<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141148/636d01119c7e80680e0a360ejpeg.jpg" alt="" width="1313" height="882"/><figcaption>Photo: UNICEF NEPAL</figcaption></figure>In terms of <a href="https://www.nepalitimes.com/opinion/hope-hyperbole-and-hypocrisy-of-covax/" target="_blank" rel="noopener noreferrer">global vaccine equity</a>, the answer to the question of whether it is ethical for rich countries to boost with a third dose of  Covid-19 vaccine, seems like a no brainer.But ethics aside, it has been pointed out that no one is safe until everyone is safe. It is in the public health interest of rich countries to ensure that as many people around the world are vaccinated to <a href="https://www.nepalitimes.com/banner/vaccines-variants-and-a-third-wave/" target="_blank" rel="noopener noreferrer">prevent new variants and spikes</a>.The graph below starkly illustrates the big gap between the jab and jab-nots – showing the wide chasm between rich and poor countries in terms of the proportion of the population which has got even the first dose.Booster vaccination is a moot point for low-income countries because at the moment the option is limited to high- income countries, where some research has shown waning antibody presence and the authorities in the US are advising a third dose eight months after the second one.As of now there is only scant data to show that boosting will help real-life protection in the general population. Clearly the vast majority of the people who received the full dose of approved  vaccines, including the Chinese VeroCell here in Nepal, already have adequate <a href="https://www.nepalitimes.com/banner/behind-the-masks/" target="_blank" rel="noopener noreferrer">protection against severe</a> (as opposed to mild or moderate infections) Covid-19 disease with the present vaccine schedule.Crucially, a strong international drive to vaccinate the unvaccinated could potentially save many more lives than would boost the already vaccinated.But this is a very wily virus which almost overnight changed the rules of the game by mutating into the <a style="letter-spacing: 0.01em;" href="https://www.nepalitimes.com/here-now/delta-variants-wake-up-call-for-nepal/" target="_blank" rel="noopener noreferrer">highly infectious Delta variant</a>. We need look no further than what happened in neighbouring India earlier this year as this variant ripped through the unvaccinated population regardless of herd immunity that was thought to be widespread.Delta surged across the open border into Nepal, where it overwhelmed the country’s inadequate and inequitable health care system. There is credible data to suggest that there might have been 3-5 million excess deaths in India during the second wave.<a href="https://covid19.healthdata.org/nepal?view=cumulative-deaths&amp;tab=trend" data-saferedirecturl="https://www.google.com/url?q=https://covid19.healthdata.org/nepal?view%3Dcumulative-deaths%26tab%3Dtrend&amp;source=gmail&amp;ust=1630901105986000&amp;usg=AFQjCNGVkeZeMBLFWPxAOLd86V8RWL22gQ">Estimates for Nepal</a> by the <a href="http://www.healthdata.org/covid" data-saferedirecturl="https://www.google.com/url?q=http://www.healthdata.org/covid&amp;source=gmail&amp;ust=1630901105986000&amp;usg=AFQjCNG9rCQIZqojh5um31-iM7GlGaMZPA">Institute of Health Metrics and Evaluation</a> of the University of Washington in Seattle show that although the official cumulative deaths due to Covid-19 as of this week was nearing 11,000, the real figure with excess mortality is closer to 40,000.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141148/636d01159c7e80680e0a360fjpeg.jpg" alt="" width="1774" height="1118"><figcaption> </figcaption></figure>It is among the vast number of the unvaccinated that the virus has a greater chance of randomly mutating and becoming a variant (from alpha to omega and now the mu variant in South America) and potentially spreading worldwide.Every time the virus replicates, its likelihood of mutation increases. The novel coronavirus, unlike the other SARS-CoV-1 from 2003 may not be as keen on killing people as it is in perpetuating infections by replicating as much as possible .After India, the Delta virus affected the UK population in a widespread manner, but there was one huge difference -- in Britain it infected many who had already been vaccinated, even though the severity of the illness was significantly lower in this subset.Hence, as these variants generally develop in the unvaccinated population and some (there are 15 variants at present) turn out like the Delta variant, it would be in the enlightened self-interest of the richer countries to have as much of the world vaccinated as possible so that random mutations and variants will be substantially limited, and will not reach their shores.But such enlightened self-interest seems to be lacking in high-income countries, especially because there are <a href="https://www.nepalitimes.com/editorial/no-vax-ask-for-mask/" target="_blank" rel="noopener noreferrer">not enough vaccines to go around</a>, and rich nations perceive an immediate benefit from boosting.Israel is already giving third jabs and France, UK and the US are strongly considering boosters. Boosting may be a good idea if the Covid-19 vaccine supply was plentiful. But currently the supply is limited and more than half the world’s population has not received even a single dose of the vaccine.Sadly, many in low and middle income countries are waiting for doses through the COVAX facility and drug manufacturers like Serum Institute of India scramble to fulfill previous contracts while grappling with the Delta virus at home.What is even more unconscionable is that many rich countries are throwing away expiring vaccines. And now with new orders for booster vaccination programs from high income countries, the developing world will have to wait even longer to have their contracts filled.With booster doses planned for the rich world, it may indeed be a zero sum game for the world if the supply of the approved Covid-19 vaccines is not dramatically increased. The good news is that Serum Institute of India, where Nepal sourced its first lot of Astra Zeneca Covishield vaccine until the pandemic took a turn for the worse in India, has greatly increased its production capacity.Given the experience of the past nearly two years, most high income countries are likely to ignore ethical considerations regarding vaccine equity and booster doses.Many institutions in the West that deal with global health may be embarrassed about not being able to persuade their governments to put their money where their mouth is and do the right thing.So far, their pleas for <a href="https://www.nepalitimes.com/opinion/global-solidarity-needs-intensive-care-in-pandemic-battle/" target="_blank" rel="noopener noreferrer">vaccine equity</a> have generally been ignored – even though they know an effective global vaccination drive would ultimately benefit them by reducing the risk of new variants emerging.In practice, if the production of vaccines revs up and COVAX is able to ship more vaccines to poor countries, regardless of boosting or no boosting by the richer countries, millions of people in the Global South will benefit.In the meantime, we have to continue to mask up, avoid crowds and sanitise, because the vaccine per se <a href="https://www.nepalitimes.com/opinion/dying-to-get-vaccinated/" target="_blank" rel="noopener noreferrer">will not stop transmission</a>.The other bit of good news is that the Nepal Health Research Council in conjunction with other local collaborators is  sequencing (identifying the molecular structure) of Covid-19 virus samples from various parts of Nepal.The Sanger Center, the world’s premier genomic institute based outside Cambridge in the UK, will validate the results from Nepal and enhance our capacity building in molecular medicine.This should help us in promptly identifying variants of Covid-19 so Nepal can deal with future infectious disease outbreaks in a scientific and orderly manner. <a href="https://www.nepalitimes.com/banner/how-nepal-must-prepare-for-3rd-covid-wave/" target="_blank" rel="noopener noreferrer">Covid-19</a> has emphasised the additional significance of sequencing even for other rampant diseases like  tuberculosis and typhoid in South Asia.Buddha Basnyat is a physician and 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=1630901105986000&amp;usg=AFQjCNH6pJWJpOhLqwh7C7o4x6py0843Jg">frequent health columnist</a> for Nepali Times.

Buddha Basnyat

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Dhanvantari

To boost or not to boost

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141128/636cfd239c7e80680e0a0bcajpeg.jpg" alt="" width="768" height="512"/><figcaption>People lining up for Covid vaccination in Kathmandu this week. Photo: AMIT MACHAMASI</figcaption></figure>The unprecedented speed at which effective Covid-19 vaccines have been discovered is truly inspiring. The problem with acceptance and <a href="https://www.nepalitimes.com/opinion/im-sad-vaccines-are-delayed-in-nepal/" target="_blank" rel="noopener noreferrer">distribution of those vaccines</a>, however, is another story.Scientists can invent vaccines faster than ever, but political scientists cannot find answers to the problems of <a href="https://www.nepalitimes.com/banner/once-nepal-gets-vaccines-they-need-to-be-fairly-distributed/" target="_blank" rel="noopener noreferrer">vaccine denial and inequity</a>.If this pandemic had happened 50 years ago and an effective and safe vaccine had ultimately been found, in all likelihood the administration of these vaccines would have happened more smoothly, probably with more equity and <a href="https://www.nepalitimes.com/opinion/why-vaccination-should-be-compulsory/" target="_blank" rel="noopener noreferrer">much less fuss</a>.To be sure, there was similar opposition to the smallpox vaccine when it was first developed, but eventually it was mandated by governments and the disease eradicated. And millions of lives are saved annually in low income countries by vaccines against preventable diseases.But the speed with which medical science has come up with effective Covid-19 vaccines has been a game-changer. If this is followed by treatment protocols, it will be even more spectacular.And the best example to showcase efficacious treatment has been the Oxford University-lead Recovery (Randomised Evaluation of Covid-19 Therapy) trial in which Nepal was the first actively participating site outside the UK.In June 2020, the results of this trial showed that an inexpensive and widely-available drug, dexamethasone (a corticosteroid) substantially reduced deaths in <a href="https://www.nepalitimes.com/here-now/helping-nepalis-breathe-again/" target="_blank" rel="noopener noreferrer">hospitalised patients requiring oxygen</a>. As a result, the drug has saved millions of lives.For those of us in the health profession in Nepal, Covid-19 evoked a feeling of déjà vu. Common rampant infectious diseases like typhoid and tuberculosis are ideally controlled by <a href="https://www.nepalitimes.com/latest/nepal-covid-19-impact-worse-than-official-figures/" target="_blank" rel="noopener noreferrer">contact tracing</a> and treatment. Implementing these measures against another human-to-human infection like Covid-19 should therefore have been a no-brainer.Unfortunately, in South Asia contact tracing even for biblical diseases like typhoid and <a href="https://www.nepalitimes.com/banner/tb/" target="_blank" rel="noopener noreferrer">tuberculosis</a> is not done. We would have been able to more easily deal with Covid-19 if we already had contact tracing in place for these rampant, but overlooked, diseases mostly afflicting the impoverished.The trajectory of the pandemic has led to revelations. Herd immunity acquired with previous infections seems to be an unreliable and less robust way to seek protection from the virus. This was dramatically illustrated with the <a href="https://www.nepalitimes.com/here-now/delta-variants-wake-up-call-for-nepal/" target="_blank" rel="noopener noreferrer">spread of the Delta virus</a> in India where many people, including doctors, thought they had enough antibody protection.The BCG vaccine (against TB) was <a href="https://www.nepalitimes.com/latest/could-an-anti-tb-vaccine-be-protecting-nepalis/" target="_blank" rel="noopener noreferrer">thought by many to protect them</a>, and that has also turned out to be probably untrue. Protection afforded by prior exposure to other respiratory viruses including coronaviruses (non-Covid 19) also seems non-existent. The fallacious argument that we are hardy people from South Asia who are protected by our spicy diet also took a hammering.The most dramatic observation during this pandemic has been in human behaviour and psychology. Literate people (many in high income countries) refusing to <a href="https://www.nepalitimes.com/here-now/3-pronged-strategy-to-save-nepal-from-covid-19/" target="_blank" rel="noopener noreferrer">wear masks</a> or be vaccinated despite overwhelming scientific evidence, is bewildering.So, while vaccine stockpiles are nearing their expiry dates in the United States and parts of Europe, people in Africa and Asia are literally dying to be vaccinated.Vedic philosophy calls this era the Kali Yug, a time when knowledge does not translate into wisdom. When individualism takes precedence over collective welfare, people are unkind and intolerant to each other.Lack of humility and an excess of human hubris is also clearly in evidence during this pandemic. Leaders of countries who boasted that they were saviours of the world by promising vaccines were brought to their knees with <a href="https://www.nepalitimes.com/banner/vaccines-variants-and-a-third-wave/" target="_blank" rel="noopener noreferrer">the spread of the Delta variant</a>. Those who extolled their superior public health status have had to eat their words.Hypocrisy is also in full display. Early grandiose talk of vaccine equity in high income countries even before the discovery of the vaccine <a href="https://www.nepalitimes.com/opinion/hope-hyperbole-and-hypocrisy-of-covax/" target="_blank" rel="noopener noreferrer">was soon forgotten</a> as countries stockpiled up to four times what was needed to vaccinate their eligible populations with two doses.Many countries did not put their money where their mouths were, espousing vaccine nationalism. The concept of vaccine distribution equity is now like talk of motherhood and apple pie.The virus clearly showed us that the world needs not only universal health care and universal basic income but just as much universal behavioural therapy. Even in their enlightened self-interest, these countries should ensure universal vaccination because science has shown that the more people remain unvaccinated, the <a href="https://www.nepalitimes.com/opinion/no-country-is-safe-until-we-are-all-safe/" target="_blank" rel="noopener noreferrer">more the danger of variants mutating</a>.Here on, since 70% vaccine coverage will take time, Nepalis need to <a href="https://www.nepalitimes.com/banner/vaccines-or-no-vaccines-mask-and-distance/" target="_blank" rel="noopener noreferrer">continue to mask up and wash hands</a>. Those who are vaccinated must remember that it does not always protect them from infection, just severe symptoms, and they can be carriers to spread it to others. Vaccines only reduce mortality and morbidity and hospitalisations.Same with masks. Wearing a mask and going into crowded places defeats the purpose. Those following proper guidelines have noted that they are less sick than usual with respiratory and gastrointestinal ailments. The use of masks and frequent hand washing in Nepal’s unsanitary conditions may lead to a decrease of other common infections besides Covid-19.All presently available vaccines are effective in the prevention of <a href="https://www.nepalitimes.com/banner/nepals-uneven-covid-19-deaths/" target="_blank" rel="noopener noreferrer">Covid-19</a> infections, especially regarding hospitalisation. The important thing is not to miss the opportunity to get vaccinated with whatever doses are available whenever. All the available vaccines are safe and have very few, if any, contraindications even in pregnancy.There is much less vaccine hesitancy and denial in Nepal now, especially after people saw how unvaccinated people in their families and neighborhood could easily succumb to the virus.We have to psychologically prepare ourselves for the likelihood that the <a href="https://www.nepalitimes.com/banner/how-nepal-must-prepare-for-3rd-covid-wave/" target="_blank" rel="noopener noreferrer">pandemic will continue for many more months</a> unless the vast majority of us in the world are promptly vaccinated. Herd immunity from vaccination is much more reliable than herd immunity from natural infection.Amazingly, no world leader has gone beyond rhetoric to actually start delivering vaccines to all corners of the world. As the pandemic plays out, the best-case scenario is that Covid-19 antibodies will be present even years after vaccination or post-infection, as was noted with SARS (a different but deadly coronavirus infection in 2002) and provide protection for years to come.Or perhaps Covid-19 will peter out and become like the influenza virus requiring a jab every winter. Variants may continue to be a problem, but no one knows for sure as this is indeed 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=1629080960620000&amp;usg=AFQjCNHYX5K-ItauU5qj1nRZM3tMxFIYsw">novel coronavirus</a>, and we are still learning. In all likelihood, vaccines will continue to be effective even against variants.One thing is for sure, all this shall also pass. But we have to learn lessons to be better prepared for the next pandemic.Buddha Basnyat is a physician and 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=1629080960620000&amp;usg=AFQjCNHYX5K-ItauU5qj1nRZM3tMxFIYsw">frequent health columnist</a> for Nepali Times.

Dying to get vaccinated

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111136/636b83649c7e80680e067732jpeg.jpg" alt="" width="3563" height="2375"/><figcaption>Photo: AMIT MACHAMASI</figcaption></figure>Only a month ago, even prominent doctors in India were declaring that the country had defeated the <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" target="_blank" rel="noopener noreferrer" 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=1620014851520000&amp;usg=AFQjCNH26pr4ATCusVi4rW_jCSccSqOyNw">novel coronavirus. </a>They felt that herd immunity in cities like Delhi would protect people from infection and death. Based on a few dubious studies, they conceded that a large proportion of Indians had acquired herd immunity through mild or asymptomatic Covid-19 infections.Just like the theory that a lifetime exposure to germs would protect South Asians, herd immunity also turned out not to be true.Here in Nepal we are seeing a surge that is proportionately similar to India. The exponential rise in the number of cases, infection of younger cohorts, and the severity of the disease, bear all the hallmarks of the contagion sweeping across India.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111136/636b83679c7e80680e067733jpeg.jpg" alt="" width="1390" height="584"><figcaption> </figcaption></figure>While we try to treat the sick by increasing hospital space and ensuring oxygen supply, we must also plan for an <a href="https://www.nepalitimes.com/opinion/a-covid-19-exit-strategy-for-nepal/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/a-covid-19-exit-strategy-for-nepal/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNGreS-S3470fwa9xi8chTwsApsL8Q">exit strategy</a> that entails acquiring more effective herd immunity through mass vaccination, and partial lockdowns enforced with all <a href="https://www.nepalitimes.com/opinion/prevention-while-searching-for-a-cure/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/prevention-while-searching-for-a-cure/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNEgv4bMUglLS5mZDf0VcnTA8rrcwA">precautionary measures</a>.<a href="https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/" target="_blank" rel="noopener noreferrer" 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=1620014851521000&amp;usg=AFQjCNFOLiROFJhRqoWS8Lm4Rrizbt_w7w">Over-preparation rather than under-preparedness </a>needs to be our mantra. Widespread vaccination is the key to get us out of this pandemic, and we have lost precious time with the delays.This means our <a href="https://www.nepalitimes.com/latest/nepal-braces-for-new-wave-with-vaccine-drive/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-braces-for-new-wave-with-vaccine-drive/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNH7Un17CIezo7XVehWgZr4IVThqzQ">vaccine diplomacy</a> has to go into top gear. If <a href="https://www.nepalitimes.com/latest/jabs-and-jab-nots/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/jabs-and-jab-nots/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNEHISgu64T2PwpgpRFk_IklnxurbA">Covishield from India</a> is not available, we must lobby for as many dosages of vaccines from <a href="https://www.nepalitimes.com/latest/the-gift-of-the-jab/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/the-gift-of-the-jab/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNFYyDtUVRKNT2a92xdtV6IBpGmKNQ">Chin</a>a, <a href="https://www.nepalitimes.com/latest/sputnik-v-vaccine-mystery-in-nepal/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/sputnik-v-vaccine-mystery-in-nepal/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNGsbwsSUqjInkvevMv3Ycj6ryTa8w">Russia</a>, or the United States, and administer them urgently.All of these vaccines are in general at least 50% effective (the ‘pass mark’ for vaccine efficacy). None of the inoculations appear to have serious adverse effects, even though there are questions about whether they provide enough protection from the new strains, and duration of immunity.We are trying to immunise the population from SARS-CoV-2, which happens to be a wily killer that exploits the human need for social interaction and mobility. Analysing this sudden and rapid spread of the virus in the Subcontinent, it looks like South Asians are more vulnerable because of <a style="letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/nepals-virus-vortex/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/nepals-virus-vortex/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNFClAleG43b0LxtmN6SUTtqq0wUeA">our co-morbidities.</a>South Asians are known to be genetically more susceptible to diabetes and cardio-vascular diseases. The diet and lifestyle of people in the 40-70 age group increases the risk factor for obesity, diabetes and hypertension. Not unsurprisingly, the death toll due to Covid-19 is higher in this age cohort among South Asias than in Europe or the Americas.The other reason for the infection suddenly taking off again in our part of the world is that we let our guard down, attending festivals, religious ceremonies and political rallies.And then there is the presence in Nepal of both the UK variant of the virus ( B.1.1.7) and the B.1.617 (Indian variant) both of which are at least 20% more transmissible. The good news (at least so far) is that these variants may not be any more lethal than the standard virus. But even if they are not, we desperately need to stop transmission.And since this is a respiratory virus, the most effective way to do that is still to wear a mask, avoid crowds and use hand sanitiser.In a pandemic of this scale, the general public also needs to know what treatment works and does not. Oxygen, if available, is definitely helpful since it is a drop in oxygen level in the blood that leads to serious complications.A drug called dexamethasone saves lives, it is easily available and cheap. Tocilizumab, unavailable in Nepal, and expensive, can also be used to treat severely ill patients and should only be administered by a physician. There are web <a href="https://www.indiacovidsos.org/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.indiacovidsos.org/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNG9m03344ZEP5kR4-D9sw3xAz7ZjQ">links</a> with pragmatic tips that may come in handy if a hospital bed is not available, as we are now seeing in India and Nepal.There is a lot of fake news about the effectivity of treatment drugs. The following commonly used drugs for well-known illnesses do not work against Covid-19 although, even today, many are rampantly and unnecessarily prescribed in South Asia: Azithromycin, ivermectin, choloroquin, colchicine, convalescent plasma, vitamin D, zinc, lopinavir-ritonavir, favipiravir, and doxycycline.Even remdesivir, the drug that many desperate families try to acquire for their hospitalised relatives, does not save lives even though it is known to reduce hospital stay.Many of these drugs were studied for their efficacy by carrying out large randomised controlled trials by the biggest, adaptive Covid-19 tests undertaken by Oxford University’s <a href="https://www.recoverytrial.net/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.recoverytrial.net/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNFWVQpxuWW8Bb9WDrI4MR584LIUww">Recovery Trial</a>.The Nepal Health Research Council was the first country set-up outside the UK that recently started collaboration with Recovery Trial as part of a global effort to in order to help find a treatment drug against Covid-19.This tragedy has exposed the inadequacy and inequity in the health care system of Nepal and South Asia. The dominant method of health care delivery in the region, especially for curative services, are private enterprises that follow the corporate health care model patterned after the United States.Nepal has also increasingly gravitated towards this system of health care, with many new private hospitals all over the country. The pandemic will force us to question this model, and ask if alternatives like the UK National Health Service would be more suitable.Despite the vested interests behind the <a href="https://www.nepalitimes.com/here-now/kcs-fast-highlights-nepals-covid-19-failure/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/kcs-fast-highlights-nepals-covid-19-failure/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNGPAmj-NNRDt3JI_--ydl8p8gFc_A">medical-industrial complex</a> in Nepal, we need to plan for <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNGNZppXCvCMgFPm4GVAEVi5e8MJRg">universal health care (UHC)</a>, and even consider universal basic income (UBI), if we are going to improve health care to the vast majority of Nepali people.Even President Joe Biden is trying to reform US health care with a stimulus package that has clear aspects of UBI. We need to look at a combination of UHC and UBI in Nepal because even if we survive this pandemic, there is certain to be another one sooner or later.The international media has only taken notice of the second wave in Nepal after reports of infections at <a href="https://www.nepalitimes.com/banner/mt-everest-city/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/mt-everest-city/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNEXmV4I4K_YnFSjorLfpqWrs5_c0g">Mt Everest Base Camp</a> last week. But it is reassuring to know that even up there at 5,364m, Nepali specialists are doing their best to follow protocols to deal with suspected Covid-19 among climbers and support staff.This work is critical because the ubiquitous ‘Khumbu cough’ and even the life-threatening high altitude pulmonary edema (<a href="https://www.nepalitimes.com/latest/high-alert/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/high-alert/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNHi0ktDBncK6SypHGzDbi44cBgObw">HAPE</a>) simulate the symptoms of Covid-19, and it can be difficult to tell them apart.Buddha Basnyat, MD, is a clinical researcher at the Patan Academy of Health Sciences and an <a href="https://www.nepalitimes.com/latest/sherpa-genes-for-covid-19-treatment/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/sherpa-genes-for-covid-19-treatment/&amp;source=gmail&amp;ust=1620014851521000&amp;usg=AFQjCNEJKfShTwfhNqAdP0GvlMmh5-IMfQ">expert in high altitude medicine</a>. He is also a <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" target="_blank" rel="noopener noreferrer" 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=1620014851521000&amp;usg=AFQjCNF_WOWRO49qKaxdIzZ6QpXh6cnQpA">frequent health columnist</a> for Nepali Times.

How Nepal can survive 2nd Covid wave

<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.

Staying safe in 2021 and beyond

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181124/636be2bb9c7e80680e083ec6jpeg.jpg" alt="" width="1656" height="750"/><figcaption>Vaccine trial of a Covid-19 vaccine at Oxford University’s Jenner Institute. Photo: UNIVERSITY OF OXFORD/JOHN CAIRNS</figcaption></figure>Many Nepalis who had felt their government had not done enough <a href="https://www.nepalitimes.com/here-now/when-will-nepals-covid-vaccine-turn-come/" target="_blank" rel="noopener noreferrer">‘vaccine diplomacy’</a> to for Covid-19 immunisation could have been assured by visiting Indian Foreign Secretary Harsh Vardhan Shringla’s remarks on Thursday that India would give preference to Nepal when trials are over.Indeed, it may be more practical and cheaper for Nepal to rely on vaccine supplies from research centres in India and China than multinationals, whose supplies of new vaccines are ‘booked’ by the world’s richest countries into next year.Handing over 2,000 vials of the broad-spectrum antiviral drug, Remdesivir, to Foreign Minister Pradeep Gyawali, Shringla said: "We will make the vaccine accessible and affordable, and it goes without saying that first priority will be for our closest neighbours like Nepal. We will put our health ministers and regulators in touch when this vaccine enters the market, Nepal will have the fullest benefit."<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181124/636be2be9c7e80680e083ec7jpeg.jpg" alt="" width="1920" height="1080"><figcaption> </figcaption></figure>This week, the vaccine made by Oxford University in collaboration with the British-Swedish firm AstraZeneca was said to have 60-90% efficacy against Covid-19. The Oxford Vaccine has relevance for Nepal because the <a href="https://www.seruminstitute.com/" target="_blank" rel="noopener noreferrer">Serum Institute of India had</a> started manufacturing millions of doses of this vaccine long before the preliminary results of the trial came in.The Serum Institute of India is the world’s largest vaccine producer and already well-known in Nepal, especially for its anti-rabies vaccine that is commonly used here. The company had so much faith in the Oxford Vaccine, and it felt there would be such a rush later on, that it just went ahead and started manufacturing the vaccine, glass vials and stainless steel vats.Sure enough, preliminary results of the Oxford Vaccine now show that this gambit may have paid off for all concerned, including the people in India and its neighbouring countries.Adar Poonawallah, CEO of the Serum Institute of India has clearly made it his mission to manufacture the Covid-19 vaccine for the world’s poor. None other than Bill Gates is so impressed with his dedication that his foundation has committed millions of dollars to help with the project.Even as global Big Pharma roll out new vaccines, the difficult part will be to find ways to pay for the poorest people in the world’s poor countries to be immunised against Covid-19. Collaborative efforts like the one by the Serum Institute of India and COVAX appear to be the way to go.There is another interesting connection between the Oxford Vaccine and Nepal. The Chief Investigator of the Oxford Vaccine study, Prof Andrew Pollard has a long history of working in Nepal, especially in the prevention of typhoid fever. In December 2019, a paper on the milestone typhoid conjugate vaccine trial was published in <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1905047" target="_blank" rel="noopener noreferrer">The New England Journal of Medicine</a> by doctors at Patan Hospital in collaboration with Pollard and colleagues. This breakthrough may well lead to policy changes around the world where typhoid is still rampant.The unusual thing about the Oxford Vaccine is that, for some reason, the scientists administered only a half-dose of the vaccine on one group followed by the full second dose, as opposed to administering two full doses. Amazingly, the group that got the half dose followed by the full dose had a 90% vaccine efficacy compared to the group that was administered the full two doses, which registered only a 60% efficacy.It will be intriguing to see if the half dosage was planned, or was an oversight that leads to this welcome finding. The history of medical breakthroughs abounds in such serendipitous discoveries.The Oxford Vaccine announcement was preceded by American companies Pfizer and Moderna unveiling the breathtaking efficacy (&gt;90%) of their own Covid-19 vaccines. However, besides the $60 cost per dose, the cold chain maintenance of -70oC for Pfizer’s vaccine would be impossible for countries like Nepal.The Oxford Vaccine, on the other hand, does not require such extreme cold chain maintenance. The regular vaccine cold chain 2-8oC will suffice. More importantly, the cost is thought to be substantially less.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181124/636be2c19c7e80680e083ec8jpeg.jpg" alt="" width="1214" height="690"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181124/636be2c49c7e80680e083ec9jpeg.jpg" alt="" width="1188" height="754">It is clear that <a href="https://www.nepalitimes.com/opinion/a-covid-19-exit-strategy-for-nepal/" target="_blank" rel="noopener noreferrer">for Nepal, just the discovery of an efficacious vaccine will not be enough</a>. We must be able to have access to it, and also afford it. In addition, whether the vaccine prevents transmission or not is also going to be important -- together with whether or not it prevents severe illness.Their important considerations are all pending, but for now, we need to continue to wear masks, wash hands, and maintain social distancing. We may have to continue that practice even after the vaccination campaigns start.Because the Oxford Vaccine will be distributed by governments (not Oxford University) the Nepal government will need to liaise with the <a href="https://www.who.int/initiatives/act-accelerator/covax" target="_blank" rel="noopener noreferrer">World Health Organization-initiated COVAX</a>, which is the only global inter-governmental initiative working with manufacturers to ensure Covid-19 vaccines are available worldwide to both the rich and the poor.Most industrialised countries have already started placing orders for vaccines from Pfizer, Moderna and AstraZeneca, so there is every likelihood that COVAX will concentrate on ensuring vaccine supply to less-developed countries.Along with the Indian vaccines, results of the Chinese vaccine against Covid-19, which may well be just as effective and affordable, will probably be announced soon.The <a href="https://www.nepalitimes.com/latest/vax-populi/" target="_blank" rel="noopener noreferrer">Nepal government needs to coordinate closely</a> with groups like COVAX and keep its attention focused on obtaining the vaccine for Nepalis of all socio-economic strata.With Harsh Vardhan Shringla’s assurance this week in Kathmandu, it may also be useful to connect directly with the Serum Institute of India, which can play an instrumental role in supplying this all-important vaccine against Covid-19.<a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" target="_blank" rel="noopener noreferrer">Buddha Basnyat</a> is a clinical researcher at Patan Academy of Health Sciences and contributes this <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" target="_blank" rel="noopener noreferrer">health column</a>, Dhanvantari, for Nepali Times.

Glimmers of hope for Nepal on vaccine

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109141112/636ba78d9c7e80680e07378djpeg.jpg" alt="" width="957" height="638"/><figcaption>Photo: BIKRAM RAI</figcaption></figure>The Nepal Health Research Council has decided to allow international researchers to conduct Covid-19 vaccine trials in the country as part of a global effort to stop the virus. However, this is not a panacea, and an exit strategy from this pandemic should not just include vaccines.Vaccines may or may not work, and their immunity rates will vary. Other methods for tackling SARS-CoV-2 need to include diagnostics and therapeutics.DiagnosisAt present the definitive diagnosis is made by a cumbersome and sophisticated RT- PCR (Reverse Transcription Polymerase Chain Reaction) with a sample taken from the back of the mouth or naso-pharynx.More user-friendly tests need to be made available soon if we are to make testing easier and more prevalent. Scientists are trying to see if saliva samples can replace the awkward oral or nasopharyngeal swab samples.Ideal would be a RDT (Rapid Diagnostic Test) like a dip stick test, similar to what is available for pregnancy that does not require well-trained technicians and can be performed at home. This is easier said than done, but scientists are feverishly (pun intended) working on trying to make a much simpler test than PCRs available now.If a diagnosis using RDT is promptly and accurately made available in large quantities, it will be easier to decide who to isolate, and hence inhibit transmission of the virus – the main tenet of Covid-19 control.In addition, the importance of prompt testing is underlined by the fact that as the Nepali winter approaches there will be influenza and other viruses which may be mixed up with SARS-CoV-2, leading to unending confusion about who to isolate if tests are not easily available.In Nepal we know all to well the consequences of a wrong diagnosis, using RDTs such as the Widal Test to diagnose typhoid fever. Post-2015 earthquake in Nepal, many false-positive Widal Tests lead to treatment for typhoid fever when the patient in reality had typhus fever, a totally different disease which required a different antibiotic. As a result, the typhus fever was not controlled, sometimes with fatal consequences.TherapeuticsTreatments make up the other important exit strategy to rid the world of the pandemic. If a single, effective treatment (none exists so far) is found, it will not only help the index patient but also mitigate transmission of SARS-CoV-2.In terms of treatment research, randomised controlled trials (RCTs) are much more reliable and superior to observational studies of patient treatment as bias can lead to incorrect conclusions. In addition a large sample size, RCTs may be able to give a definitive answer.The importance of a proper sample size is illustrated by this example. Chinese doctors in Wuhan did such a good job in controlling Covid-19 that when they performed RCTs on Covid-19 patients using Remdesivir (an expensive antiviral drug, now available in Nepal ) in their hospital, they ran out of patients to study and did not have a large enough sample size to arrive at a definitive conclusion.Subsequently other groups studied Remdesivir and showed that it cut down the days (not mortality) in hospital for the sick patient. It was a spot of good luck that the largest (9,000 patients) randomised trial in for Covid-19 from the UK (the Recovery Trial) showed that the cheap steroid, Dexamethasone, although not a silver bullet, significantly decreased mortality in patients requiring oxygen.In the treatment of Covid-19, cost effectiveness will be an even more important factor for countries like Nepal. Ventilators may be important, but they are the last resort. Worldwide up to 90 % of Covid-19 patients on ventilators succumb to their illness because their condition is already so serious when they are attached to the machines.In this part of the world where a functioning arterial blood gas machine to help with the ventilator settings and other technical issues like availability of adequate oxygen are already potential problems, getting ventilators to work properly may also be an issue.The Covid-19 pandemic is a saga, it is a marathon not a 100 metre sprint. It will be important to be psychologically ready for the long-haul with this virus until at least one of the strategies -- vaccine, diagnostics or therapeutics -- works well.Luck is obviously going to play a big part in all of this, including serendipitous findings of which there is a history in medical research. Remember Alexander Fleming’s accidental discovery of penicillin?The good news is that the best scientific minds in the world are devoting all their time and energy in finding a way out. There is a lot of punditry and advice floating about, but most of it is at best guess work because this is a very wily virus.The <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=1598421240339000&amp;usg=AFQjCNH0zvBSZMMLSQvc5kYtRhr_xwj7_Q">Nepal government has got its work cut out</a> with the surge of the past month, it has to monitor the situation closely with the mantra of test, isolate and treat – as well as listen carefully to scientific facts, not rumours.Frequent hand washing is probably as important as distancing and wearing a mask, and adequate soap and water has to be provided including in quarantine areas. The government should not pretend the situation is getting better as it did when it <a href="https://www.nepalitimes.com/latest/nepal-ends-covid-19-lockdown/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-ends-covid-19-lockdown/&amp;source=gmail&amp;ust=1598421240339000&amp;usg=AFQjCNHvrS-j-Z63qT-h62KmHeFUPcysYg">lifted the lockdown on 21 July</a>. It is better to be over-prepared than under-prepared with periods of on-and-off lockdowns in the coming months.<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=1598421240339000&amp;usg=AFQjCNGHix4rBrAx8vz_0a47HkcVdlKHWg">Buddha Basnyat</a> 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=1598421240339000&amp;usg=AFQjCNGHix4rBrAx8vz_0a47HkcVdlKHWg">frequent health columnist</a> for Nepali Times.

A Covid-19 exit strategy for Nepal

<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221129121128/6385ed659c7e80680e0cc8d3jpeg.jpg" alt="" width="540" height="350"/>This pandemic is a time for clinical research to help humanity out of the crisis, and scientists are scrambling to find a <a href="https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines">COVID-19 vaccine.</a>It is urgent because if they do not do human trials during the pandemic, the infection rate may decline and the vaccine will not be well-tested enough to prevent this disease.This lack of cases and the resulting inability to test a strong candidate vaccine is exactly what happened to the zika virus vaccine. Zika may have run its course even as the vaccine study was getting underway. But there is every likelihood it may return with a vengeance without an effective vaccine in place.Many big pharma including Astra Zenca, Pfizer, Merck, and Johnson and Johnson are involved in the testing and manufacture of the COVID-19 vaccine. Companies in India, China, and Japan are also ramping up their efforts.Unfortunately, no promising drug treatment is on the horizon. <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31022-9/fulltext">Remdesivir,</a> convalescent plasma, interleukin inhibitors like tocilizumab, chloroquin are certainly not the silver bullets they are made out to be. But every bit of hope is useful.Last week, <a href="https://science.sciencemag.org/content/368/6495/1041">a riveting scandal rocked the medical world</a> that involved a team of doctors whose research into choloroquine and the journals that published the result.This antimalarial drug, discovered in 1934 and introduced generally in 1947, is one which humans have been most exposed to. Chloroquine is inexpensive and simple to administer. It remains a first-line treatment for non-falciparum malaria and is on the World Health Organisation (WHO) List of Essential Medicines.It has been used extensively as a continuous prophylaxis <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/Buzz-guts-of-the-anopheles,548">against malaria</a> for individual periods often exceeding five years, and has been the prophylactic drug of choice in pregnancy in order to avoid non-falciparum malaria. In addition to its antimalarial use both chloroquine, and the closely related hydroxychloroquine, are used in continuous daily dosing for common joint diseases like rheumatoid arthritis and lupus.Cholorquine in viral culture cells in research laboratory has been shown to suppress the novel betacoronavirus SARS-CoV-2, the cause of the <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/">COVID-19 infection</a>. This effect occurred when the drug was given either before or immediately after viral inoculation, not after a long lag period.An observational study purporting to use data from a multi-country registry was recently published in <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31324-6/fulltext">The Lancet</a>, revealing that regardless of any benefit chloroquine may (or may not) have for the treatment of COVID-19, there were unacceptable side-effects on the heart leading to decreased survival of the patients.But there was a problem with the study. Sapan Desai, one of the authors and owner of <a href="https://www.theguardian.com/world/2020/jun/03/covid-19-surgisphere-who-world-health-organization-hydroxychloroquine">Surgisphere Corporation</a> based in Chicago from where this registry  data was obtained, was, when requested, unable to share the dubious list.Desai’s colleague, Mandeep Mehra, the lead author, and other co-authors including Amit Patel have now <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31180-6/fulltext">retracted the article from The Lancet</a>. But the story does not end there.This same group of authors, some of whom work in prestigious institutions like Harvard (Mehra), also retracted a recent <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2016638">New England Journal of Medicine (NEJM) article</a> regarding COVID-19 where they had used data from Surgisphere Corporation, and when requested, were unable to share it.These retractions by the same set of authors (one of whom owns the data collection corporation) from two of the highest impact medical journals could suggest possible fraud. In addition, the editors of both the <a href="https://www.nejm.org/doi/full/10.1056/NEJMe2020388">NEJM</a> and <a href="https://www.abc.net.au/radionational/programs/healthreport/major-research-papers-retracted-over-data-controversy/12326900" target="_blank" rel="noopener noreferrer">The Lancet</a> were caught with their pants down in the rush to publish data.Finally, a proper randomised controlled trial named the Recovery Trial from the UK that utilised large numbers of patients who were treated with hydroxychloroquine revealed this week that the drug does not work in the treatment of COVID-19 patients.But whether chloroquin works in prevention (as opposed to treatment) of <a href="https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/">COVID-19</a>, especially in the vulnerable group of health workers, is not known and studies are continuing regarding pre-exposure to the virus. Medical science can be tricky. A drug not useful for treatment can often be useful for prevention.Potentially fraudulent studies notwithstanding, it is beneficial for countries like Nepal, after proper examination, to collaborate in international observational or randomised controlled trials like the <a href="https://www.nepalitimes.com/opinion/countries-cooperating-to-find-covid-19-cure/">WHO’s Solidarity Trials</a> for COVID-19 antidotes -- especially because it will help with capacity building in our region without desperately having to look for funding.The <a href="http://archive.nepalitimes.com/news.php?id=10203#.XuBQOS0w0Wo">Nepal Health Research Council</a> has been doing an excellent job of reviewing manuscripts and usually providing prompt feedback to the researchers in the region. However, what we medical researchers in South Asia lack is an appreciation of equipoise.‘Equipoise’ means curiosity, but it also has an element of humility. A true state of equipoise exists in research when there is no good basis for a choice between two or more options. In fact, the state of equipoise is the reason for doing research using RCTs.Unfortunately, many health care professionals in South Asia do not make room for this quality. For example, some institutions have turned down doing potentially useful, well-written and well-grounded multilateral studies in the mistaken belief that we know better that the drug or treatment in question does not work. How can this be assumed?This narrow belief may shut useful research out which ultimately could inform clinical treatment and help the patient. Helping the patient, at the end of the day, is what we all are trying to do.Buddha Basnyat is a clinical researcher at Patan Academy of Health Sciences and writes this <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/">frequent health column</a> Dhanvantari for Nepali Times.

The truth about the chloroquine scam

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221129121128/6385ed629c7e80680e0cc8d2jpeg.jpg" alt="" width="3501" height="1500"/><figcaption>Photos: MONIKA DEUPALA</figcaption></figure>The government has officially announced that the young woman who died in Dhulikhel Hospital on Saturday ten days after giving birth was Nepal’s first COVID-19 fatality.Although tests showed that she indeed was infected with the novel coronavirus, we do not know the true cause because she does not fit the demographics. There is no evidence yet that pregnant women or those who have just given birth are more prone to the illness.Could she, while being infected with COVID-19, have died of pulmonary embolism, or did she have fulminant pulmonary TB which is always a possibility in Nepal? Similar questions will be asked about the young Nepali worker who died in quarantine in Banke on Sunday soon after returning from India, the second to die of the coronavirus.The number of Nepalis testing positive for the novel coronavirus has now reached 291, with another 11 cases on Sunday from Rautahat. Overseas, 96 Nepalis have died of the virus, 77 of them women and 19 women. The majority of the deaths (63) were in UK, with 15 fatalities in the United States.COVID-19 continues its relentless global rampage, but it has also helped transform medicine in more positive ways.For example, patients with COPD (chronic obstructive pulmonary disease) are literally breathing easier because of cleaner air. Anecdotally, they are using much less supplemental oxygen, or have even stored their oxygen machines for now. Asthma exacerbations also appear to be significantly less.Doctors had thought such relief for COPD patients was not possible. And they acknowledge that this may just be a temporary reprieve, as air pollution levels are sure to climb once the lockdown is lifted.If people continue to wear masks (even a simple cloth masks) and frequently wash hands with soap, it will help keep in check out not only COVID-19 but other chronic respiratory and gastro-intestinal infections.<a href="https://www.nepalitimes.com/banner/covid-19-revives-nepals-wash-drive/">COVID-19 revives Nepal's WASH drive</a>, Sonia AwaleThere is every likelihood that because of COVID-19 precautions, <a href="https://www.nepalitimes.com/opinion/prevention-while-searching-for-a-cure/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/prevention-while-searching-for-a-cure/&amp;source=gmail&amp;ust=1589790313386000&amp;usg=AFQjCNHvgzXMfy84xALGle9mNXH0RXx7og">doctors in Nepal will be seeing fewer patients with lung and stomach ailments</a> once the pandemic retreats. This would be similar to the dramatic drop in orthopedic injuries at hospital emergencies post-breathalyser testing in Nepal.There could be many before and after COVID-19 studies, especially pertaining to infectious diseases that may show these differences in stark relief.Interestingly, there are heated debates about the efficacy of masks even though Hong Kong, China, Taiwan, South Korea and Japan have clearly shown that masks are instrumental in slowing the spread of the virus. Pro-mask advocates in the United States (where wearing one is seen as a violation of personal liberty) are fighting back with colourful twitter hashtags like #wearafuckingmask.Together with physical distancing, hand washing and masks are practical ways to prevent against this virus, regardless of when the vaccine will be available. Unfortunately, no promising drug treatment seems to be on the horizon in the ongoing clinical trials.<a href="https://www.nepalitimes.com/opinion/countries-cooperating-to-find-covid-19-cure/">Countries cooperating to find COVID-19 cure</a>, Buddha BasnyatAnother area that COVID-19 could change in medicine would be in diagnostics. The pandemic has revealed the importance of quick, reliable test kits for pre-existing biblical diseases that still plague countries like Nepal: tuberculosis, typhoid and typhus. These are some of the greatest killers in our part of the world and yet we have no quick reliable tests. Maybe COVID-19 will speed up the development of quick test kits for these disease too.The coronavirus crisis has also underlined the <a href="http://archive.nepalitimes.com/news.php?id=19038#.XsDmP_8za70" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/news.php?id%3D19038%23.XsDmP_8za70&amp;source=gmail&amp;ust=1589790313386000&amp;usg=AFQjCNE56RLoRySzMMticl6fCVZMtKP1sQ">importance of universal health care</a> which can save millions of poor in the poorest countries against catastrophic outbreaks.  Telemedicine, the importance of vaccines and properly conducted drug trials including other forms of medical research may now more clearly be understood, not only by health care professionals but the public at large.The other area of transformational change as a result of COVID-19, is in the  field of medical publications. There are more than 7,000 papers on the pandemic and many of them have published in pre-print sites like BioRxiv, MedRxiv, and Rxiv. Anyone can submit a paper and site managers will give a cursory look and decide to publish or not so that, if published, it is readily available to the world especially during the pandemic when speed and sharing of knowledge is of the essence.This is potentially hugely advantageous as scientists may be able to act on the findings and make a difference. These pre-prints can later be  subjected to the regular peer review process and be published in traditional journals which are slower, more secretive and cumbersome procedure.There is a down-side because unscrupulous scientists can make things up and publish in the pre-print format which has a greater chance of escaping the rigors of proper peer review. Indeed this is recently what happened.In January, Indian scientists claimed in BioRXiv that the <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=1589790313386000&amp;usg=AFQjCNFJWl79SvZNky2BZ44-K7znpR1G9Q">novel coronavirus </a> was manufactured in the laboratory because there were strong similarities between the genetic sequence of HIV and SARS-CoV-2. However many well-known molecular researchers were strongly critical of the methodology in the Indian study, which was thought to be a hoax, and was eventually retracted.The pandemic turbocharged the pre-print process for research papers. Most scientists may not bother with the ossified ways of initial peer reviewing, even though there clearly are dangerous pitfalls.Read also: <a href="https://www.nepalitimes.com/opinion/prevention-while-searching-for-a-cure/">Prevention while searching for a cure</a>, Buddha BasnyatBuddha 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=1589790313386000&amp;usg=AFQjCNFJWl79SvZNky2BZ44-K7znpR1G9Q">frequent health columnist</a> for Nepali Times.

Silver linings in the COVID cloud

<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

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110911110/636b7a719c7e80680e06475fjpeg.jpg" alt="" width="4096" height="2730"/><figcaption>Photo: BIKRAM RAI</figcaption></figure>We are in for the long-haul with <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=1585631034431000&amp;usg=AFQjCNE0aoyspsOeHIBjtexE2rB8xE3KOw">COVID-19</a>, as the rotating apex of the pandemic now jumps across the Atlantic to North America.Regardless of how this disease continues to play out this northern hemisphere summer, <a href="https://www.nepalitimes.com/banner/why-nepal-must-watch-about-coronavirus-but-not-panic/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/why-nepal-must-watch-about-coronavirus-but-not-panic/&amp;source=gmail&amp;ust=1585631034431000&amp;usg=AFQjCNGsF9kCG9HdHTkbHnhJCph-YXvjyg">we in Nepal</a> and elsewhere will still be dealing with it for the rest of 2020. All models predict there will be ‘hill and valley’ outbreaks as the epidemic peaks and falls.Widespread testing, <a href="https://www.nepalitimes.com/banner/covid-19-revives-nepals-wash-drive/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/covid-19-revives-nepals-wash-drive/&amp;source=gmail&amp;ust=1585631034431000&amp;usg=AFQjCNHYGCrEzyig3O9ciAuasBRIgLs7UA">hand washing</a>, physical distancing and masks in certain situations will certainly make a difference together with lockdowns of the kind we are going through.An effective vaccine will be the game-changer, but it is still at least a year away if we are lucky. In the meantime a potent  drug therapy antidote against this disease would be most welcome.Labs in China, Italy, France, USA, the UK and other countries are doing drug trials even as they deal with the onslaught of the disease. Once the disease is established, there is no other way but to do proper drug trials to treat the disease.The <a href="https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---27-march-2020" data-saferedirecturl="https://www.google.com/url?q=https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---27-march-2020&amp;source=gmail&amp;ust=1585631034431000&amp;usg=AFQjCNGcLzzT197xKt0zj3Z9v_q9ITSVtg">World Health Organization (WHO)</a> has come up with an  innovative idea of carrying out what it calls a public health emergency ‘Solidarity’ trial – an international, randomised trial of hospitalised patients with COVID-19.This is ground-breaking because rich and poor countries will be involved in the study, and crucially, it is being carried out in the midst of the pandemic. There was a time when studies like these would be considered after the dust settled.Difficult as it may be, the pandemic is the best time to find a treatment so that more people can benefit. Large sample sizes are needed for conclusions from such a study to be robust and reliable. Findings from a trial using 100 patients will be less certain than a study which employs 1,000.Norway, South Africa, Argentina, and Iran among others have already signed up for the study which has just begun. The WHO is inviting many countries to participate in Solidarity trials so that the results can be generalised and trustworthy.Because the study is being carried out ‘in the heat of the battle’ WHO has kept the study very simple. The trial procedures are greatly simplified, and no paperwork is required. Once the institution has obtained national approval and informed consent from the patient, electronic data entry takes a few minutes.These modern studies using electronic data entry versus paperwork are really not new in countries in South Asia including Nepal which have taken part in state-of–the art collaborative studies before.This WHO COVID-19 trial has four drug arms: Remdesivir, Kaletra (2 anti-HIV drugs), Interferon and Kaletra, and Chloroquin or hydroxychloroquin. All patients will receive the standard of care in their country, and in addition will be randomised to  one of the arms.These drugs are not new and have been used against various viral and parasitical diseases in the past. For example, chloroquin has been used for many decades against malaria. Doctors will be familiar with these repurposed drugs and their side-effects which sometimes can  be worse than the treatment. Hence the importance of a robust drug trial.The final outcomes to determine which is the best choice, if any, among these four arms have also been kept clear-cut: number of deaths, ventilator use, and number of days in hospital.Because this is a WHO-lead practical study focusing on helping resource-limited settings, it is important that countries in South Asia including Nepal be involved. Funding may not necessarily be a problem.  Many countries in South Asia can at least be randomised to chlorquin or hydroxycholorquin which are not expensive to see if this drug works against COVID-19 or not.President Trump said he “felt good” about hydoxychloroquin, but this needs scientific backing which does not exist yet. The published French study that concluded usefulness of chloroquin had a very small sample size, did not report clinical outcomes and was not randomised to be scientifically sound.Similarly the Chinese study using Kaletra and recently reported in the <a href="https://www.nejm.org/" data-saferedirecturl="https://www.google.com/url?q=https://www.nejm.org/&amp;source=gmail&amp;ust=1585631034431000&amp;usg=AFQjCNHGStErHdTfc8Gm40_rBDqZh_c9Mg">New England Journal of Medicine</a> also had shortcomings. Hence the need for a larger sample size which the WHO’s Solidarity trial is poised to do.In Nepal, the best-placed institution to help carry out such an important study with potentially multiple hospitals involved is the Nepal Health Research Council ( NHRC), a revered 30-year-old institution.True, Nepal has only three COVID-19 patients in hospitals right now, but the possibility of this number growing exponentially soon cannot easily be dismissed. It is best to get the practical research system in place, especially because the WHO will welcome the move, and may help with the process so that we may be better able to help our patients with useful, and not harmful, drugs.It will also give NHRC a chance to help nurture the talent of a young Nepali researcher to help drive this study in Nepal, coordinating with the different hospitals. This is an opportunity that should not be missed.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=1585631034431000&amp;usg=AFQjCNE0aoyspsOeHIBjtexE2rB8xE3KOw">frequent health columnist</a> for Nepali Times.

Countries cooperating to find COVID-19 cure

Nepal’s only international aviation gateway, at Kathmandu airport, will cut night-time operation hours to allow construction of taxiways, and airlines have been told to curtail flights. This is expected to lead to more than normal chaos during the height of peak autumn and spring tourist seasons at an airport that is congested even at the best of times. The airport will close from 10PM to 8AM from 8 November-31 March 2025. The taxiways will now connect to the thresholds at both ends of the runway, making the airport more efficient in handling higher frequencies of landings and takeoffs. The parallel taxiway extension will allow international flights to land every 4 minutes instead of the current every 7 minutes. At present planes have to wait to land until a plane taking off backtracks along the runway.&nbsp; Kathmandu is Nepal’s only airport with international operations, and it has only one runway that is only one way in from the south over the mountains. With the taxiway improvement, the airport will be able to handle 42 aircraft landings and takeoffs per hour — double the current capacity.&nbsp; The Civil Aviation Authority of Nepal (CAAN) has been trying to entice international airlines to also start flying to and from the other two international airports at Pokhara and Bhairawa (Lumbini) by slashing landing and handling charges. But so far only Nepal Airlines operates a weekly flight to Bhairawa from Kuala Lumpur.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241018161016_046569e53d1d66cd445cc66c697c0ef724810aec9f54bdf827481e3cd6b80c32.jpg" data-media-id="editor_0" data-image-id="20241018161016_046569e53d1d66cd445cc66c697c0ef724810aec9f54bdf827481e3cd6b80c32" data-rendition-name="original" width="2356" height="1134" loading="lazy" alt="Kathmandu airport expansion"> <figcaption>Kathmandu Airport Expansion plan with extension of taxiways to the thresholds of runways 02 and 20 that will limit airport operations from 8 November 2024 - 31 March 2025. Areas in blue are existing structures, including the international terminal which in future will be the domestic airport, and the new international terminal near the north end of the runway,</figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241018121028_6e17cc2ee87c1b02d78cb54905825b7aa15299b7a00f5eddb01a59579ab85c1a.jpg" data-media-id="editor_1" data-image-id="20241018121028_6e17cc2ee87c1b02d78cb54905825b7aa15299b7a00f5eddb01a59579ab85c1a" data-rendition-name="original" width="1353" height="1328" loading="lazy" alt="Kathmandu airport NT"> </figure>  CAAN has reportedly told international airlines to cut their flight frequency to Kathmandu citing the shorter operation hours and has told budget airlines to shift some of their flights to Pokhara or Bhairawa, or face cuts. Many airlines currently operate regular flights to and from Kathmandu between 10PM and 8AM: Air Arabia to Sharjah, Fly Dubai to Dubai, Jazeera Airways to Kuwait, Cathay Pacific to Hong Kong, Singapore Airlines, several Nepal Airlines flights, and one of four daily flights by Qatar Airways to Doha. Jazeera Airways, FlyDubai, and Thai AirAsia have applied and got permission from CAAN to begin regular flights to Bhairawa’s Gautam Buddha International Airport. Starting 9 November, FlyDubai will start making a stopover in Bhairawa before flying on to Kathmandu. Immigration, customs and security are all fully functional in Bhairawa. In Kathmandu, the next phase of the airport upgrade includes converting the current international terminal for domestic operations, the construction of a new international terminal where the domestic departure area is now, as well as moving the hangars and the Nepal Army Air Wing to the eastern side of the runway. The apron area will also double its parking space for widebody jets. This is part of a Airport Capacity Enhancement Project that was initially funded through a $80 million loan from the Asian Development Bank (ADB), and the entire masterplan is expected to cost $800 million. This project is the latest upgrade to Nepal’s only international airport since it saw its first flight in 1949. The current international and domestic terminals are too small to handle the current annual traffic volume of 8.5 million passengers a year that is growing at 20% a year.

Kathmandu airport to cut flight hours

As Kathmandu becomes more congested and polluted, and with remote online work becoming the norm, many professional Nepalis are planning to retire in Pokhara, or move there.&nbsp; With its stunning mountain panorama, balmy winters and proximity to a profusion of wilderness areas, builders are responding to this demand with new townhouses, housing development and apartments. One such block of flats is the 10-storey <a href="https://sungavaapartment.com/">Sungava Apartment</a> located at Phulbari above the Seti River, near the point where it flows into and under Pokhara. The imposing structure near Manipal Hospital is almost complete, and on a recent visit the site was strewn with huge boulders unearthed while digging the foundation.&nbsp; The Seti brought down these boulders during a gigantic flood that geologists estimate happened 800 years ago when a chunk of Annapurna IV broke off and ploughed into the glacier below. Today, Sungava (means ‘orchid’) sits safely on a high terrace, 100m above the blue-green Seti and commands a view of Dhaulagiri, Annapurna South, Machapuchre, Annapurna III and IV.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024102411104_5f8fc736c86ea3c08d7bef43bb727081d3cc1a2caa55ae2b441717e6044de7e9.jpg" data-media-id="editor_1" data-image-id="2024102411104_5f8fc736c86ea3c08d7bef43bb727081d3cc1a2caa55ae2b441717e6044de7e9" data-rendition-name="original" width="2016" height="1512" loading="lazy" alt="High living below the Himalaya NT"> </figure>  The soil here is conglomerate that has solidified like concrete, and the boulders were extracted by heavy earthmovers. It is intriguing to think that these metamorphic rocks as big as cars, rounded by glacial grinding, were once a part of a much higher Annapurna IV. Even for those with little interest in geology, Sungava is an ideal place to contemplate the tectonic forces that pushed these peaks into the sky to be sculpted into delicate shapes by wind, snow, earthquake and avalanche over millions of years. The view of the Himalayan panorama from Sungava’s many balconies are breathtaking when not obscured by clouds, or the haze that drifts in from across the southern border. On most days, just watching the towering pyramid of Machapuchre (Tamu name: कतासुँ क्लिको) play hide and seek with the clouds is mesmerising. There are rocks aplenty at Phulbari, and it is probably the flowers that grew along the flat terraces e that gave the place its flowery name. The boulders will hopefully be turned into a rock garden while landscaping. An nearby restaurant complex is making the best use of the stones in its design, using flat rocks as outdoor benches and tables. Sungava was designed by the husband-wife architect team of Deepak Sherchan and Jyoti Joshi of <a href="https://thedarkmermaidamarbshrestha.blogspot.com/2013/12/creative-builders-collaborative-cbc.html">Creative Builders Collaborative (CBC)</a>, which also built Heritage Plaza, Indreni Apartment and numerous other projects in Nepal. Sadbhavana retains CBC’s trademark Newari-style masonry and here it borrows from the orange brickwork of the old town of Pokhara, integrating it with modern design elements. A few of those heritage houses are still standing in Ganesh Tole and Ram Krishna Tole in Pokhara’s old quarter.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024102411108_5eb64a4885961b6d30781cefeb1e8a313da313ac5227c7a66b60f0c7d48d6fab.jpg" data-media-id="editor_3" data-image-id="2024102411108_5eb64a4885961b6d30781cefeb1e8a313da313ac5227c7a66b60f0c7d48d6fab" data-rendition-name="original" width="1362" height="595" loading="lazy" alt="High living below the Himalaya NT"> </figure>  About 400m from the apartment past a bend on the river, and down below three tiers of terraces in the canyon is a suspension bridge. Below it, the Seti is still swollen with post-monsoon flow as it tumbles away in a hurry to head down south.&nbsp; Back at the apartment, it is quiet, far away from the hubbub of Lakeside a 15 minute drive away, and in the lap of greenery. There are 52 units at Sungava and it already has a close-knit prospective community of professionals, including doctors, publishers, engineers, and businesspeople from the renewable energy and IT sectors.&nbsp; Some residents say they opted for a second home in Pokhara to make it a ‘base camp’ to explore the Annapurnas with its many hiking trails made newly accessible with new roads. With the NRN citizenship law, overseas Nepalis can now also buy the flats. &nbsp; The floor plans include options for north and south-facing 3-bedroom apartments with verandas, and the facility has underground parking has EV charging, heated pool, sauna and gym. There are still some unsold apartments with panoramic views of the mountains and one can imagine oneself at the kitchen with its huge window, humming a ditty while preparing breakfast: “खाना पकाउँ हिमाल हेरेर...”

High living below the Himalaya

When the United Nations held its Summit of the Future at its headquarters in New York in September, many world leaders, including Nepal’s Prime Minister K P Oli, highlighted the effect of climate breakdown in increasing the frequency and intensity of natural disasters. What did not get as much attention was the long term impact of the climate crisis on food production. In fact, heat stress, weather extremes and the consequences on rain-fed agriculture is already being felt worldwide, undermining the chances of the <a href="https://unstats.un.org/sdgs/">UN’s Sustainable Development Goals (SDGs)</a> being met by 2030.&nbsp; The SDG’s 17 targets commit countries like Nepal to reduce poverty and inequality, end malnutrition, protect the natural environment, and ensure that citizens all enjoy health, justice and prosperity without leaving anyone behind.&nbsp; However, besides the impact of climate breakdown on agricultural production, in Nepal the area under cultivation is impacted by urban expansion, falling productivity and the need for expensive inputs like fertiliser and pesticides.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241019041052_626413c5baf4dae407ac9579231b41daeb51510aa636b75aeb7489d94cca6a62.jpg" data-media-id="editor_1" data-image-id="20241019041052_626413c5baf4dae407ac9579231b41daeb51510aa636b75aeb7489d94cca6a62" data-rendition-name="original" width="999" height="1500" loading="lazy" alt="urban agriculture in Kathmandu"> <figcaption>Kathmandu's urban sprawl is eating into its fertile cultivable lands. Photo: TAYLOR MASON</figcaption> </figure>  Now, a new study led by Nepali researcher Prajal Pradhan at the University of Groningen in The Netherlands looks at how urban agriculture may offer a solution to falling food production and meeting SDG targets. The researchers evaluated 1,450 publications exploring the contributions of urban agriculture with both positive and negative effects, and published their findings in the journal Cells Report Sustainability. Urban agriculture can help achieve 17 SDGs, positively influencing 81 targets. However, it could also undermine 51 goals.&nbsp; Read also: <a href="https://nepalitimes.com/here-now/the-vanishing-land">The vanishing land</a>, Taylor Mason “Urban agriculture offers immense potential for sustainable development, but realising this potential depends crucially on adopting practices that minimise its adverse effects while maximising its benefits,” Pradhan explains. Urban agriculture can substantially enhance urban food security, provide employment to the urban poor, serve as ground water recharge in built-up areas, and preserve open spaces that can serve as safe havens during disasters like earthquakes. However, it also presents problems like the potential health risks from contamination and the need for expensive inputs. &nbsp; “Urban agriculture plays a definitive role in advancing the SDGs, but achieving this requires tailored, context-specific solutions that address the unique challenges of different regions,” says Yuanchao Hu of Wuhan University in China and who is a researcher at the Potsdam Institute for Climate Impact Research. “But it needs equitable access and rigorous management of environmental risks.”&nbsp; Rapid urbanisation is eating into Nepal’s most fertile agricultural land, which means farming in remaining open spaces inside cities can be a viable alternative, especially as food prices rise.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241019041052_7b7c9413086226fbdc630d45acf772cfa1ced77a8970b9056ec5ec7e5226fdf8.jpg" data-media-id="editor_3" data-image-id="20241019041052_7b7c9413086226fbdc630d45acf772cfa1ced77a8970b9056ec5ec7e5226fdf8" data-rendition-name="original" width="1500" height="999" loading="lazy" alt="urban agriculture in Kathmandu"> <figcaption>A vegetable patch in between new houses in Thimi. Photo: TAYLOR MASON</figcaption> </figure>  “The conversion of Nepal’s most fertile land into cities is a severe problem,” Pradhan told Nepali Times. “Crop cultivation, horticulture, agroforestry, beekeeping, livestock rearing, or aquaculture can all be farming activities within and around cities.”&nbsp; The study makes recommendations for sustainable practices that build on the positive aspects of urban agriculture while mitigating the downsides, thereby promoting more resilient cities in future. Research shows that urban agriculture has been helping many countries attain SDG targets by enhancing food security and biodiversity while helping education and preservation of open spaces.&nbsp; Indeed, many farmers from the hinterland who have settled in Kathmandu Valley or other urban areas of the country have been practicing urban agriculture, leasing neighbourhood patches or cultivating roof gardens both out of necessity because of inflation and falling income to grow their own food, and also as a fulfilling hobby. Saurav Dhakal, a sustainability advocate with Story Cycle and now research fellow at the Asian Institute of Technology in Thailand, says there are socio-economic and environmental benefits of urban agriculture. “It provides benefits to all urban dwellers, regardless of their income status,” says Dhakal, “families get fresh food, and there are many other benefits like water retention, heat regulation and biodiversity. These are all public goods, so special government incentives may be needed.” It is not unusual to see vegetable patches and even paddy fields within inner city Kathmandu where an older generation of farmers are using available fertile land and <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/rooftop-gardens-kathmandu,1415">roof gardens to produce fresh, nutritious food </a>to reduce their dependence on food items that have to be bought after being trucked in from large distances.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024101905100_1291ce98dbbb8caed8702ac4b1d469b3e13016d7ecaaf3bfd5f91c974d3c0c77.jpg" data-media-id="editor_5" data-image-id="2024101905100_1291ce98dbbb8caed8702ac4b1d469b3e13016d7ecaaf3bfd5f91c974d3c0c77" data-rendition-name="original" width="1500" height="999" loading="lazy" alt="urban agriculture in Kathmandu"> <figcaption>An older generation of farmers are using any available fertile land to continue farming but it is getting more and more difficult. Photo: TAYLOR MASON </figcaption> </figure>  Nepal’s urban population grew rapidly from only 3.6% in 1991 to 25% today. There is large outmigration from the mountains to peri-urban areas of the Tarai, to Kathmandu Valley and Pokhara, with many young men then moving abroad for work. Kathmandu Valley’s population has swelled to nearly 3 million, and is growing at 6.5% a year. Dilip Shrestha, 71, used to work for Nepal Food Corporation, so he knew firsthand about inflation, shortages and vegetables with pesticide residue. So, when he designed his new house in Kathmandu, he built a spacious roof where he grows cucumber, ginger, garlic, coriander, onions, tomatoes, chili, beans, okra, pumpkin and lettuce. His family eats healthier, and he has reduced dependence on the market.&nbsp; The co-author of the Cell Reports Sustainability journal article, Daya Raj Subedi who is a PhD candidate at Beijing Forestry University, says urban agriculture also promotes inclusion and psycho-social wellbeing.&nbsp; He says, “A crucial finding of the study is the identification of opportunities and challenges associated with urban agriculture, it can promote sustainable transformation of society.” In Banepa, 55-year-old Bijaya Manandhar in her lifetime has watched the fertile farms of her neighbourhood that used to supply vegetables to Kathmandu, now completely built up with no open space left. The pandemic lockdown prompted her to turn to the family’s <a href="https://nepalitimes.com/banner/rooftop-agriculture-on-the-roof-of-the-world">ancestral livelihood by growing food</a> not on terrace farms, but on the roof terrace. Manandhar is now a part of <a href="https://nepalitimes.com/banner/rooftop-agriculture-on-the-roof-of-the-world%5C%5C">कौसी खेती र करेसाबारी क्रान्ती</a> (Rooftop Farming and Garden Revolution) which has an online membership of 52,000, and awards annual prizes to women who excel in urban agriculture.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241019041052_7257f5def8f823f35a799fa6f6825e153f2ffa406ac11325d4fe74049b79e96d.jpg" data-media-id="editor_8" data-image-id="20241019041052_7257f5def8f823f35a799fa6f6825e153f2ffa406ac11325d4fe74049b79e96d" data-rendition-name="original" width="1600" height="736" loading="lazy" alt="urban agriculture in Kathmandu"> <figcaption>Rooftop farming is gaining popularity as a form of urban agriculture. </figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241019041052_beff1a4494ce896dd8fd383ee1f518e5448bcf7ea8bb138255391c7bcb9769ed.jpg" data-media-id="editor_9" data-image-id="20241019041052_beff1a4494ce896dd8fd383ee1f518e5448bcf7ea8bb138255391c7bcb9769ed" data-rendition-name="original" width="4000" height="3000" loading="lazy" alt="urban agriculture in Kathmandu"> </figure>  Pradhan says the challenge now is to upscale such examples of successful urban agricultural practices so they support Neal’s efforts to meet SDG targets. He adds, “Crop cultivation around cities can be protected by land use plans and regulations. Promoting community-based agriculture, including rooftop gardens, requires community engagement and public-private partnerships across the food value chain.”&nbsp; Such support would accelerate the popularity of existing rooftop farming and community gardens in Kathmandu Valley, or kitchen garden initiatives in Pokhara, and building on traditional farming practices that are preserved and integrated into urban settings like in Bhaktapur and Banepa. In Lalitpur, the Women Entrepreneurship Facilitation Center promotes urban farming enhancing both sustainability and empowerment.&nbsp; Another co-author of the report, Yuanchao Hu from China says followup research of the team will aim to identify good practices in local urban agriculture practices. He adds, “There are examples of urban agriculture that optimise sustainability, ensuring that it remains a viable solution for cities globally while countries try to meet SDG targets.” Prajal Pradhan, Daya Raj Subedi, Kshitij Dahal, Yuanchao Hu, Prakriti Gurung, Sijal Pokharel, Sagar Kafle, Biplav Khatri, Sudeeksha Basyal, Monika Gurung, and Aruna Joshi. Urban Agriculture matters for sustainable development. Cell Reports Sustainability, 1:100217, 2024. [DOI: 10.1016/j.crsus.2024.100217] Prajal Pradhan (<a href="mailto:p.pradhan@rug.nl">p.pradhan@rug.nl</a>) This article is brought to you by <a href="https://nepalitimes.com/" target="_blank">Nepali Times</a>, in collaboration with <a href="https://inpsjapan.com/en/" target="_blank">INPS Japan</a> and <a href="https://sgi-peace.org/" target="_blank">Soka Gakkai International</a>, in consultative status with UN ECOSOC.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240630110640_30c3782f9c09219bf1c249b51483a3cfb7a53a06d117d2aebd23ca7080d12758.jpg" data-media-id="editor_14" data-image-id="20240630110640_30c3782f9c09219bf1c249b51483a3cfb7a53a06d117d2aebd23ca7080d12758" data-rendition-name="original" width="680" height="103" loading="lazy" alt="SDG logo"> </figure>

Back to the land in the cities

The 700-year-old Lakshmi Narasingha temple in Bhaktapur houses a rare half-lion and half-human incarnation of Lord Vishnu carrying the Goddess Lakshmi. The temple was destroyed in the 1934 mega earthquake that killed 10,000 people and destroyed many monuments in Kathmandu Valley. It was rebuilt by a German project in the 1980s, but as a single-storey structure instead of its original two-tier pagoda design.&nbsp; With new findings from in-depth research, Bhaktapur municipality began re-restoring the temple in 2021, preserving its original architecture.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241017131016_2fae38cce543ad7b1f6de632feb3e212e08ed1acedd747830e949d7b8e878f18.jpg" data-media-id="editor_0" data-image-id="20241017131016_2fae38cce543ad7b1f6de632feb3e212e08ed1acedd747830e949d7b8e878f18" data-rendition-name="original" width="2048" height="1365" loading="lazy" alt="In with the old in Nepal NT"> </figure>  “Our temples and heritage sites hold deep meaning. It is disheartening to witness how often they lose their original elements, whether by design or accident,” explains Kumar Chawal of the Consumer Committee of Bhaktapur. “There is a need to preserve our architecture and protect its historical value for future generations. Otherwise, we risk losing a vital part of our identity.” The Laksmi Narsingha restoration is similar to the Bhai Dega temple in Patan Darbar Square which also collapsed in 1934, but was rebuilt with a Moghul-style dome by the Rana government at the time. Only two months before the 2015 earthquake, heritage conservationists had started to rebuild Bhai Dega as the original three-tier based on early photographs. But priorities shifted when four other temples in the square were brought down by the 7.8M earthquake on 25 April 2015.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241017131016_697ea707d9ad163be5de5f2efbf5b70d3cab771adcc22f0fae6bf937c6cb0130.jpg" data-media-id="editor_1" data-image-id="20241017131016_697ea707d9ad163be5de5f2efbf5b70d3cab771adcc22f0fae6bf937c6cb0130" data-rendition-name="original" width="2048" height="1365" loading="lazy" alt="In with the old in Nepal NT"> </figure>  This showed how damage to monuments in Kathmandu Valley spanned from one earthquake to the next. Bhai Dega restoration remains half-complete to this day because money for its restoration ran out.&nbsp; Whereas Bhai Dega restoration was done by the Kathmandu Valley Preservation Trust with grants from western embassies and international foundations, in Bhaktapur it is the municipality itself that allocated the Rs30.7 million needed to restore the Lakshmi Narasingha temple. The expected date of completion is early 2025. The municipality and local communities are focusing on two main aspects: preserving the past and promoting localisation. The restoration team has designed a blueprint for the temple by using historical photographs and insights from older generations.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241017131016_182882fdc393c99e70d1d0490319e415229563666c4934e3a582426ebf00ca30.jpg" data-media-id="editor_2" data-image-id="20241017131016_182882fdc393c99e70d1d0490319e415229563666c4934e3a582426ebf00ca30" data-rendition-name="original" width="1200" height="560" loading="lazy" alt="In with the old in Nepal NT"> </figure>  “At first, the Lakshmi Narasingha temple had only one entrance, but during the demolition process, we uncovered the foundations of four doors. Now, we are restoring all of them. This is an example of how our ancient structures have changed over time, often without our knowledge,” says Chawal. “Constructing temples is not like building houses. They carry historical and spiritual values, which is why they hold a special place in our hearts,” he adds. By replicating ancient design elements and rebuilding the temple as accurately as possible to its original form, the team has stayed true to Bhaktapur’s soul. But the restoration also revived ancient techniques that were in danger of being forgotten, generating employment for woodcarvers, masons, and contractors. The community of Bhaktapur’s Gahiti neighbourhood near the famous Nyatapola Temple has also set aside specific days for locals to volunteer in the reconstruction work. This has encouraged young people to take pride in ownership of their heritage. Families have also supported the effort by donating funds for bells, the temple pinnacle, and other structural features to the temple.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241017131016_db850ec0c084cdbe54f65bee92dad2ad8122d20fd60ec87ec086fbb9d2f72bd6.jpg" data-media-id="editor_3" data-image-id="20241017131016_db850ec0c084cdbe54f65bee92dad2ad8122d20fd60ec87ec086fbb9d2f72bd6" data-rendition-name="original" width="2048" height="1365" loading="lazy" alt="In with the old in Nepal NT"> </figure>  “I feel at peace knowing I have contributed my sweat to restoring this temple,” said one volunteer. “It is our duty to preserve our temples and heritage. The Nyatapola area will look magical once this temple is completed.” Community mobilisation is a long-standing tradition in Bhaktapur. In the past, locals have actively participated in the restoration of other temples in the city, such as Bhairav and Nyatapola fostering a strong sense of ownership. This collective engagement has not only been crucial in preserving the city's historical monuments but also in strengthening the bond between local communities and their heritage, says officials at the municipality. While securing funding is essential, and the municipality showed it values heritage conservation, the Lakshmi Narasingha restoration is proof that active involvement and sense of responsibility of the local community is as important, if not more. Local involvement also means that the monuments will be cared for into the future, When locals take ownership of these efforts, the restored monuments are not only protected in the present but are also cared for in the future.