We knew the tsunami was approaching

A month ago, Nepal was reporting an average of only 300 Covid-19 cases daily, and the number of deaths was zero for several days in a row. The people, and the government, thought the worst was over and in any case, a vaccine was arriving.

This week, the total number of active cases exceeded 100,000 with daily infections staying above 9,000 for a week. Daily fatalities are now above 150 every day. The nationwide test positivity rate is as high as 50%.

For a country of 30 million, Nepal’s figures are higher than that of India and the rest of the world. As such experts have warned of a health catastrophe as bad if not worse than of the southern neighbour. And our curve has not even started to flatten yet, we are nowhere near the peak.

Nepalganj and Kathmandu have already turned into ‘mini India’ with the coronavirus spreading like a wildfire, and infected doctors and nurses having to treat patients with the same disease. Nepal’s health care system has already exceeded the breaking point.

“It has become a challenge to treat all patients. People are taking longer to recover, plasma therapy and remdesivir aren’t effective and 90% of those admitted need oxygen,” says Sagar Kumar Rajbhandari, director of Teku Hospital in Kathmandu. “Unlike during the first wave when we could maintain a patient with 1-2 litres of oxygen per day, we now need more than 15 litres per individual.”

Doctors are having to select which patients have a better chance of survival on scarce ventilators. Patients are dying in the corridors because they cannot breathe.

Hospitals across the country are now stopping admits because of serious shortages of beds with oxygen, and patients are sleeping on parking lots and verandahs. They are now reporting shortages of masks, PPE and essential medicines as well.

The Covid-19 Crisis Management Centre’s latest decision to limit oxygen supply per hospital at 100 litres a day has added to the challenge. Patients under treatment in hospitals including Bhaktapur and Grande face critical oxygen shortages and can’t take on any more people. The quota system has made the situation even more dire.

The first consignment of 400 oxygen cylinders out of the 20,000 promised by China was flown in from Beijing on Tuesday by a Nepal Airlines jet, which also brought ventilators, oxygen concentrators and other equipment.

As of 12 May, 71 out of 77 districts in Nepal are under prohibitory orders. The lockdown in Kathmandu, Lalitpur and Bhaktapur has been extended by another two weeks with further restrictions.

International and domestic flights have been grounded until 31 May except for two Kathmandu-Delhi flights a week under the Nepal-India air bubble agreement. Only some cargo charters and rescue flights are permitted.

During a virtual meeting on Tuesday health minister Hridayesh Tripathi hinted that the government might have to declare a “health emergency” since the steps it had taken so far were not adequate in addressing the extent of the crisis.

But long before prime minister K P Oli lost a confidence vote in the parliament and plunged the country into further uncertainty, the government’s response to the pandemic was dismal at best.

Leaders were busy organising political rallies with thousands in attendance in a show of force after Oli dissolved the parliament in December. Then there were religious gatherings, lavish inaugurations and indoor political meetings.

Similarly, Holi and Biska celebrations went ahead because of protests against government efforts to restrict it. Bars, malls, cinema halls, concerts all continued as if there was no pandemic. Border checkpoints in the Tarai were understaffed.

“If we talk in numbers I’d say 70% of the blame for the new surge goes to the public and 30% to the government,” says Sameer Mani Dixit of the Centre for Molecular Dynamic Nepal. “The government could have done more to procure vaccines through diplomacy, enforce safety measures and expand contact tracing. But it was the people who were crowding public spaces without masks or physical distancing, we wouldn’t have required lockdowns otherwise.”

The Covid-19 crisis has magnified and brought into sharp focus the result of a lack of investment in Nepal’s health system. Medical care is either too sloppy in government hospitals, or too expensive in private ones. Either way, for most Nepalis health care is either inaccessible or unaffordable.

To be sure, the scale of this crisis would have overwhelmed even an industrialised country’s health system. But despite knowing that a tsunami of coronavirus was approaching from India, Nepal’s health infrastructure remained severely lacking, and hospitals were sorely unprepared, understaffed and under-equipped. The limited resource now has to be distributed also among patients with other diseases.

There are a total of 18,917 general, 1,446 ICU and 634 ventilator beds across the country. But that is much less than what is needed. Doctors and nurses are working in longer shifts with diapers because they cannot waste time going to the rest room.

“Having already lived through the first wave albeit the milder one, we knew there was a risk and should have invested in preparedness but both the government and people didn’t realise the severity until it was too late,” says infectious disease specialist Sher Bahadur Pun.

He adds: “We have no visible increase in human resource or infrastructure to show as the stronger surge grips us all. We haven’t even begun to think about how to manage children with multisystem inflammatory syndrome requiring ICU due to Covid.”

The Health Ministry has projected the second wave to peak in Nepal with at least 15,000 cases a day by July. Even if that were true, nothing is stopping Nepal from falling victim to the 3rd, 4th and more waves as has happened in Europe and the Americas with new mutants.

The only way out of this pandemic is herd immunity through mass vaccination. But only 2.1 million of Nepal’s 30 million populations have received the first dose of either Covishield or VeroCell vaccines. Fewer than 400,000 have been fully inoculated with the booster shot.

Nepal’s plan to buy five million doses of Covidshield fell through after the Indian ban on exports of vaccines. Nepal is yet to receive one million doses it paid for.

The COVAX initiative hasn’t been able to deliver owing to a manufacturing bottleneck after the first consignment of its 348,000 doses was delivered in March.

The UN resident coordinator in Nepal Sara Beysolow Nyanti tweeted on Tuesday that Nepal ranked ninth among the 10 top countries in terms of daily increase in Covid-19 cases, but it has the smallest population and the highest case positivity rate.

She appealed for immediate assistance, writing: “Nepal has not been able to secure vaccines for even 20% of those who need to be vaccinated. Nepal should be prioritised at the top. I appeal to the countries that can spare vaccine to send them to Nepal immediately.”

Meanwhile, the government has announced that it will resume inoculating people in Kathmandu Valley with the Chinese Sinopharm VeroCell shots from 15 May. The vaccine received WHO approval last week, and the vaccinations will be from the 800,000 doses donated by China last month. Some 300,000 people have already got their first jabs of the vaccine.

Nepal should now concentrate all its efforts towards vaccine diplomacy to secure more doses for 20% of its population, say public health experts, wherever it may come from and there is no time to waste.

The health ministry maintains that it has approached countries other than India to procure vaccines and funding is not the problem but the supply.

Said health minister Hridayesh Tripathi during Tuesday's press meet: “The government can buy 10 million doses of Covid vaccine if someone can provide it at $4 per shot.”