istanbul Airport, however passengers were required to stay on board and the same aircraft flew on to Kathmandu with a different set of crew. This was a good precaution since the plane did not have to be sanitised again, and passengers did not face the risk of additional exposure at the terminal building.

However, it did mean that passengers were cooped up in the same plane for a long time. Medical advice is for passengers to stretch frequently during prolonged flights to prevent clot formations in the legs that can eventually lead to deep vein thrombosis. This was especially important since many of the passengers were elderly and it was a straight 18 hours in the air with two hours inside the plane on the ground in Istanbul.

Long and winding road home to Nepal, Upasana Khadka

After takeoff from Istanbul, and as we neared Kathmandu the crew distributed the Traveler Public Health Declaration Form which was different from the Nepal Embassy’s form, but requested similar information about symptoms if any, and test results.

After landing at Kathmandu, airport health staff came on board first and made announcements about the process of disembarkation, especially about physical distancing measures and moving to holding centres. However, we noticed that most passengers were barely listening because they were busy turning on their phones to make family calls.

Much more effective would have been if an arrival video with instructions could have been screened while the plane was on descent to Kathmandu. Passengers were allowed to deplane after the announcements, and taken on ramp buses carrying only 30 passengers each to queues at the arrival terminal.

Here, we were required to submit two forms, the Health Declaration Form (available from the Nepal Embassy website) and the Traveler Public Health Declaration Form which had been distributed on the plane. Many elderly passengers had not filled the forms, and this resulted in passengers moving through the queue at a slow pace. That is why the process of submitting the forms and immigration took two hours. The circles on the floor did help in keeping separation with other passengers.

https://www.youtube.com/watch?v=QKaVRtfxXI0&feature=youtu.behttps://youtu.be/9JJspmkVoPA

The thermal gun temperature checks were taken after the forms were submitted, and then it was on to the immigration queue. The wait there and in the ‘metal free’ x-ray check was not much longer than during normal times at Kathmandu Airport.

The baggage turnstile was as chaotic as it used to be before the lockdown,  because the luggage conveyors were not working. Passengers crowded around in search of their bags. No longer were people keeping a safe distance. What surprised us was that the same passengers who stood in disciplined queues at JFK maintaining separation, were not following the rules at Kathmandu airport. The only saving grace was that since this was the only flight arriving the baggage area was not more crowded.

Kathmandu airport is notorious for its smelly and dirty toilets, and it was disappointing to see that despite all the reported improvements at the airport, the toilets were as filthy as ever. The washroom had no water, and there was no safe drinking water anywhere in the arrival terminal.

The elderly, already at greater risk of infection, were now tired, jet-lagged and hungry. They also had not had enough water to counter the dehydration on the long flight. On top of that, they were forced to use a waterless restroom. Welcome home.

Finally getting our luggage, we made it out to buses that were designated by province. This was probably the most efficiently managed part of the arrival process, perhaps because it is handled by the Nepal Army. The buses took passengers to separate province-wise holding centres which are also managed by the military. For example, passengers going to Kathmandu were taken to Basundhara (pictured below).

We were inside the bus for an hour at the airport before driving off to the holding centre. However, just five minutes before reaching Basundhara, the bus took a U-turn and drove back to the airport apparently because some people were missing. So, we were inside the bus for about 2.25 hours for a ride that was just actually about half an hour.

Before getting off there were three staff assigned to take down our names and addresses. By this time, we had provided the same information four times during this journey. Not only was this a waste of time and inefficient, but it also exposed staff to unnecessary risk.

Here is a checklist of what passengers should expect when they reach the holding centre:

Step 1: Mandatory hand-washing on arrival.

Step 2: Queue up and have temperature taken and hands santitised.

Step 3: Staff wearing plastic shields once more collect information from passengers.

Step 4: An NTC prepaid SIM card is distributed to all passengers not just so they can all relatives but also so our whereabouts can be monitored through geo-location.

Step 5: Passenger passports are scanned

Step 6: Passengers are taken to a waiting room until a guardian or companion arrives to take them home if they have PCR negative, or to hotel, quarantine if they don’t.

The information collected at the holding centre included temperature, name, age, sex, permanent address, temporary address, type and day of test done different symptoms of COVID-19, as well as information about parents. Once more, we realised that this was information that we had already provided, and this was the fifth time we were giving out the same details.

By this time, some of the passengers were losing patience and venting off steam. They were tired, hungry, thirsty and fed up with repeating the same information over and over again, with the long queues. We were really feeling bad for the elderly people because this homecoming was made unnecessarily difficult and stressful for everyone.

Each passenger is required to have someone to meet them. Guardians and receiving families have to also provide information about themselves and wait in a different area. Each passenger is also photographed with the guardian before going home.

Finally, we were let go. We were very curious and asked why our parents needed to come, as we would not have liked them exposed to the holding centre environment. The staff explained that it was important for contact tracing. Finally, more than seven hours after landing in Kathmandu, we were home.

The days since, we have been thinking about what could have been done better on arrival for the passengers to make it more convenient and less tortuous.

Firstly, measures could easily have been taken so that the same information about each passenger was shared right down the line from the Nepal Embassy in Washington right till the holding centre. Why ask the passengers to repeat the same information ad nauseum? The same redundant information was collected multiple times.

Many passengers complained that though they had been tested negative before travel, they might actually have got infected during the 7.5 hour long process which demanded multiple exposure and interaction at different places and with different people from the airport to the holding centre.

We were surprised to learn that the Ministry of Health actually has the Hamro Swasthya app which, with some modifications, can be just one electronic form that can be used everywhere for repatriated Nepalis. Making this app comprehensive by incorporating the information of health declaration and traveler declaration form together, it would digitise all the information that we were repeatedly providing on the same system.

Passengers can be told about this app by the Nepal embassies abroad or while buying the ticket, and it could be mandatory to have it filled before boarding. For the people who do not own a smart phone or are not able to use the app, the same information can be entered in a web-based system by getting an assistance desk in the airport itself, by using the relevant human resource and logistics.

This would reduce the administrative effort as well as unwanted exposure and interaction among people, and also save the information digitally to be accessed anywhere from the system.

The Nepal government can take very good individual initiatives, as we know, but lacks the coordination capacity to integrate them, and bundle them seamlessly together for effective implementation. Proper and efficient use of communication tools and technology can easily solve this problem online, make travel more efficient, and also minimise human contact.

The difference with Maryland is that Nepal, despite more than three months of lockdown, still lacks adequate testing, contact tracing and proper management of Nepalis returnees from India. Had there been adequate test evidencing, a decrease in seven-day average cases could have been used to ease the lockdown safely.

Unfortunately, we in Nepal are relaxing restrictions even while the number of cases are going up. This is not a wise way to handle the pandemic, and actually reverses all the gains made by the lockdown. For now, the most effective thing the government can do is to increase testing, enforce mask use and physical separation in public places.

This is not easy to do even in America, as we have seen. In Kathmandu, the use of masks is surprisingly common (probably because people are used to wearing them because of the pollution) although there is still a lot of crowding the markets and streets.

Wearing a mask reduces transmission by 14.3%, and a physical distance of 1 meter reduces it by 10.2% . The risk decreases with further increasing distance. This information needs to get out to the public in an easy-to-understand way – and not just on the mobile phone rings.

Seema Subedi is a Fulbright Scholar, an MPH graduate from Johns Hopkins Bloomberg School of Public Health, and currently working as Faculty Associate at Global Disease Epidemiology and Control Division, International Health Department.

Raju Bhandari is a General Surgeon, an Alumni  of Institute of Medicine, TUTH, currently working at Alka Hospital.