Orthopedic surgeon Anil Shrestha’s journey to medicine was laid down well before he was born. His father, noted industrialist Juddha Bahadur Shrestha, had aspired to become a doctor but was turned away from a medical school in India.&nbsp; "It became his mission that one of us, his sons, nephews, or nieces, would don that white coat," recalls Shrestha. That dream fell upon him, the youngest son, and he enrolled at Calcutta Medical College.&nbsp; Freshly graduated he returned to Nepal, where he hoped for a comfortable post at a hospital in Kathmandu. Instead, he was assigned to Jumla, a district which was even remoter and underserved than it is now. But that journey 40 years ago would prove transformative.&nbsp; "It was an eye-opener. I had no idea what rural Nepal was really like. When I reached Jumla, I asked myself why do we become doctors? It is because we have to make a difference," he recalls.&nbsp; The moment that would forever shape his approach to medicine happened at a government-run medical camp. An injured man had travelled from a remote village all the way to Kathmandu for surgery, selling his land to pay for it. He needed to remove his implants but faced a grim reality of having to sell more of his land to afford the procedure.&nbsp; "I thought to myself that we treat the x-rays, but we don’t treat the patients," &nbsp;Shrestha told us in an interview. &nbsp;"What good is a perfectly functioning hand if this man could no longer have a land to plough?" The encounter made the physician realise that healthcare in Nepal should look beyond symptoms and &nbsp;diagnoses, and consider the socio-economic realities of patients. He made it his mission to provide care that didn’t just fix bodies but addressed the underlying factors affecting people’s lives.&nbsp; He co-founded the <a href="https://noh.com.np">Nepal Orthopaedic Hospital</a> in 1998 to provide high-quality surgery at affordable prices. But when he arrived at the site near Gokarna, it was anything but promising.&nbsp; Read also:<a href="https://nepalitimes.com/here-now/nepali-surgeon-with-a-vision-for-the-world"> Nepali surgeon with a vision for the world</a>, Kunda Dixit  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024101613108_1a9d74aa1c1b550ff9db42dd8092f214de353ffbb2eb48549db110201424cafd.jpg" data-media-id="editor_2" data-image-id="2024101613108_1a9d74aa1c1b550ff9db42dd8092f214de353ffbb2eb48549db110201424cafd" data-rendition-name="original" width="813" height="520" loading="lazy" alt="Nepal Orthopaedic Hospital"> <figcaption>Photo courtesy: NEPAL ORTHOPAEDIC HOSPITAL</figcaption> </figure>  "It was just two blocks of a one-story building," he recalls. "They said: Here’s the hospital. Run it. But buildings don’t make hospitals. You need doctors, you need equipment, you need patients."&nbsp; With a bold plan and support of friends and international donors, Shrestha started with 15 beds, providing care to anyone in need, regardless of their ability to pay. Initially, 93% of their operating expenses were covered by international donors but in less than 10 years, it had reversed the figures so that most of the cost was covered by internal resources. The hospital is self-sufficient today and does not turn away any patient that cannot afford the cost. Over the past 25 years, it has given more than $1 million in charity care.&nbsp; But Shrestha’s job was far from over. Realising the chronic lack of proper spinal care in Nepal, he got involved with the <a href="https://sisn.org.np/sirc/">Spinal Injury Rehabilitation Center in Sanga</a> in 2001, offering holistic treatment to paraplegic and quadriplegic patients. It was a leap of faith-started with a few friends, a handful of nurses, and no specialised doctors.&nbsp; "We just knew the need. People, especially women were falling off trees and cliffs, injuring their backs," Shrestha says, “They needed rehabilitation and physiotherapy, and we thought, why wait? You start small, and if you’re doing well, others will help you."&nbsp; Shrestha had long believed that healthcare in Nepal needed to reach the farthest corner, and after working with Nick Simons Institute (NSI) he realised that <a href="https://nepalitimes.com/news/jim-simon-s-gift-to-nepal">partnering with government hospitals</a> can better strengthen the overall health system. Shrestha’s journey took another turn when he was asked to join the board of OneHeart Worldwide, whose mission, to reduce maternal and neonatal mortality in Nepal’s most underserved areas, deeply resonated with him.&nbsp; Read also: <a href="https://nepalitimes.com/here-now/nepal-s-flying-doctor">Nepal's flying doctor</a>, Kunda Dixit  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241016131020_15d6c1483ea69455b998ba6fd6ecc0ac5eafe3af6effc2214f48f148bee0b540.jpg" data-media-id="editor_6" data-image-id="20241016131020_15d6c1483ea69455b998ba6fd6ecc0ac5eafe3af6effc2214f48f148bee0b540" data-rendition-name="original" width="2048" height="1365" loading="lazy" alt="Spinal Injury Rehabilitation Center"> <figcaption>A caretaker with a patient at the Spinal Injury Rehabilitation Center.</figcaption> </figure>  Shrestha’s approach to leadership is as grounded as his approach to medicine, it was never about control but rather always about enabler-ship. He explains: "Humility is key, and treating staff equally fosters a sense of unity and trust that is essential in difficult times.”&nbsp; He recalls a time at the Orthopaedic Hospital when funds were so tight that salaries could not be paid. The trust was so great that staff worked without pay for three months.&nbsp; Shrestha has a vision to open centres for spinal rehabilitation across all seven provinces of Nepal to provide specialised care – since the number of spinally injured patients rises dramatically because of highway accidents. He wants a health system where each district's hospital is properly equipped and functional, thereby discouraging referral of critical patients to Kathmandu over long and bumpy roads. &nbsp; His message to the next generation of Nepali doctors and social entrepreneurs: "You don't have to wait until everything is perfect to get started. All you need is an idea, and if you see a need, jump into it. Start small and you will always have people to help if you’re passionate and clear about your goals."&nbsp; Shrestha avoids the limelight, and had to be convinced to agree to this profile interview. He says, "When you build an institution, don’t think it’s yours. It belongs to everyone who helped along the way." Read also: <a href="https://nepalitimes.com/here-now/the-barefoot-doctor-of-rolpa">The barefoot doctor of Rolpa</a>, Pinki Sris Rana

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Doctor who does not just treat symptoms

A new mother in Kathmandu took her two-month-old baby to hospital to treat an infection. The doctor diagnosed upper respiratory infection (URI) and prescribed half a dozen medications, including the cough syrup Dextromethorphan. Dextromethorphan is not recommended for children under four by the US Food and Drug Administration (FDA) since 2008 after studies showed it to be ineffective for colds and causes damage to the central nervous system. In Saptari, a 14-month-old boy with chronic cough was taken to a private clinic multiple times. In each visit, the doctor there prescribed Dextromethorphan and Beclomethasone, a corticosteroid. The child’s skin became swollen and sore, and he was brought to Om Hospital in Kathmandu. Doctors concluded that his nervous system was affected by overdose of Dextromethorphan, and referred the baby to AIIMS Hospital in New Delhi. The baby died during treatment. A paper titled Adverse Events Associated with Pediatric Exposure to Dextromethorphan published in the medical journal Clinical Toxicology had already concluded that the cough syrup should only be given to children above four, and only for the most serious cases. Sixty percent of the 1,716 children under four in this study who were prescribed Dextromethorphan were found to have side effects ranging from vomiting, breathing problems, and effects on the nervous system. Other studies have noted that the drug can cause the respiratory system of children to slow down severely, leading to suffocation. Read also: <a href="https://nepalitimes.com/here-now/a-taste-of-our-own-medicine">A taste of our own medicine</a>, Yugeshwor Koirala A four-year-old boy in Bhaktapur suffering from cough and constipation was taken to a nearby private hospital. The doctor diagnosed common cold and prescribed six types of medicines including a nasal drug with the generic name Oxymetazoline, commonly used to treat nasal polyps. Oxymetazoline has also been prohibited for use in children under six by the FDA and other regulatory bodies. Doctors at the Bhaktapur hospital have been found to be prescribing this medicine to children to treat colds. Overuse of oxymetazoline can eventually cause inflammation of the nasal cavity, affecting breathing. As more and more Nepalis, especially children and the elderly, suffer from respiratory infections due to increasing air pollution, the misuse and overuse of drugs by an over-commercialised medical and pharmaceutical sector is also increasing. Doctors have also been found to be prescribing Montelukast, usually given only to patients with complications like asthma and rhinitis, to treat the common cold, sore throat, rashes or arthritis in children. FDA studies have shown that Montelukast in children and adolescents can cause behavioural and psychological side effects, including suicidal ideation. The drug has a black box warning, the FDA’s strictest alert to warn the public about its side effects, to be used only in cases where its benefit outweighs its harm.&nbsp; The Global Initiative for Asthma (GINA) guidelines also mention that parents must be made fully aware of the possible side effects of Montelukast before it is prescribed to children with asthma. Read also: <a href="http://archive.nepalitimes.com/article/nation/Antibiotic-resistance,1974">Antibiotic resistance</a>, Buddha Basnyat and Hellen Gelband&nbsp; Medical Sector on Steroids Doctors in Nepal also over-prescribe steroids, usually recommended to treat cancer, arthritis, vasculitis, asthma, muscular dystrophy, and arrhythmia, for children suffering colds and coughs. Steroids suppress the body's immune system, which is why doctors might prescribe them to address short-term health problems. The random prescription of such powerful medication can have long-term effects on health. At a clinic in Jhapa, doctors prescribed a one-year-old with a common cold, the steroid Prednisolone. When the cold persisted, the boy’s parents eventually began to buy the medicine over the counter whenever their son got sick. This went on for three and a half years until the child was unable to walk. When he was brought to a hospital in Kathmandu, doctors discovered that he had cataracts in both eyes as well as myopathy, a rare condition that causes the muscles of the legs to deteriorate. The child had to undergo cataract surgery, usually performed on elderly patients over 60. But there was no treatment for his myopathy. A study published in the British Medical Journal found that the prescription of steroids in children causes complications including obesity, diabetes, increased blood pressure, cataracts, weakened bones and muscles, as well as excessive body hair growth. Immunology and paediatric rheumatologist Dharmagat Bhattarai has seen many patients with disabilities and other lifelong health complications caused by the prescription of steroids to treat common colds.&nbsp; “Steroids should be used according to guidelines only in cases of serious diseases, to prevent amputations and in lifesaving situations,” says Bhattarai. “It cannot be used for general health problems.” Children under five are more susceptible to viral infections such as the common cold and diarrhoea, for which there is no specific medication. With proper care, such infections clear up on their own within a few days. An investigation by this paper of prescriptions by doctors in Kathmandu Valley showed that at least 8 out of 10 children who had been diagnosed with cold and cough had been prescribed unnecessary medication. Read also: <a href="https://archive.nepalitimes.com/article/nation/growth-of-antibiotic-resistance-in-nepal,1975">"Patients are impatient"</a>, Sonia Awale  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240419160452_d7c7652e36019a55861a667c5f4c475a30473ba893b1c44dc6f6f608e7424090.jpg" data-media-id="editor_3" data-image-id="20240419160452_d7c7652e36019a55861a667c5f4c475a30473ba893b1c44dc6f6f608e7424090" data-rendition-name="original" width="1000" height="1500" loading="lazy" alt="Pandemic of drugs overuse Page 10-11 NT #1208"> <figcaption>HEALTH IS WEALTH: Belmaya Nepali who mortgaged her house to pay off her hospital bills.</figcaption> </figure>  Molecular microbiologist Guna Raj Dhungana says: “Uncontrolled use of antibiotics cause pathogens to evolve, and develop the ability to fight the drug.” Physicians we showed the prescriptions to found that even in cases of viral infections, doctors in various hospitals in Kathmandu had recommended antibiotics like Amoxicillin, Azithromycin, Cefixime, Metronidazole, and Ofloxacin to children. Antibiotics are designed to fight bacterial infections, and they do not work for viral conditions. Excessive use of antibiotics causes antimicrobial resistance (AMR) which means the drugs will not work against more serious infections.&nbsp; The WHO has identified AMR as one of the top global public health threats, warning of as many as 10 million deaths each year by 2050 due prescription drugs failure.&nbsp; Infectious disease specialist Prabhat Adhikari estimates that even the stronger antibiotics have stopped working in 80% of patients with bacterial infections at ICUs of major hospitals in Kathmandu. Read also:<a href="https://nepalitimes.com/opinion/comment/nepal-s-wildlife-at-risk-from-drug-resistance"> Nepal’s wildlife at risk from drug resistance</a>, Siddhant Pandey “Patients who have had surgery are likely to develop infections, and people with heart failure are at risk of developing pneumonia when intubated,” explains Adhikari. “Antibiotics can be ineffective in treating such infections, causing premature deaths.” Most parents do not realise that minor conditions like the common cold can clear up in a week and do not require treatment and there is no needfor a trip to the hospital. Some doctors take advantage of worried parents to make a quick buck on commissions from pharmaceutical companies. “We can require prescriptions for certain drugs, but it all depends on the doctor’s conduct,” says healthcare expert Kiran Raj Pandey. International regulatory bodies have medical guidelines which are regularly updated. Once there is evidence that a certain drug has negative side effects, its use is restricted. Some doctors have not read those guidelines, and continue to prescribe discontinued medicines. Just as alarming is the nexus between the drug manufacturers and healthcare institutions in Nepal. Pharmaceutical companies pay as much as 60% of their profit to hospitals and doctors for prescribing their brands. Doctors therefore prescribe expensive and strong antibiotics to patients who can be treated with more affordable alternatives.&nbsp; For instance, European countries prescribe patients cheap penicillin-based antibiotics to treat pneumonia, whereas Nepali doctors prescribe expensive and last-resort antibiotics like Linezolid, Vancomycin, Meropenem, and Colistin. Read also: <a href="https://archive.nepalitimes.com/article/nation/I-am-an-amchi,3349">I am an amchi</a>, Sabine Pretsch “Pharmaceutical companies have incentivised doctors to prescribe more drugs with commissions and gifts,” says infectious disease specialist Anup Subedee. “Many doctors do not think in terms of whether their patient will get better but what will earn them more.” Misuse of prescription drugs is also driving many Nepalis, already overburdened with out of pocket medical costs, into poverty. Medicine makes up for nearly 75% of the total health expenditure of Nepalis. “Studies have shown that drug purchases can cause three to four percent of people to fall into poverty, and cause financial stress in up to 15% of families of patients,” says health economist Shiva Raj Adhikari. The mushrooming of private health institutions in Nepal has also created competition in the health sector such that hospitals and clinics try to make money through unnecessary medications and laboratory tests as well as other redundant administrative fees. In Nepal, the Nepal Medical Council (NMC) administers the licensing examination of doctors and regulates their medical practice. However, it does not monitor the conduct of individual doctors without a complaint. “It is not possible to check on the type and dosage of medication prescribed by an individual doctor, but we will review any complaints,” says NMC’s Satish Kumar Deo. Infectious disease specialist Subedee says that the NMC should audit prescriptions of doctors to check whether they follow relevant guidelines: “If the council has the professional skills, leadership and sense of accountability to do what is right, this problem can be solved overnight.”&nbsp; Read also: <a href="https://nepalitimes.com/here-now/medicine-goes-back-to-its-roots">Medicine goes back to its roots</a>, Sonia Awale

Pandemic of drugs overuse

<figure><img width="720" height="480" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101124/63720a179c7e80680e0b5580jpeg.jpg" alt=""/><figcaption>Paul Farmer visiting Bayalpata Hospital in Achham run by Nyaya Health Nepal on its third anniversary in 2012. Photo: DEEPAK BISTA/NHN</figcaption></figure>When we were in 11th grade, my friends and I wanted to bring healthcare services to an impoverished village near Pokhara, my hometown. The best solution we could imagine was what is colloquially called a ‘health camp’: show up in a village with a doctor and some medications, go through hundreds of patients in a few hours, and leave.  We believed that since doctors and medications were expensive, and the poor could not pay, a health camp was the best we could do. In college, my anthropology professor introduced me to the <a href="https://www.newyorker.com/magazine/2000/07/10/the-good-doctor" data-saferedirecturl="https://www.google.com/url?q=https://www.newyorker.com/magazine/2000/07/10/the-good-doctor&amp;source=gmail&amp;ust=1645761874284000&amp;usg=AOvVaw3b9WqU9uyWoWQXT8nuhnk4">work</a> and writings of the physician and medical anthropologist Paul Farmer, who described relegating the poor to such meager services as, quite simply, a ‘failure of imagination’. His influence transformed my thinking regarding the most vexing problems in global health: the poor are not to blame for their economic condition and its attendant health challenges. Rather, the blame falls on our collective lack of imagination, which is rooted in, to borrow another phrase from Paul, ‘the idea that some lives matter less’. And that is how Paul began to live in my mind, as he did for thousands of others interested in healthcare.  Paul provided the requisite vocabulary to make sense of deep inequities, and he inspired with his actions. He and his team at the non-profit, Partners in Health, have brought life-saving healthcare services to indigent populations by supporting 230 healthcare facilities in 12 countries.  His work inspired me to go to medical school and co-found the non-profit organization <a href="https://possiblehealth.org/" data-saferedirecturl="https://www.google.com/url?q=https://possiblehealth.org/&amp;source=gmail&amp;ust=1645761874284000&amp;usg=AOvVaw0lctDu7mtRSz9-LxQCCK2B">Possible</a> with other like-minded medical students, all of us committed to expanding high quality healthcare in rural Nepal.  We had no track record, credibility, or adequate funding but Paul supported us. Graciously, he joined our Board, advised and mentored us, helped make connections, and let us leverage his credibility to raise funds. On the Partners in Health website, he <a href="https://www.pih.org/pages/mission-partners-supported-projects" data-saferedirecturl="https://www.google.com/url?q=https://www.pih.org/pages/mission-partners-supported-projects&amp;source=gmail&amp;ust=1645761874284000&amp;usg=AOvVaw0QSINhU0jOZ6rB98WFGhQo">included Possible</a> as an organisation expanding the mission for high quality care for the poor.  He shared his expansive platform by including <a href="https://www.pih.org/article/mental-health-in-nepal" data-saferedirecturl="https://www.google.com/url?q=https://www.pih.org/article/mental-health-in-nepal&amp;source=gmail&amp;ust=1645761874284000&amp;usg=AOvVaw3_FbKTKhT2o1BEL7JLC2RV">Possible’s work</a> alongside his. His generosity could have cut into his own fundraising efforts, but he always rejected the belief that the pie is small, and we should fight over it. He inspired us to fight for a bigger pie, and he willed that world into existence. Back in Nepal, we began with a small clinic in Achham, where 250,000 people had no access to even a single doctor. We faced many detractors, and sometimes we doubted ourselves. But his words, spoken clearly and earnestly, helped us form our moral compass and inspired a determination that would not countenance failure.  Because more funding was available for HIV programs, many advised us to open an HIV clinic, but we knew that Achham needed comprehensive services beyond strictly HIV care. Well-meaning supporters lamented, sounding much as my friends and I had in high school, that the best we could do was a series of health camps. Surely, they fretted, there was no money for anything long-term.  People seemed to have an unspoken collective agreement that when it comes to serving the poor, there are not enough resources. Paul had a phrase to describe this social myth: ‘socialisation for scarcity’. The reality is, he taught, there are enough resources in the world to provide high-quality health services to every poor person, but we fail to make this a reality. We back away from this challenge, simply because we assume it is not possible.  A well-wisher suggested that we build something in Kathmandu rather than in rural Nepal because people in Kathmandu can pay for services. This time, we thought of another phrase that Paul popularised as a reminder that the system needs to be built to serve those with the greatest needs. He called this ‘a preferential option for the poor’.  In 2009, we established <a href="https://www.nyayahealthnepal.org/" data-saferedirecturl="https://www.google.com/url?q=https://www.nyayahealthnepal.org/&amp;source=gmail&amp;ust=1645761874284000&amp;usg=AOvVaw2daT7Rc6LOR2LKA2EjC2hS">Nyaya Health Nepal</a>, a Nepal-based sister organisation to Possible, and collaborated with the Nepal government to expand to <a href="http://archive.nepalitimes.com/news.php?id=17650#.YhaPTejMKPo" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/news.php?id%3D17650%23.YhaPTejMKPo&amp;source=gmail&amp;ust=1645761874284000&amp;usg=AOvVaw3m5v35ikDhKesjhvT5U0Tp">Bayalpata Hospital</a>. In 2012, Paul <a href="http://archive.nepalitimes.com/blogs/thebrief/2012/06/22/dr-farmer-comes-to-nepal/?fbclid=IwAR2CfOIxGCHSF4JfjKrloDWHXpBJfI9sZLjtj88cWvajfHhPs9si9iCa7Tk" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/blogs/thebrief/2012/06/22/dr-farmer-comes-to-nepal/?fbclid%3DIwAR2CfOIxGCHSF4JfjKrloDWHXpBJfI9sZLjtj88cWvajfHhPs9si9iCa7Tk&amp;source=gmail&amp;ust=1645761874285000&amp;usg=AOvVaw201XBVs_ztoxyj50hJZze8">visited Bayalpata</a>, rounding on patients with the local clinicians, teaching and inspiring with his intellect and humor. He expressed genuine admiration towards the healthcare workers living and serving in rural Nepal.  He somehow managed to express more gratitude than he received, in a way most people would not expect from someone with his level of accomplishment. After the 2015 earthquake, our team expanded to Dolakha, and at its peak, was overseeing three permanent hospitals with 350 staff: a long way from sporadic health camps. A few years ago, I was in a small global health conference and we were waiting for Paul Farmer to speak. As most busy speakers do, we expected him to sweep in, give a talk, and jet off to the next event. I felt a tap on my shoulder. It was Paul. I was surprised to see him with the audience. We hugged. He asked me how I was doing and wanted to know how he could help with our work in Nepal. I thanked him for having highlighted the importance of mental health in high-profile global health meetings.  He thanked me for working in mental health, <a href="https://archive.nepalitimes.com/article/nation/Neglect-of-the-neglected,3157" data-saferedirecturl="https://www.google.com/url?q=https://archive.nepalitimes.com/article/nation/Neglect-of-the-neglected,3157&amp;source=gmail&amp;ust=1645761874285000&amp;usg=AOvVaw0auYYYnEoYwjjdnKwxAe0y">a persistently ignored area</a>. He then walked around the room, surprising and personally checking in with several people who were working in different parts of the world. Later, the organisers told me that Paul had asked for the list of attendees so he could check in with the people he knew were doing similar work in global health.  He did not need to do any of this. He had a way of being present with you, listening, inspiring, and building solidarity for his commitment to the most vulnerable. On 21 February, 2022, Paul passed away in his sleep in Rwanda, where he had been teaching and seeing patients at the University of Global Health Equity, a <a href="https://ughe.org/the-story-behind-the-university" data-saferedirecturl="https://www.google.com/url?q=https://ughe.org/the-story-behind-the-university&amp;source=gmail&amp;ust=1645761874285000&amp;usg=AOvVaw2OnM0VBt6sfqmNWZknDP__">world-class university</a> that he helped to establish. He was 62. He left behind three children and his wife, Didi Bertrand Farmer, a medical anthropologist from Haiti.  As Bill Gates <a href="https://www.theatlantic.com/health/archive/2022/02/paul-farmer-obituary-bill-gates/622876" data-saferedirecturl="https://www.google.com/url?q=https://www.theatlantic.com/health/archive/2022/02/paul-farmer-obituary-bill-gates/622876&amp;source=gmail&amp;ust=1645761874285000&amp;usg=AOvVaw2pWB2FnOg2yFeVjuBWHH4X">wrote recently</a>, the void Paul left cannot be filled by anyone. But I know that although he is gone, his work will continue through how he influenced us, through his incisive writing and inspiring legacy. He will continue to live in my mind, urging us not to succumb to failures of imagination, and instead to fight against socialisation for scarcity to boldly build a preferential option for the poor.Bibhav Acharya, MD is a psychiatrist, an Associate Professor at University of California San Francisco, and co-founder of <a href="https://possiblehealth.org/" data-saferedirecturl="https://www.google.com/url?q=https://possiblehealth.org/&amp;source=gmail&amp;ust=1645761874285000&amp;usg=AOvVaw2uxxH-GIR4y6Vtn4zPKdmr">Possible</a>, a nonprofit organization that has been working to improve health care in Nepal since 2007.<a href="https://twitter.com/BibhavAcharya" data-saferedirecturl="https://www.google.com/url?q=https://twitter.com/BibhavAcharya&amp;source=gmail&amp;ust=1645761874285000&amp;usg=AOvVaw2b7VkvX7y7Myrrsnt6EM7o">@BibhavAcharya</a> <img width="77" height="109" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101124/63720a199c7e80680e0b5581jpeg.jpg" alt="">Read also:<a href="https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/"> At the Covid frontlines in rural Nepal</a>, Priti Thapa

Paul Farmer on my mind

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109121140/636b91ab9c7e80680e06f104jpeg.jpg" alt="" width="960" height="640"/><figcaption>Photo: BIKRAM RAI/NEPALI TIMES ARCHIVES</figcaption></figure>Prashuma Malla had never felt so helpless as a physician. Her patient, a man in his 40s, was suffocating, incapable of drawing in breath.But the hospital ventilators were all occupied, and the central supply of oxygen was very low. She pronated her patient while his wife sobbed near him.“With no oxygen, we can do nothing,” said the 28-year-old second year medical resident specialising in anaesthesia at Bir Hospital in Kathmandu. “It is scary. It is non-stop. I try to tell myself everything is OK. But what can we do? Eight people have already died on my watch.”Malla and her colleagues are on the <a href="https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-covid/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-covid/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNEZnm1Wh-lIyg9tsnCRr9-mgD_R4Q">Covid frontlines in Nepal</a>. Her world is a haze of 36-hour intense, and often terrifying shifts, at Nepal’s oldest and best-known public hospital.As in many <a href="https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-the-epidemic/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-the-epidemic/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNELCBtyZv7D1U8LDXT-i7HJPRZbeQ">government hospitals in Nepal</a>, relatives follow patients in the wards, providing food and running to pharmacies to purchase medicine. <a href="https://www.nepalitimes.com/here-now/nepals-frontline-workers-brave-it-out/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/nepals-frontline-workers-brave-it-out/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGmvFGTkOC_M_eTcOYyHWYTMLFBJw">Bir Hospital is overwhelmed</a>. People are sleeping in hallways, stairways, curled up on patients’ beds, pacing from room to room.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109121140/636b91ad9c7e80680e06f105jpeg.jpg" alt="" width="1500" height="850"><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109121140/636b91b09c7e80680e06f106jpeg.jpg" alt="" width="768" height="513"><figcaption>Crowded Covid ward at Teku Hospital. Photo: AMIT MACHAMASI</figcaption></figure>Doctors believe many relatives are sick as well, but the hospital does not have enough PPEs for them, and there is a serious shortage of oxygen.“We are exposed to the virus all the time,” Malla said of her shifts with the sickest of patients. “Everywhere you go is a Covid ward.”Malla and her colleagues have also become counsellors. But with every patient, her job gets harder because most are in their 30s and 40s, and increasingly some in their 20s are being brought in.In the chaos, it calms her to explain every detail to relatives. What does it mean to be intubated? Why once intubated it is hard to take patients off, and they usually die if they are taken out. No, they cannot take the body to be cremated: only police or soldiers can remove it from the hospital.“They are confused, they have never seen someone come off an intubator. I remind them: there is no guarantee,” Malla said.Every move Malla makes, every decision she takes, she reports to her superior. And every day at the shift handover, she has to be careful with the safety precautions.At the end of her shift that lasts more than 24 hours, Malla heads home on her scooter through light traffic because of the lockdown. She lives in a tiny two-room apartment with her two brothers, and is terrified of infecting them.She washes immediately, including her mask and face shield. Masks are always on, they cook together. Briefly unmasked, she eats alone on a miniature terrace. She talks on Viber with her parents in central Nepal.Every day, sometimes every hour, they remind each other to stay safe. She tries to focus on her online medical classes. She doesn’t want to fall behind. But always that nagging fear. Death is lurking. Near her. Floating and invisible.Although Nepal’s second wave appears to have peaked, and the official number of Covid-19 cases and mortality is down, there are <a href="https://www.nepalitimes.com/latest/nepal-covid-19-impact-worse-than-official-figures/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-covid-19-impact-worse-than-official-figures/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGD_zw--sdgKNcbkUD2EUdjZg82Lw">doubts about how accurate the figures are</a>.The number of daily recoveries is now higher than new infections, and the official death toll is hovering around 100 every day, which is half what it was three weeks ago. The number of active cases fell below 100,000 for the first time in more than one month on Saturday. But there are still more than 1,500 <a href="https://www.nepalitimes.com/latest/nepal-designates-more-hospitals-for-covid-19-treatment/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-designates-more-hospitals-for-covid-19-treatment/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNHxZUs6NeKiFHYbFIJkkSZzx7D9vg">patients in ICUs</a> nationwide, with 450 of them needing ventilator support.More and more cases in city and <a href="https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNFpAtg51hSoSi41jBs4YjPKQ9MsVA">district hospitals</a> now are from the hinterland, and there are indications that the <a href="https://www.nepalitimes.com/editorial/nepals-humanitarian-emergency/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/editorial/nepals-humanitarian-emergency/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGRytlb8jAYJB_hKJQNVCuwiFBmEQ">virus has spread to the remotest communities </a>in the mountains where there is no hospital care. And no <a href="https://www.nepalitimes.com/latest/life-hangs-by-an-oxygen-tube-in-nepal/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/life-hangs-by-an-oxygen-tube-in-nepal/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNF2Eis06JvGsCzy_McEPymUP-h5sw">supplemental oxygen</a>.<a href="https://www.nepalitimes.com/latest/in-nepal-virus-climbs-from-plains-to-mountains/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/in-nepal-virus-climbs-from-plains-to-mountains/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNEsKzdZRZejQF0SGnV4lSHoAk0EHQ">In rural Nepal</a>, there is now hope from ground-breaking tele-health that is transforming medical care.Hari Neupane is fighting Covid-19 with his cell phone. He is simultaneously a doctor, nurse and mental health expert, and works with <a href="https://www.healthfoundationnepal.org/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.healthfoundationnepal.org&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGdGiTiG90TCoPVsSwtrWug2LqVYA">Health Foundation Nepal</a>, a Kathmandu-based volunteer-staffed telemedicine service that reaches out to patients across 35 districts in Nepal via its Kathmandu hotline.Neupane leads a team of seven doctors in Dang Valley in mid-western Nepal. Because of the large numbers of workers returning from India and its rudimentary medical facilities, Dang bore the brunt of the pandemic in both the first and second waves.As the monsoon approaches, it is soon rice planting season but a national lockdown has left fields, streets and roads empty, void of the everyday crowds and cacophony of passing trucks.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109121140/636b91b39c7e80680e06f107jpeg.jpg" alt="" width="1500" height="1000"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109121140/636b91b69c7e80680e06f108jpeg.jpg" alt="" width="1500" height="1000">In Dang in western Nepal, the highways are empty because of the lockdown, while farmers are busy preparing for rice-planting. Photos: HARI NEUPANE<a href="https://archive.nepalitimes.com/article/nation/long-distance-medicine-in-nepal,3521" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://archive.nepalitimes.com/article/nation/long-distance-medicine-in-nepal,3521&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGKSSvGC8yUXhCQ9FP5G-0uZmJjng">Telemedicine is new in Nepal</a>, and medical teams in the field in Nepal are supervised by Ashok Devkota, a doctor of internal medicine in Providence, Rhode Island, in the United States The organisation’s seven full-time workers and 50 part-time physicians are all volunteers.Most of Neupane’s patients across Nepal have Covid symptoms, but most have not been tested. Working closely with local health posts, Neupane’s team identifies symptoms, using cell phones – voice, photos and videos – as medical communicators.They connect patients via cell phone with pharmacies and if necessary source portable oxygen. The very sick are referred to the hospital.“We focus on people in home isolation and counsel them on the medicines they need and how to get them. We prescribe steroids and do follow-ups and notify local government officials,” Neupane explained.In Dang, cell phones have become transformative lifelines at many levels. They are a critical means of money transfers from relatives working abroad, so that families can pay school fees, medical bills and food.This year’s lockdown has made day-long walks to access medical care virtually impossible. Even if patients can get to a hospital, chances of a bed are slim. In Dang, there are only 155 intensive care beds and 15 ventilators, most of them occupied.Health Foundation Nepal advertises its telemedicine counselling through social media and newspapers. It cannot take blood tests, but with the help of local health workers can monitor oxygen saturation, blood pressure and temperature and can gauge the condition of the patients to recommend a solution.“Telemedicine existed in Nepal before but before Covid people did not accept it much, but now it is helping save lives,” said Ashok Devkota, the Nepali doctor in the US who supervises medical staff like Neupane half-way around the world Nepal. And as long as Neupane’s cell phone stays charged, he is on duty.The pandemic and political crisis in Nepal have increased the risk of Nepal becoming an imploding catastrophe. The country was just beginning to recover from the 2015 earthquake, and was struggling with pre-existing health challenges, and earlier this year was beginning to think the worst was over when the second Covid-19 wave struck.The health and economic crises <a href="https://www.nepalitimes.com/latest/covid-19-to-reverse-child-survival-gains/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/covid-19-to-reverse-child-survival-gains/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNHA2oJKTj8wDzac2WJdbkvphDJODQ">threaten the gains Nepal has made</a> in the past years in fighting malnutrition, immunisation against other infectious diseases, child labour, early marriage and women’s rights.But if Nepal is a petri dish of disasters, it is also one of innovation and individual dedication. This pandemic once again is a place where despair is often met by individual and community fortitude by medical workers like Prashuma Malla and Hari Neupane.Donatella Lorch is a former New York Times foreign correspondent who lived three years in Nepal. She blogs at: <a href="https://tangledjourneys.com/about/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://tangledjourneys.com/about/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNEHm4HaaRyE_KrqKL6VlN7zbgNjlQ">tangledjourneys</a>

Nepal’s doctors are like soldiers fighting a war

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131144/636cf2839c7e80680e09d913jpeg.jpg" alt="" width="960" height="640"/><figcaption>Photo: BIKRAM RAI/NEPALI TIMES ARCHIVES</figcaption></figure>Prashuma Malla had never felt so helpless as a physician. Her patient, a man in his 40s, was suffocating, incapable of drawing in breath.But the hospital ventilators were all occupied, and the central supply of oxygen was very low. She pronated her patient while his wife sobbed near him.“With no oxygen, we can do nothing,” said the 28-year-old second year medical resident specialising in anaesthesia at Bir Hospital in Kathmandu. “It is scary. It is non-stop. I try to tell myself everything is OK. But what can we do? Eight people have already died on my watch.”Malla and her colleagues are on the <a href="https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-covid/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-covid/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNEZnm1Wh-lIyg9tsnCRr9-mgD_R4Q">Covid frontlines in Nepal</a>. Her world is a haze of 36-hour intense, and often terrifying shifts, at Nepal’s oldest and best-known public hospital.As in many <a href="https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-the-epidemic/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-the-epidemic/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNELCBtyZv7D1U8LDXT-i7HJPRZbeQ">government hospitals in Nepal</a>, relatives follow patients in the wards, providing food and running to pharmacies to purchase medicine. <a href="https://www.nepalitimes.com/here-now/nepals-frontline-workers-brave-it-out/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/nepals-frontline-workers-brave-it-out/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGmvFGTkOC_M_eTcOYyHWYTMLFBJw">Bir Hospital is overwhelmed</a>. People are sleeping in hallways, stairways, curled up on patients’ beds, pacing from room to room.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131144/636cf2869c7e80680e09d914jpeg.jpg" alt="" width="1500" height="850"><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131144/636cf2899c7e80680e09d915jpeg.jpg" alt="" width="768" height="513"><figcaption> </figcaption></figure>Doctors believe many relatives are sick as well, but the hospital does not have enough PPEs for them, and there is a serious shortage of oxygen.“We are exposed to the virus all the time,” Malla said of her shifts with the sickest of patients. “Everywhere you go is a Covid ward.”Malla and her colleagues have also become counsellors. But with every patient, her job gets harder because most are in their 30s and 40s, and increasingly some in their 20s are being brought in.In the chaos, it calms her to explain every detail to relatives. What does it mean to be intubated? Why once intubated it is hard to take patients off, and they usually die if they are taken out. No, they cannot take the body to be cremated: only police or soldiers can remove it from the hospital.“They are confused, they have never seen someone come off an intubator. I remind them: there is no guarantee,” Malla said.Every move Malla makes, every decision she takes, she reports to her superior. And every day at the shift handover, she has to be careful with the safety precautions.At the end of her shift that lasts more than 24 hours, Malla heads home on her scooter through light traffic because of the lockdown. She lives in a tiny two-room apartment with her two brothers, and is terrified of infecting them.She washes immediately, including her mask and face shield. Masks are always on, they cook together. Briefly unmasked, she eats alone on a miniature terrace. She talks on Viber with her parents in central Nepal.Every day, sometimes every hour, they remind each other to stay safe. She tries to focus on her online medical classes. She doesn’t want to fall behind. But always that nagging fear. Death is lurking. Near her. Floating and invisible.Although Nepal’s second wave appears to have peaked, and the official number of Covid-19 cases and mortality is down, there are <a href="https://www.nepalitimes.com/latest/nepal-covid-19-impact-worse-than-official-figures/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-covid-19-impact-worse-than-official-figures/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGD_zw--sdgKNcbkUD2EUdjZg82Lw">doubts about how accurate the figures are</a>.The number of daily recoveries is now higher than new infections, and the official death toll is hovering around 100 every day, which is half what it was three weeks ago. The number of active cases fell below 100,000 for the first time in more than one month on Saturday. But there are still more than 1,500 <a href="https://www.nepalitimes.com/latest/nepal-designates-more-hospitals-for-covid-19-treatment/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-designates-more-hospitals-for-covid-19-treatment/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNHxZUs6NeKiFHYbFIJkkSZzx7D9vg">patients in ICUs</a> nationwide, with 450 of them needing ventilator support.More and more cases in city and <a href="https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNFpAtg51hSoSi41jBs4YjPKQ9MsVA">district hospitals</a> now are from the hinterland, and there are indications that the <a href="https://www.nepalitimes.com/editorial/nepals-humanitarian-emergency/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/editorial/nepals-humanitarian-emergency/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGRytlb8jAYJB_hKJQNVCuwiFBmEQ">virus has spread to the remotest communities </a>in the mountains where there is no hospital care. And no <a href="https://www.nepalitimes.com/latest/life-hangs-by-an-oxygen-tube-in-nepal/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/life-hangs-by-an-oxygen-tube-in-nepal/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNF2Eis06JvGsCzy_McEPymUP-h5sw">supplemental oxygen</a>.<a href="https://www.nepalitimes.com/latest/in-nepal-virus-climbs-from-plains-to-mountains/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/in-nepal-virus-climbs-from-plains-to-mountains/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNEsKzdZRZejQF0SGnV4lSHoAk0EHQ">In rural Nepal</a>, there is now hope from ground-breaking tele-health that is transforming medical care.Hari Neupane is fighting Covid-19 with his cell phone. He is simultaneously a doctor, nurse and mental health expert, and works with <a href="https://www.healthfoundationnepal.org/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.healthfoundationnepal.org&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGdGiTiG90TCoPVsSwtrWug2LqVYA">Health Foundation Nepal</a>, a Kathmandu-based volunteer-staffed telemedicine service that reaches out to patients across 35 districts in Nepal via its Kathmandu hotline.Neupane leads a team of seven doctors in Dang Valley in mid-western Nepal. Because of the large numbers of workers returning from India and its rudimentary medical facilities, Dang bore the brunt of the pandemic in both the first and second waves.As the monsoon approaches, it is soon rice planting season but a national lockdown has left fields, streets and roads empty, void of the everyday crowds and cacophony of passing trucks.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131144/636cf28c9c7e80680e09d916jpeg.jpg" alt="" width="1500" height="1000"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131144/636cf28f9c7e80680e09d917jpeg.jpg" alt="" width="1500" height="1000">In Dang in western Nepal, the highways are empty because of the lockdown, while farmers are busy preparing for rice-planting. Photos: HARI NEUPANE<a href="https://archive.nepalitimes.com/article/nation/long-distance-medicine-in-nepal,3521" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://archive.nepalitimes.com/article/nation/long-distance-medicine-in-nepal,3521&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNGKSSvGC8yUXhCQ9FP5G-0uZmJjng">Telemedicine is new in Nepal</a>, and medical teams in the field in Nepal are supervised by Ashok Devkota, a doctor of internal medicine in Providence, Rhode Island, in the United States The organisation’s seven full-time workers and 50 part-time physicians are all volunteers.Most of Neupane’s patients across Nepal have Covid symptoms, but most have not been tested. Working closely with local health posts, Neupane’s team identifies symptoms, using cell phones – voice, photos and videos – as medical communicators.They connect patients via cell phone with pharmacies and if necessary source portable oxygen. The very sick are referred to the hospital.“We focus on people in home isolation and counsel them on the medicines they need and how to get them. We prescribe steroids and do follow-ups and notify local government officials,” Neupane explained.In Dang, cell phones have become transformative lifelines at many levels. They are a critical means of money transfers from relatives working abroad, so that families can pay school fees, medical bills and food.This year’s lockdown has made day-long walks to access medical care virtually impossible. Even if patients can get to a hospital, chances of a bed are slim. In Dang, there are only 155 intensive care beds and 15 ventilators, most of them occupied.Health Foundation Nepal advertises its telemedicine counselling through social media and newspapers. It cannot take blood tests, but with the help of local health workers can monitor oxygen saturation, blood pressure and temperature and can gauge the condition of the patients to recommend a solution.“Telemedicine existed in Nepal before but before Covid people did not accept it much, but now it is helping save lives,” said Ashok Devkota, the Nepali doctor in the US who supervises medical staff like Neupane half-way around the world Nepal. And as long as Neupane’s cell phone stays charged, he is on duty.The pandemic and political crisis in Nepal have increased the risk of Nepal becoming an imploding catastrophe. The country was just beginning to recover from the 2015 earthquake, and was struggling with pre-existing health challenges, and earlier this year was beginning to think the worst was over when the second Covid-19 wave struck.The health and economic crises <a href="https://www.nepalitimes.com/latest/covid-19-to-reverse-child-survival-gains/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/covid-19-to-reverse-child-survival-gains/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNHA2oJKTj8wDzac2WJdbkvphDJODQ">threaten the gains Nepal has made</a> in the past years in fighting malnutrition, immunisation against other infectious diseases, child labour, early marriage and women’s rights.But if Nepal is a petri dish of disasters, it is also one of innovation and individual dedication. This pandemic once again is a place where despair is often met by individual and community fortitude by medical workers like Prashuma Malla and Hari Neupane.Donatella Lorch is a former New York Times foreign correspondent who lived three years in Nepal. She blogs at: <a href="https://tangledjourneys.com/about/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://tangledjourneys.com/about/&amp;source=gmail&amp;ust=1623050870892000&amp;usg=AFQjCNEHm4HaaRyE_KrqKL6VlN7zbgNjlQ">tangledjourneys</a>

<figure><img width="957" height="638" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111152/636b866b9c7e80680e067852jpeg.jpg" alt=""/><figcaption>Photo: BIKRAM RAI</figcaption></figure>On 20 May, the Health Ministry released a condolence message for doctors including Ishwor Lal Acharya, Mukesh Chaudhary and Pujya Shree Karki who lost their lives to Covid-19.Nepal doesn't yet have an exact figure on the total number of <a href="https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-the-epidemic/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-the-epidemic/&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNE67Zklb3ITwY-EN9ZPs4LRP2MFtQ">medical staff</a> infected by the SARS-CoV-2 but the Nepal Health Research Council (NHRC) is currently conducting a study to find out. “Majority of our frontline health care provides have been fully vaccinated, so even if they are being infected, they are only mild to moderately sick,” says cardiologist and chair of the Nepal Medical Council (NMC) <a href="https://www.facebook.com/bhagawan.koirala" data-saferedirecturl="https://www.google.com/url?q=https://www.facebook.com/bhagawan.koirala&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNEOs-qwziT36jBSTwwrTvDCe4MA1A">Bhagawan Koirala.</a> “This combined with a better understanding of Covid-19, they are now more confident and have a better sense of responsibility this time around.”At the National Trauma Centre in Kathmandu, nursing staff Suman Chaudhary is back to work after recovering from the coronavirus herself and draws motivation from health workers who are battling the pandemic in major hotspots like Birganj.“This is our chance to make a real contribution and having been infected myself has given me a new perspective on how patients feel,” says Chaudhary who was pursuing Masters in Nursing at Bir Hospital during the first wave. “It is difficult to work in a PPE all day without water or bathroom breaks. I still feel weak and have shortness of breath, but watching people recover keeps us going.”Both Koirala and Chaudhary, however, agree that there is a <a href="https://www.nepalitimes.com/here-now/nepals-frontline-workers-brave-it-out/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/nepals-frontline-workers-brave-it-out/&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNG1eSnzgkQ-VmoauOQrzkj_c0eUzA">chronic shortage of medical staff</a> across the country. Hospitals outside Kathmandu and even Covid dedicated institutions are overstretched, and now doctors and nurses are themselves falling sick. In some hospitals, since patients and staff are all positive, nurses and doctors with mild symptoms have just kept working, since there is no one else to take care of the sick.Last week, more than 47 of Dhading District Hospital’s emergency and ward staff were infected with Covid-19, with many of them in isolation and some requiring ICU treatment even as the facility was finding it difficult to source enough <a href="https://www.nepalitimes.com/latest/why-is-there-still-an-oxygen-shortage/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/why-is-there-still-an-oxygen-shortage/&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNGkShQk2X-gpsUuQceFplgqsL0bSg">oxygen for existing patients</a>.“We are a hospital of only 8 doctors, 5 paramedics and 23 nurses and with no backup, we were very close to collapsing,” says Medical Superintendent at Dhading District Hospital Tribhuvan Jha, adding that everyone had to be called back to work after 10 days of isolation. “We are in this position due to a lack of preparedness, shortage of staff and limited infrastructure.”At Charikot Hospital in Dolakha, which is also a Covid-dedicated hospital, the majority of coronavirus patients are critical and there is at least one fatality every day. The 17 nurses work three shifts a day, and are unable to handle patient inflow, so the hospital has brought in community nurses from outlying villages. The hospital is consistently reporting a 45% test positivity rate among those tested.“If a majority of our health workers get infected and are in isolation, we have no Plan B and this is especially worrying because we are the sole care provider for Covid here,” says Binod Dangal of Charikot Hospital. “Medical staff are all  overworked, and they do not have any insurance or allowances.”As dire as the situation is in Nepal’s big cities and district hospitals, the <a href="https://www.nepalitimes.com/editorial/nepals-humanitarian-emergency/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/editorial/nepals-humanitarian-emergency/&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNE3z3JV_9xnJ0reDy2ABkI8VuY16A">pandemic has now infiltrated rural Nepal</a> where there is just one doctor for every 15,000 people. Kathmandu’s doctor-to-patient ratio is 1:850.In her village of Phediguth of Okhaldhunga district, <a href="https://www.nepalitimes.com/banner/saving-nepali-mothers-on-mothers-day/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/saving-nepali-mothers-on-mothers-day/&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNErggt96LmoW-c38IzduDUsayQwIg">Rita Khatri</a> is the only skilled birth attendant. Despite the growing risk of the second wave, she is still performing deliveries and ante-natal check-ups wearing a mask and her single PPE suit. There are no tests of health workers and the public.“We are working despite fears of transmission, I wish we had more PPEs, masks and gloves so that we could conduct more regular check-ups and make home visits,” adds Khatri. “At the moment many people in the community have high fever and are staying at home, but there is no way to test them.” This time last year while in the grip of the first wave of a new pandemic, there was stigma associated with Covid-19 and people who were infected were ostracised in the community. There were many instances where <a href="https://www.nepalitimes.com/here-now/nepal-health-workers-battle-covid-19-but-also-stigma/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/nepal-health-workers-battle-covid-19-but-also-stigma/&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNECgLl_SyeWRy6kuDEPnEbsSFoCyQ">healthcare providers were mistreated</a>.Doctors and nurses interviewed for this report say that is still the case, but there is also more praise for frontline medical workers risking their own health to save lives. However, there is growing concern about the worry and over-work affecting the mental health of nurses and doctors.“Among other things we need psychological support and counselling. I have seniors who have children infected with the new variant, and they are having a hard time coping,” says Suman Chaudhary, nursing staff at the Trauma Centre in Kathmandu.As most of Nepal enters the fourth week of lockdown, nationwide daily Covid-19 infections, positivity rate as well as fatalities are going down slightly. The number of recoveries have also risen to nearly equal new confirmed cases on some days.Bayalpata Hospital in remote Accham District had to turn its Emergency Room into a Covid-19 ward last month to cope with a flood of patients. It had 33 patients, 18 of them needing high flow oxygen support. On Wednesday, it had only 12 Covid-19 patients with only two on oxygen. Four of those infected are medical staff. “The situation is easing somewhat here, in Mangalsen, Doti and Dadeldhura. There are beds available, and oxygen is coming in. But we are desperately short of medical staff,” says Mandeep Pathak, a physician at Bayalpata which is also caring for trauma and maternity patients from surrounding districts.However, the cases and the test positivity rate <a href="https://www.nepalitimes.com/here-now/its-an-emergency/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/its-an-emergency/&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNHx4NfPYsEDb5xqY31L966E2avOdg">have not gone down as expected</a> and fatalities nationwide have stayed above 160 for nearly two weeks now as the highly contagious and more lethal B.1.617.2 variant spreads rapidly through communities.Health Minister Hridayesh Tripathi sounded optimistic at a virtual press meet on Monday, predicting that there would be a decline in the infection rate in the next four weeks. As Nepal receives large shipments of oxygen cylinders, liquid oxygen, test kits, PPEs and masks, doctors say the emphasis now needs to shift to more testing, mass vaccination, and replenishing exhausted and over-stretched medical staff at hospitals, both in the cities and the districts. A non-profit One Heart Worldwide that works primarily in maternal care in Nepal’s 21 districts has been helping district hospitals by mobilising oxygen cylinders and medical kits it procured from China.<a href="https://www.nepalitimes.com/banner/what-can-be-more-fulfilling-than-saving-lives/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/what-can-be-more-fulfilling-than-saving-lives/&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNFzGOK8F0-jy4gwuRmK8iyNBD7AIA">Executive director Surya Bhatta</a> gives three reasons why despite the lockdown the infection rate is still high. “There is virtually no contact tracing, people are still not following health protocols and patients isolating at homes are not doing it right, resulting in a gross underestimation of total cases and fatalities.”		
			<h2>Weddings into hotspots</h2>		
		Gopal Dahal in DhankutaOn 30 April, when a young man in Okhre village in Dhankuta district got married, the whole . The whole community was invited for the feast.But a few days later, the groom suddenly fell sick. When he showed coronavirus symptoms, a test at the primary health care centre confirmed he was <a href="https://www.nepalitimes.com/here-now/its-an-emergency/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/its-an-emergency/&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNHx4NfPYsEDb5xqY31L966E2avOdg">Covid-19</a> positive.Now, every household in Okhre village has members showing similar symptoms. Most of them had attended the wedding. Of the 51 people tested, 25 tested positive. “This is a crisis, the pandemic has spread to the whole village now,” says Ward Chair Palak Basnet.One of the guests at the wedding was a man who had returned recently from the Tarai with mild symptoms. He was hired to wash dishes at the wedding, and had died a few days after the feast. No one tried to find the cause of death, and there was no PCR test done. Dhankuta MP Jitendra Rumdali Rai says there are probably many more cases than the ones who have tested positive so far. “The pandemic is spreading out of control here because the municipality wasn’t able to manage it on time,” he adds.Okhre village has now been sealed off till 8 June. Some of those infected are in critical condition, and six who were more serious were taken to hospital in Dharan. It is difficult for the others because the municipality does not have an ambulance, and some who had taken sick relatives to Dharan returned because there were no beds, or it was too expensive. “Initially they were charging Rs10,000 per day for the bed and we paid Rs4,000 daily for the doctor. But then they hiked it to Rs14,700 and I couldn’t pay it any more,” says one patient’s family who returned recently from Dharan’s Bijayapur Hospital.Another <a href="https://www.nepalitimes.com/latest/rural-nepal-fights-back-covid-19/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/rural-nepal-fights-back-covid-19/&amp;source=gmail&amp;ust=1622085873679000&amp;usg=AFQjCNHu0t7Yl9XzW-TA064jBcggx4L-TA">coronavirus</a> patient says ambulances are also expensive, making it hard to get patients to hospitals. Buses refuse to take passengers who are sick.The municipality called an emergency all-party meeting and decided to set up a 10-bed isolation centre with two staff nurses, and a doctor. Talks are underway to get at least a pickup from Dhankuta Red Cross to use as an ambulance.

Sonia Awale

Protecting those who protect us from Covid

<figure><img width="957" height="638" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110131128/636cee759c7e80680e09ae2fjpeg.jpg" alt=""/><figcaption>Photo: BIKRAM RAI</figcaption></figure>On 20 May, the Health Ministry released a condolence message for doctors including Ishwor Lal Acharya, Mukesh Chaudhary and Pujya Shree Karki who lost their lives to Covid-19.Nepal doesn't yet have an exact figure on the total number of <a href="https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-the-epidemic/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-the-epidemic/&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNE67Zklb3ITwY-EN9ZPs4LRP2MFtQ">medical staff</a> infected by the SARS-CoV-2 but the Nepal Health Research Council (NHRC) is currently conducting a study to find out. “Majority of our frontline health care provides have been fully vaccinated, so even if they are being infected, they are only mild to moderately sick,” says cardiologist and chair of the Nepal Medical Council (NMC) <a href="https://www.facebook.com/bhagawan.koirala" data-saferedirecturl="https://www.google.com/url?q=https://www.facebook.com/bhagawan.koirala&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNEOs-qwziT36jBSTwwrTvDCe4MA1A">Bhagawan Koirala.</a> “This combined with a better understanding of Covid-19, they are now more confident and have a better sense of responsibility this time around.”At the National Trauma Centre in Kathmandu, nursing staff Suman Chaudhary is back to work after recovering from the coronavirus herself and draws motivation from health workers who are battling the pandemic in major hotspots like Birganj.“This is our chance to make a real contribution and having been infected myself has given me a new perspective on how patients feel,” says Chaudhary who was pursuing Masters in Nursing at Bir Hospital during the first wave. “It is difficult to work in a PPE all day without water or bathroom breaks. I still feel weak and have shortness of breath, but watching people recover keeps us going.”Both Koirala and Chaudhary, however, agree that there is a <a href="https://www.nepalitimes.com/here-now/nepals-frontline-workers-brave-it-out/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/nepals-frontline-workers-brave-it-out/&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNG1eSnzgkQ-VmoauOQrzkj_c0eUzA">chronic shortage of medical staff</a> across the country. Hospitals outside Kathmandu and even Covid dedicated institutions are overstretched, and now doctors and nurses are themselves falling sick. In some hospitals, since patients and staff are all positive, nurses and doctors with mild symptoms have just kept working, since there is no one else to take care of the sick.Last week, more than 47 of Dhading District Hospital’s emergency and ward staff were infected with Covid-19, with many of them in isolation and some requiring ICU treatment even as the facility was finding it difficult to source enough <a href="https://www.nepalitimes.com/latest/why-is-there-still-an-oxygen-shortage/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/why-is-there-still-an-oxygen-shortage/&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNGkShQk2X-gpsUuQceFplgqsL0bSg">oxygen for existing patients</a>.“We are a hospital of only 8 doctors, 5 paramedics and 23 nurses and with no backup, we were very close to collapsing,” says Medical Superintendent at Dhading District Hospital Tribhuvan Jha, adding that everyone had to be called back to work after 10 days of isolation. “We are in this position due to a lack of preparedness, shortage of staff and limited infrastructure.”At Charikot Hospital in Dolakha, which is also a Covid-dedicated hospital, the majority of coronavirus patients are critical and there is at least one fatality every day. The 17 nurses work three shifts a day, and are unable to handle patient inflow, so the hospital has brought in community nurses from outlying villages. The hospital is consistently reporting a 45% test positivity rate among those tested.“If a majority of our health workers get infected and are in isolation, we have no Plan B and this is especially worrying because we are the sole care provider for Covid here,” says Binod Dangal of Charikot Hospital. “Medical staff are all  overworked, and they do not have any insurance or allowances.”As dire as the situation is in Nepal’s big cities and district hospitals, the <a href="https://www.nepalitimes.com/editorial/nepals-humanitarian-emergency/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/editorial/nepals-humanitarian-emergency/&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNE3z3JV_9xnJ0reDy2ABkI8VuY16A">pandemic has now infiltrated rural Nepal</a> where there is just one doctor for every 15,000 people. Kathmandu’s doctor-to-patient ratio is 1:850.In her village of Phediguth of Okhaldhunga district, <a href="https://www.nepalitimes.com/banner/saving-nepali-mothers-on-mothers-day/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/saving-nepali-mothers-on-mothers-day/&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNErggt96LmoW-c38IzduDUsayQwIg">Rita Khatri</a> is the only skilled birth attendant. Despite the growing risk of the second wave, she is still performing deliveries and ante-natal check-ups wearing a mask and her single PPE suit. There are no tests of health workers and the public.“We are working despite fears of transmission, I wish we had more PPEs, masks and gloves so that we could conduct more regular check-ups and make home visits,” adds Khatri. “At the moment many people in the community have high fever and are staying at home, but there is no way to test them.” This time last year while in the grip of the first wave of a new pandemic, there was stigma associated with Covid-19 and people who were infected were ostracised in the community. There were many instances where <a href="https://www.nepalitimes.com/here-now/nepal-health-workers-battle-covid-19-but-also-stigma/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/nepal-health-workers-battle-covid-19-but-also-stigma/&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNECgLl_SyeWRy6kuDEPnEbsSFoCyQ">healthcare providers were mistreated</a>.Doctors and nurses interviewed for this report say that is still the case, but there is also more praise for frontline medical workers risking their own health to save lives. However, there is growing concern about the worry and over-work affecting the mental health of nurses and doctors.“Among other things we need psychological support and counselling. I have seniors who have children infected with the new variant, and they are having a hard time coping,” says Suman Chaudhary, nursing staff at the Trauma Centre in Kathmandu.As most of Nepal enters the fourth week of lockdown, nationwide daily Covid-19 infections, positivity rate as well as fatalities are going down slightly. The number of recoveries have also risen to nearly equal new confirmed cases on some days.Bayalpata Hospital in remote Accham District had to turn its Emergency Room into a Covid-19 ward last month to cope with a flood of patients. It had 33 patients, 18 of them needing high flow oxygen support. On Wednesday, it had only 12 Covid-19 patients with only two on oxygen. Four of those infected are medical staff. “The situation is easing somewhat here, in Mangalsen, Doti and Dadeldhura. There are beds available, and oxygen is coming in. But we are desperately short of medical staff,” says Mandeep Pathak, a physician at Bayalpata which is also caring for trauma and maternity patients from surrounding districts.However, the cases and the test positivity rate <a href="https://www.nepalitimes.com/here-now/its-an-emergency/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/its-an-emergency/&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNHx4NfPYsEDb5xqY31L966E2avOdg">have not gone down as expected</a> and fatalities nationwide have stayed above 160 for nearly two weeks now as the highly contagious and more lethal B.1.617.2 variant spreads rapidly through communities.Health Minister Hridayesh Tripathi sounded optimistic at a virtual press meet on Monday, predicting that there would be a decline in the infection rate in the next four weeks. As Nepal receives large shipments of oxygen cylinders, liquid oxygen, test kits, PPEs and masks, doctors say the emphasis now needs to shift to more testing, mass vaccination, and replenishing exhausted and over-stretched medical staff at hospitals, both in the cities and the districts. A non-profit One Heart Worldwide that works primarily in maternal care in Nepal’s 21 districts has been helping district hospitals by mobilising oxygen cylinders and medical kits it procured from China.<a href="https://www.nepalitimes.com/banner/what-can-be-more-fulfilling-than-saving-lives/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/what-can-be-more-fulfilling-than-saving-lives/&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNFzGOK8F0-jy4gwuRmK8iyNBD7AIA">Executive director Surya Bhatta</a> gives three reasons why despite the lockdown the infection rate is still high. “There is virtually no contact tracing, people are still not following health protocols and patients isolating at homes are not doing it right, resulting in a gross underestimation of total cases and fatalities.”		
			<h2>Weddings into hotspots</h2>		
		Gopal Dahal in DhankutaOn 30 April, when a young man in Okhre village in Dhankuta district got married, the whole . The whole community was invited for the feast.But a few days later, the groom suddenly fell sick. When he showed coronavirus symptoms, a test at the primary health care centre confirmed he was <a href="https://www.nepalitimes.com/here-now/its-an-emergency/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/its-an-emergency/&amp;source=gmail&amp;ust=1622085873678000&amp;usg=AFQjCNHx4NfPYsEDb5xqY31L966E2avOdg">Covid-19</a> positive.Now, every household in Okhre village has members showing similar symptoms. Most of them had attended the wedding. Of the 51 people tested, 25 tested positive. “This is a crisis, the pandemic has spread to the whole village now,” says Ward Chair Palak Basnet.One of the guests at the wedding was a man who had returned recently from the Tarai with mild symptoms. He was hired to wash dishes at the wedding, and had died a few days after the feast. No one tried to find the cause of death, and there was no PCR test done. Dhankuta MP Jitendra Rumdali Rai says there are probably many more cases than the ones who have tested positive so far. “The pandemic is spreading out of control here because the municipality wasn’t able to manage it on time,” he adds.Okhre village has now been sealed off till 8 June. Some of those infected are in critical condition, and six who were more serious were taken to hospital in Dharan. It is difficult for the others because the municipality does not have an ambulance, and some who had taken sick relatives to Dharan returned because there were no beds, or it was too expensive. “Initially they were charging Rs10,000 per day for the bed and we paid Rs4,000 daily for the doctor. But then they hiked it to Rs14,700 and I couldn’t pay it any more,” says one patient’s family who returned recently from Dharan’s Bijayapur Hospital.Another <a href="https://www.nepalitimes.com/latest/rural-nepal-fights-back-covid-19/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/rural-nepal-fights-back-covid-19/&amp;source=gmail&amp;ust=1622085873679000&amp;usg=AFQjCNHu0t7Yl9XzW-TA064jBcggx4L-TA">coronavirus</a> patient says ambulances are also expensive, making it hard to get patients to hospitals. Buses refuse to take passengers who are sick.The municipality called an emergency all-party meeting and decided to set up a 10-bed isolation centre with two staff nurses, and a doctor. Talks are underway to get at least a pickup from Dhankuta Red Cross to use as an ambulance.

<figure><img width="1500" height="1000" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111140/636b83bd9c7e80680e067753jpeg.jpg" alt=""/><figcaption>Photo: MONIKA DEUPALA</figcaption></figure>Ever since he was a child, Ramesh* knew he wanted to be a doctor to serve society and "do something good for others". Even now, as an MBBS student at B P Koirala Institute of Health Sciences (BPKIHS) in Dharan, his zeal is intact. As a part of his curriculum, he is required not just to attend lectures but also complete clinical postings. And that is what he was doing till a few days ago when he tested positive for Covid-19."I started feeling unwell during the exams, and took a PCR test. The result came out positive. I have been isolating since," Ramesh told us on the phone from Dharan.In January, when the government announced the priority list for the <a href="https://www.nepalitimes.com/banner/nepal-begins-covid-19-vaccination-drive/" target="_blank" rel="noopener noreferrer">first round of Covid-19 vaccines</a>, medical interns and doctors were on it. Many admin staff working in the hospitals also qualified for the jab. However, missing from the list were medical students who work in close proximity with the patients as a part of the curriculum. BDS and MBBS students have to do ward and clinical postings in their third, fourth and fifth years. Nursing students too have hands-on training as part of their course work."We all know that wearing a mask is one of the best precautions we can take against Covid. But as dental students, we need to treat patients when they are not wearing masks. The risk of exposure is the same for us as the interns, yet we did not get the vaccine," says a dentistry student from BPKIHS, whose friend recently tested positive as well.<a href="https://www.nepalitimes.com/opinion/masks-and-vaccines-to-stop-nepals-2nd-wave/">Masks and vaccines to stop Nepal’s 2nd wave</a>, Sushil KoiralaAfter the first lockdown, BPKIHS like many others <a href="https://www.nepalitimes.com/latest/face-to-face-classes-online/" target="_blank" rel="noopener noreferrer">conducted classes online</a>. However, as the country opened up slowly, clinical postings for fourth year students started from 1 December. While they conducted PCR tests for those seeking admission in wards, those coming to the Out Patient Department (OPD) could not be monitored. "Even in wards, although patients were tested the same was not true for the visitors," says a final year medical student at BPKIHS. According to the students as many as 25 of these colleagues have tested positive over the past few months. Students say they have talked with the school administration, but were told there was no government protocol to get them the vaccine. Medical students from other schools that Nepali Times spoke to shared similar stories. "We would be a little more confident if we were vaccinated," says a medical student from Birat Medical College in Biratnagar. "It is not just about us being exposed or working, we have lost a lot of valuable time in terms of our course work.” After the first lockdown, classes here went online and the practical classes were conducted without hospital exposure. "But after the third year finals, we were called for clinical postings," says the student. "Maybe they could have given us the vaccine and we could continue with our classes."It is not just the students, new interns who recently graduated, have entered, or are soon entering the workforce were also left out.<a href="https://www.nepalitimes.com/banner/nepal-fights-infodemic-to-push-vaccine/"> Nepal fights infodemic to push vaccine</a>, Sonia AwaleGita* is a medical student at Kathmandu University's medical school recently passed her final exams, and is starting her internship. Even though she and friends were omitted from the priority list last year, she was planning to get the <a href="https://www.nepalitimes.com/latest/the-gift-of-the-jab/" target="_blank" rel="noopener noreferrer">Vero Cell jab</a> this time around. Poor planning and overcrowding prevented her from getting vaccinated, then she had to return to school to start her internship. "New interns who just started last Saturday were left out from the list," says an intern coordinator at a medical school in Biratnagar. "Students don't get the same level of protection as the faculty. We have talked to interns about safety measures and precautions. And we are also looking into simulation-based teaching for practical classes.”It is not just for the safety of students but the patients as well that the students and new interns need to be vaccinated. When they are vaccinated, they can ensure that the patients are not going to get infected through the ones who are treating them, say the students."While the vaccines may not work against the new variants and there are chances of being infected even when you are vaccinated, the severity of symptoms is less," says an intern doctor who tested positive after the second jab.With the lockdown on 28 April, medical schools have also now suspended classes. Trainee doctors in India are being pulled from the exams to work on the frontline, and Nepal’s medical students may have to do the same. "Maybe keeping this in mind, they could still give this a serious consideration and vaccinate the students and new interns," says a final year student at BPKIHS.Spokesperson for Ministry of Health Jageshwor Gautam, however, says that young people are still not a priority. "We are aware of the situation,  the reason medical students didn't get vaccines is because there are just not enough doses." Asked if medical students will be given priority once new vaccines arrive, Gautam replied flatly: "People above 60 years are still a priority. Everyone else comes after that."*Some names have been changed or withheld for privacy reasons.

Medical students deprived of Covid-19 vaccines

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110915110/636bb29f9c7e80680e07baf2jpeg.jpg" alt="" width="2048" height="1366"/><figcaption>Photo: BIKRAM RAI</figcaption></figure>Nepal reported the first death of a medical worker from Covid-19 last week, a 35-year-old health assistant in Mahottari district. Across the country, over 500 <a href="https://www.nepalitimes.com/here-now/nepals-frontline-workers-brave-it-out/" target="_blank" rel="noopener noreferrer">healthcare providers</a> including doctors, nurses and lab technicians have tested positive for SARS-CoV-2.But instead of crediting them for putting their own lives on the line at the frontlines of the war against the pandemic, heath workers in Nepal <a href="https://www.nepalitimes.com/here-now/overseas-nepalis-on-the-covid-19-frontlines/" target="_blank" rel="noopener noreferrer">are being ostracised</a>, publicly humiliated, and sometimes threatened by landlords and neighbours who fear that they will spread the virus.Even as they battle community transmission, in many cases it is the community itself that has turned against <a href="https://www.nepalitimes.com/here-now/overseas-nepalis-on-the-covid-19-frontlines/" target="_blank" rel="noopener noreferrer">medical personnel</a>.Over 20 staff at Bayalpata Hospital in Achham district have tested positive for Covid-19 in the last month, and all are currently isolated in the facility’s staff quarters because landlords have driven them out of their rented rooms in town.“The government has directed asymptomatic people to isolate themselves at home, but this shows just how difficult this is in reality,” says Bikash Gauchan, a doctor at Bayalpata. “It is harder to fight society than Covid-19.”Gauchan himself was in isolation after a previous outbreak and tested negative, but on a recent trip to the market to buy grocery, the shopkeeper stopped him from entering just because he worked at the hospital.At the Patan Academy of Health Sciences, the newly appointed director Rabi Shakya gets resignation letters from staff every day, and the reason cited by everyone of them is because of community harassment, or due to family pressure.“Health workers are already working in less than ideal conditions, they are not properly equipped, are overworked and have no incentives. Many don’t even have family support,” says Shakya. “They are risking their own health for the public, but when that very public turns against you, it is very painful.”Shakya says many younger doctors are now rethinking their decision to work in the medical field in Nepal. He adds, “Societal stigma stems from ignorance, and it means we have failed to communicate to the public how the virus is transmitted. Even some health workers themselves are not fully aware.”Says epidemiologist Mahesh Maskey: “It is ironic that these brave workers are receiving abuse from the very people they are protecting. I am surprised by how the psychology of fear has led us to do this, and I urge everyone to change their mentality.”https://youtu.be/6-IvZtDfPmYThe flood of positive cases in Kathmandu and other cities in the past month has led to public panic about Covid-19, and this is turning people against those who are self-isolating at home, or those working at close quarters with patients.Experts partly blame the relentless media focus on the daily case totals and fatalities, instead of the recovery rate, Nepal’s relatively low death rate, and the precautions the public needs to take. This has fed the notion that Covid-19 is highly lethal, fuelling the irrational fear.On Tuesday, Nepal recorded 1,069 new confirmed cases, 481 of them in Kathmandu Valley alone. There were 11 additional deaths, bringing the total to 239. However, what was buried in the news reports was that Tuesday also saw 768 recoveries, highest in a single day bringing the total recoveries to 22,178.Some doctors have retorted on social media with messages for those who stigmatise health workers, saying they should also think about who is going to save their lives when they find themselves in the ICU.Amidst the gloom and doom, there are glimmers of hope. Nepal Scouts, Nepal Medical Association and Higher Institutions and Secondary Schools' Association Nepal in coordination with the Ministry of Health have started a free bus service for medical personnel inside Kathmandu Valley to take them to and from hospital and their homes.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110915110/636bb2a29c7e80680e07baf3jpeg.jpg" alt="" width="800" height="450"><figcaption> </figcaption></figure>Charities are offering free daily meals for those without any source of sustenance. In Biratnagar, local youth groups are helping rehabilitate Covid-19 patients who have recovered (see below). And there are communities which have honoured medical frontline workers who live in their midst, saying they are true heroes.However, these are exceptions. Anisha Shakya, a medical officer at International Friendship Children Hospital says she and her colleagues are already working with limited equipment and resources, and the harassment heaped on health workers is stressful.She adds, “What would build morale is positive reinforcement, emotional support in this difficult time and more tolerance on the part of the public.”<h2>Youth help</h2>Kamal Rimal in Biratnagar<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110915110/636bb2a49c7e80680e07baf4jpeg.jpg" alt="" width="800" height="416"><figcaption> </figcaption></figure>Worried by the ostracisation and harassment of even those who have recovered from novel coronavirus infections, youth groups in Biratnagar have taken it upon themselves to help in their reintegration into society.They conduct home visits, sanitise homes and help with the management of funerals. Bargahi Youth Group recently helped perform the funeral of an individual who had passed away due to coronavirus in Birat Hospital, and who was shunned by relatives and the community. The entire team is now in quarantine. High Court Biratnagar recently ruled that the final rites of Covid-19 victim should be performed by the families, or as per their wishes.When a person was infected in Ashok Chok recently, locals blocked off the streets preventing residents from commuting.Nepal Communist Party Biratnagar Ward 8 committee chair Ram Pokhrel says increased fear of coronavirus in the community and the resulting societal stigma has forced his office to scale up the campaign.“We are sanitising homes among other things in order to prevent more incidents like this from happening in the future. But first and foremost, we need to change the way society thinks,” says Pokhrel, adding that even well-educated neighbours who are engineers and school principals were against the presence of infected individuals in the community.In its home visits and sanitisation campaign, the group tries to inform locals that the virus does not transmit if sufficient distance is maintained. They have also distributed masks, gloves, sanitiser and food rations to 54 households.Biratnagar Municipality members are also making home visits with immunity-boosting Ayurvedic herbs for those in self-isolation, and help them eventually reintegrate into society by boosting their morale.Former chair Binod Raut says he has sanitised about 70 houses with his own money: “Coronavirus is now spreading in the community. We are going house to house, informing people about how the virus spreads and sanitising the homes of infected people.”

Nepal health workers battle Covid-19, but also stigma

<figure><img width="825" height="460" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109141132/636bac7d9c7e80680e077f35jpeg.jpg" alt=""/><figcaption>Kanchan Bista at the government lab in Dhangadi says she wears three menstrual pads at once so she does not have to go frequently to the bathroom to change.</figcaption></figure>Until the COVID-19 crisis hit Nepal, the phrase ‘frontline health worker’ mainly referred to the 55,000 Female Community Health Volunteers (FCHVs) who form the backbone of the country’s rural health service for vaccinations and mother-child survival.With the pandemic, it has now come to mean doctors, staff nurses, hospital staff, counselors, health assistants, and even security personnel who are on the trenches at the frontlines enforcing rules, doing surveillance and detection, lab technicians, staffing quarantine centres, isolation wards and the medical personnel taking care of critical cases.Frontline health workers are exposed to massive viral loads, and so far 20 health workers and 12 security personnel have tested positive for a virus that they have been fighting in the public. Returnees from abroad have gone back to their homes, and with the threat of community transmission, Nepal is falling back on its <a href="https://www.nepalitimes.com/latest/enlisting-female-health-volunteers-to-fight-covid-19/" target="_blank" rel="noopener noreferrer">FCVHs for house-to-house surveillance and counseling</a>.Besides the constant risk of being infected, frontline workers have other woes: overwork, the lack of adequate personal protective equipment (PPE), extra allowance the government promised in March that has not arrived, the threat of eviction by stigmatisation by landlords has forced many to move to hotels.        <a href="https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-the-epidemic/">Protecting those who protect us from the epidemic</a>, Ramu Sapkota"The workload is very heavy with 700 to 800 samples to be tested daily,” says Sanjay Chaudhary, a microbiologist at the Surkhet Provincial Hospital lab. “Some of us work in the PCR testing laboratories from six in the morning till two in the morning.” <figure><img width="1100" height="731" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109141132/636bac7f9c7e80680e077f36jpeg.jpg" alt=""><figcaption>Microbiologist Sanjay Chaudhary at the lab in the Provincial Hospital in Surkhet says it is difficult to work all day wearing a PPE, mask and gloves and sweating inside.</figcaption></figure>Chaudhary says it is difficult working in full PPE with mask, gowns, gloves and visors, and they are dripping with sweat inside. He tries to drink as little water as possible because going to the bathroom is such a ordeal.Ananda Mandal at the government lab in Dhangadi says he even wears an adult diaper so he does not have to keep going to the bathroom in his PPE. A throat and nasal swab of a patient takes up to six hours to give a result, and sometimes they need to be re-tested to confirm the result. Healthcare personnel like Mandal have to be in their PPE throughout, without drinking, eating, or going to the bathroom in the humid heat of the Tarai.Till 7 July, Nepal had 15,964 people testing positive for coronavirus with 9,118 in isolation.<a href="https://www.nepalitimes.com/here-now/bhutan-refugee-to-coronavirus-care-giver/">Bhutan refugee to coronavirus care-giver</a>, Gopal GartoulaAnother 29,700 are in quarantine centres, and there have been 35 fatalities. Fortunately, there have not been big numbers of critical COVID-19 cases needing ICU treatment or ventilators. This means the frontline workers most under pressure are lab technicians.At the COVID-19 laboratory in Bhaktapur Hospital, Nitu Adhikari says the general public has little understanding of how difficult working in a lab is. She says, “Some men wear diapers, some cut an opening in their PPEs when they have to use the bathroom and then seal it with tape afterwards. It is so difficult to get in and out of the gowns.” <figure><img width="1050" height="645" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109141132/636bac829c7e80680e077f37jpeg.jpg" alt=""><figcaption>Nitu Adhikari at Bhaktapur Hospital says the public has little idea how difficult it is working in a coronavirus lab.</figcaption></figure>All this stress and irregular eating exposes health workers to dehydration which can also lead to health problems. "When we watch the news about so many new PCR tests were done nationwide, let us give a thought to the frontline workers who put themselves at risk not just of infection but also long-term complications to carry out those tests in difficult conditions,” says health workers Radha Poudel in Jumla.A microbiologist working in a laboratory in Province 1 has diabetes, which puts him in a high risk group for COVID-19 infection. He needs to drink lots of water, and needs to use the bathroom frequently. But for the past three months, his meals have been irregular and he suffers from dehydration.“Even under normal circumstances, we do not work more than five hours at a stretch, and if they have to go to the bathroom, they have to change into another PPE,” says Runa Jha at the National Public Health Laboratory in Kathmandu.<a href="https://www.nepalitimes.com/here-now/overseas-nepalis-on-the-covid-19-frontlines/">Overseas Nepalis on the COVID-19 frontlines</a>, Upasana KhadkaHowever, this guideline is hardly ever put into practice. Most health facilities have barely enough PPEs for healthcare personnel, let alone to change in and out of during breaks. There is also the lack of testing kits, or improper and unreliable kits that give the wrong results.  Radha Poudel says the government has not paid attention to the problems faced by healthcare personnel despite the global focus on frontline workers. As a menstrual hygiene activist even before the coronavirus pandemic, Poudel is especially concerned about female health workers who have specific problems working in hospitals and labs during their periods.Kanchan Bista, a medical technologist at the government testing lab in Dhangadi says she wears three menstrual pads at once so she does not have to go to the bathroom to change. “It is very difficult to change and often there is no new PPE to get into afterwards,” she says.  Nitu Adhikari says the government has to ensure adequate PPEs so that lab technicians, doctors and nurses do not have to wear PPEs for long stretches. She adds: “There also have to be enough PPEs, diapers and pads for us to use. These problems need to be addressed so that those working on the frontline are comfortable and safe."Read also: <a href="https://www.nepalitimes.com/here-now/post-pandemic-mental-health-epidemic/">Post-pandemic mental health epidemic</a>, Sonia Awale

Nepal’s frontline workers brave it out

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.