One in every three Nepalis carries the <a href="https://nepalitimes.com/editorial/tb-or-not-tb">tuberculosis</a> bacillus. There may be no active symptoms, but they can at any point progree into a full blown infection. TB kills up to 47 Nepalis daily. If so many people died every day in road traffic accidents, it would make headlines every day. But they do not because tuberculosis afflicts the poorest people in the poorest parts of Nepal.&nbsp; The annual 17,000 fatalities from <a href="https://nepalitimes.com/banner/for-nepal-a-game-changer-in-tb-control">tuberculosis in Nepal</a> are preventable with cost-effective treatment. A new pilot study in Chitwan and Piuthan in the past two years showed that 1,160 (out of 1,173 household contacts) completed the Tuberculin Skin Test (Mantoux Test) of whom 542 (45%) were positive. After doing a chest x-ray, 509 met the eligibility criteria for TB preventive therapy. 500 (97%) gave consent to the treatment.&nbsp; Researchers were pleasantly surprised. As in other countries in the region, they were expecting very few to agree to take preventive therapy medicines because they did not have TB symptoms, so a 95% agreeing to the treatment was exceptionally high. “People in Chitwan and Piuthan who participated in the study were not sick, they were just carrying the TB bacteria, but they agreed to take the preventive drugs because they have all known of relatives who had died of TB,” explains Buddha Basnyat, a physician who advised the Birat Nepal Medical Trust (BNMT) that conducted the research.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240325030340_43b4bc93b22c3964ee021a9dc9df40f9da783917b2ebfbe798a03a82276421a7.jpg" data-media-id="editor_2" data-image-id="20240325030340_43b4bc93b22c3964ee021a9dc9df40f9da783917b2ebfbe798a03a82276421a7" data-rendition-name="original" width="1500" height="1125" loading="lazy" alt="Tuberculosis preventive therapy in Nepal"> <figcaption>Health care volunteers during an outreach screening program in Dhanusha as part of active case-finding for tuberculosis in local communities.</figcaption> </figure>  BNMT is now extending the study to Nawalparasi and Rupandehi with the National Tuberculosis Control Centre. Latent TB is more prevalent in the Tarai districts because of their higher population density. With Nepal suffering such an <a href="https://nepalitimes.com/here-now/nepal-tb-cases-grossly-underestimated">enormous disease burden from tuberculosis</a>, one would have thought World TB Day on Sunday 25 March would have got more attention. But it was overshadowed by Holi celebrations. It would have been interesting to see how many in the crowds attending the concert at Darbar Marg would test positive. Scientists worry that the World Health Organisation’s END TB strategy of reducing global tuberculosis incidence by 90% and deaths by 95% in the next ten years is too ambitious unless latent tuberculosis cases are also treated.&nbsp; What makes this failure all the more tragic is that tuberculosis is a completely preventable and treatable infection. Every $1 invested in TB gives a $39 return, yet there is little investment and advocacy to combat this biblical illness. South Asia accounts for some 40% of all TB cases and 38% of all TB deaths — most of them occurring in the thickly-populated states across the Nepal border in India. The region also has a high burden of multi-drug resistant TB, one-third of global cases. In the past, Directly Observed Therapy Short Course (DOTS) drug therapy in which patients were administered medicines at health posts was considered a cure-all for tuberculosis. <a href="https://archive.nepalitimes.com/news.php?id=294">Nepal had a high success rate for DOTS</a>, but there were loopholes in the program: latent cases remained hidden and only the cases that came to the health system were treated. DOTS also added to the pre-existing stigma so that patients travelling to the health posts would be identified as having tuberculosis. In one instance, a patient in Bardia chose to take a dangerous tiger-infested jungle route to reach the health post. &nbsp; Meanwhile, BNMT had been setting up a strong community network of health volunteers, and was <a href="https://nepalitimes.com/banner/nepal-tests-and-treats-tb-with-a-flying-pharmacy">tracking active TB cases</a>. Unlike DOTS, it involved meeting family and friends of patients, allowing more case detection and treatment. Even so, they were not looking for latent infections.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240325030340_39b79cbd0799bee83a8ae67fd8016d9c75b539d89679e5a4328a7b8540bbca01.jpg" data-media-id="editor_6" data-image-id="20240325030340_39b79cbd0799bee83a8ae67fd8016d9c75b539d89679e5a4328a7b8540bbca01" data-rendition-name="original" width="1687" height="1125" loading="lazy" alt="Tuberculosis preventive therapy in Nepal"> <figcaption>Female Community Health Volunteers (FCHVs) have played a significant role in active case finding.</figcaption> </figure>  Latent cases can progress to active tuberculosis especially when a patient's immune system is weak because of malnutrition, illnesses like HIV, or age. In fact, half of TB worldwide can be attributed to undernourishment. Latent TB can be confirmed in two simple steps: a Mantoux test with an above 10 score and a clear chest x-ray. If positive, the patient is given the 3HP preventive therapy — a once-weekly treatment with isoniazid-rifapentine for 12 weeks. This treatment can prevent reinfection for as long as six years, and is not to be confused with the one for active cases which requires daily treatment for six months. “On an individual level, you can still get reinfected if you are living in a house with active cases. But if you treat the community at large with preventive therapy, you drive down the prevalence of TB and in turn, people won't get reinfected,” explains Maxine Caws of BNMT. She adds: “If we can use preventive therapy to push down the reservoirs of infection then we extend the amount of time people are protected as is the case in Europe for example where people don't get TB anymore because they are not exposed to the bacteria at all. We have to eradicate that reservoir.” The traditional BCG vaccine given within 28 days of birth is effective against childhood tuberculous meningitis and miliary disease, but does not prevent TB in adults. Efforts are underway to develop a new effective vaccine but there are many challenges.&nbsp; TB vaccine development is difficult because exposure to the tuberculosis bacillus does not seem to induce sufficient protective immunity. A new viable vaccine could take a decade, but in that time 13 million more people would die.&nbsp; “We cannot wait and do nothing until a new effective vaccine is developed. Preventive therapy is a vaccine until we have one,” adds Basnyat. Indeed, the 3HP preventive therapy after diagnosis costs only $5 per regimen. So, Nepal’s strategy should be a simultaneous focus on 3HP preventive therapy and case finding.&nbsp; The problem has been a lack of priority for preventive therapy at national and international levels because it does not involve costly research and interventions, and the patients are poor. Explains Caws: “On paper, we have very strong policies but the commitment in terms of funding from the governments has not materialised, essentially because it is not affecting the rich unlike with Covid when we threw everything at it to have a vaccine developed in a year.” TB’s main problem, <a href="https://nepalitimes.com/opinion/comment/pandemic-eclipses-nepals-tb-epidemic">unlike Covid</a> and HIV/AIDS is that it is a disease of the poor.&nbsp;

Sonia Awale

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Ending TB is possible, and cost-effective

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101144/63720e899c7e80680e0b7923jpeg.jpg" alt="" width="1400" height="933"/><figcaption>Photo: ANTONIO BELTRÁN RODRÍGUEZ</figcaption></figure>Daily wage labourers Dharma and Gita lost their jobs during the pandemic. The young couple exhausted their meagre savings in less than a month, after which they started to buy food on credit. Still unable to repay loans, they limited their diet to one small meal a day.Soon, Gita started feeling weak. She often had a fever and cough. As the lockdown extended, her health deteriorated and the medicines were of little help. The couple even took a PCR test which came out negative. They visited five different health centers and bought bags full of medicines. The treatment was so expensive they had to sell their two cows. A month later, and heavily in debt, she was diagnosed with tuberculosis.Tuberculosis mainly afflicts the poorest. The numbers are staggering: one in every three people globally is infected by Mycobacterium tuberculosis, and even if they carry the bacteria most people do not get sick unless their immune system is weakened due to disease or malnutrition.And yet, this easily preventable and curable biblical disease thrives in Nepal and the Subcontinent due to inadequate measures taken to prevent, diagnose and treat the infection.A 2020 National TB Program report revealed that over 100,000 people are living with tuberculosis in Nepal. This figure is much higher than previously estimated but has most likely increased since as many patients have been unable to access treatment during the pandemic.Of these cases, 40,000 patients were not diagnosed or treated at government centres, which means nearly one in every two people were not diagnosed. Oftentimes, people reach standard TB treatment and care after months or even years. Their pathway to cure is complex, long and include misdiagnosis leading to unnecessary prescriptions. This in turn could lead to unnecessary death and suffering. Patients are also ostracised by friends and families, resulting in self-isolation from communities.These challenges are exacerbated by Nepal’s limited health infrastructure. Health care centres are understaffed and poorly managed, maintenance of laboratory equipment, as well as supply of quality chemicals for tests, are erratic.Across Nepal’s Tarai, settlements are overcrowded, people live in extreme poverty, hygiene and sanitation are at a bare minimum. In the hills and the mountains, difficult geographical terrain and poor road networks pose obstacles for people seeking health care.These deeply-rooted structural inequities collectively resulted in magnified impact on TB service delivery during the pandemic. As a result, we observed increased deaths from the disease.In 2018, global leaders committed to reducing TB by 2022. To meet this goal, we need comprehensive intervention programs with sufficient investment for prevention, early diagnosis and treatment. There are four key areas that require increased funding to decrease TB fatalities:1 PreventionWe saw how the world community got together to rapidly develop vaccines for Covid-19 with unprecedented funding and resources. TB on the other hand has only one vaccine and a very weak one at that. Developed over a century ago, BCG does not prevent adults from developing TB disease.UnderNepal's national TB program, young children living with adults who have TB are provided medicines to kill any TB bacteria they have inhaled and prevent the development of the disease. The Birat Nepal Medical Trust for the first time in Nepal is providing a shorter 12-dose course of TB preventative medicine to adults infected with the bacteria to stop them from getting sick and spreading the disease.In 2020, only $684 million of the estimated $2.16 billion needed globally for TB research and development was available from donors. Covid-19 on the other hand received over $100 billion in just two years to develop vaccines. The pandemic exposed this global inequity, and is proof of what sufficient funding and political commitment can achieve.If funding for the global TB prevention program is increased by 3-4 fold, we could design better community-based services, develop a more effective vaccine and promote shorter treatment regimens, all of which will achieve a TB-free Nepal sooner.TB awareness and health promotion messages also do not get as much coverage in the media as they used to. World TB Day, observed every year on 24 March, should serve as a reminder that TB is an epidemic and needs accelerated efforts for elimination.2 Diagnosis and InnovationGovernment health centres provide TB diagnosis and treatment free of cost. Yet, people spend a lot of money and time before they are correctly diagnosed and enrolled in treatment. This is because symptoms of the disease are common to many infections. People develop cough and fever and immediately resort to taking paracetamol and general antibiotics before realising that they have TB.Moreover, Nepal needs to quickly adopt GeneXpert machines which use PCR testing, and chest X-ray that diagnoses early-stage TB effectively and efficiently. Investment should be concentrated to expand, strengthen and maintain these diagnostic tools at health centers all over the country. Health care providers should be similarly trained to operate these machines.GeneXpert technology should be deployed with active case finding where community health workers make home visits to screen and identify TB patients. This method also commonly known as contact tracing was applied in containing the spread of the Covid-19 virus, and has been used in TB programs for decades.Although proven to be effective, new diagnostic technologies are expensive and active case-finding strategies require large and sustained financial commitments. One might question if a country like Nepal can afford such investments. But the question we should be asking is, can we afford not to?The costs of the continued TB epidemic are far greater than the investments required to reduce it. Investing in better  tools including tax waivers on the import of TB diagnostic machines and test kits, and increased global funding for implementation of active case finding strategies for low and middle-income countries like Nepal are urgently needed.3 Community-based Treatment and Care Incomplete or delayed treatment can cause drug resistant TB and even death. Therefore, the treatment of tuberculosis should be patient-centred.TB programs have been implemented in Nepal for over half a century, we now have plenty of experience to employ the best strategies and  to eliminate the scourge.One of the challenges to eradicating TB is the long duration of treatment. Under the DOTS program, tuberculosis patients have to visit health centres daily for medication to be taken in the presence of care providers. But this could expose them to other TB patients, and resulting stigma. It is also time-consuming and comes with additional transport expenses.Investment in research and development of shorter course treatment regimens, and scaling up telemedicine is a priority area.4 Social Protection TB and poverty form a vicious cycle, each fuelling the other. It is mainly the neediest in society who are most affected. Having TB increases financial strain in their families with far-reaching socio-economic consequences. Children may have to forgo education and seek employment to compensate for the loss of income in families with an infected adult. Providing cash to families after the diagnosis will alleviate the financial burden.TB also causes malnutrition making people more vulnerable. Providing diversified food packages with appropriate nutritional value will be a big support, it will also help reduce the mental stress of fulfilling family needs.But these are just a few recommendations, a study to identify feasible and acceptable support for people with TB will enable us to design an improved tuberculosis support program. These should incorporate health education to people with TB and their families to better understand the disease, cope with its treatment and overcome stigma.Ultimately, it is the government’s responsibility to protect the lives of its people. Therefore, investing in and incorporating locally appropriate social protection schemes within the TB program should be the key agenda and priority of policymakers.The slogan this World TB Day today on 24 March is ‘Invest to End TB. Save Lives’, which reiterates the need to increase funding to prevent, diagnose and treat TB. Without substantial investments that will accelerate collective efforts of the community, country and the world, it is unlikely we will win the fight against TB, reverse the huge setback caused by the pandemic or save lives.Kritika Dixit is the Research Manager at Birat Nepal Medical Trust (BNMT) and a doctoral student at Karolinska Institutet, Sweden. Rajan Paudel is the Research Associate at BNMT.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101144/63720e8c9c7e80680e0b7924jpeg.jpg" alt="" width="80" height="109"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101144/63720e8d9c7e80680e0b7925jpeg.jpg" alt="" width="82" height="109">Read also: <a href="https://www.nepalitimes.com/banner/for-nepal-a-game-changer-in-tb-control/">For Nepal, a game-changer in TB control</a>, Buddha Basnyat and Maxine Caws

Pandemic eclipses Nepal's TB epidemic

<figure><img width="1236" height="856" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85a09c7e80680e067804jpeg.jpg" alt=""/><figcaption>Photo: AMIT MACHAMASI</figcaption></figure><h2>1. Oxygen</h2> To save lives, Nepal’s most urgent need now is oxygen. Not just cylinders, but oxygen generators, concentrators and liquid oxygen. Most infected people are not succumbing to Covid-19, they are <a href="https://www.nepalitimes.com/here-now/helping-nepalis-breathe-again/" target="_blank" rel="noopener noreferrer">dying because of low oxygen saturation</a> in the blood, and lack of hospital beds -- patients who need not have died of coronavirus. Dire as the situation is in the cities, Nepal’s pandemic has now <a href="https://www.nepalitimes.com/editorial/nepals-humanitarian-emergency/" target="_blank" rel="noopener noreferrer">infiltrated the remotest villages</a> where there is no hospital care and no oxygen. The virus is preying on people already suffering malnutrition, previous ailments, and decades of structural state neglect. In Rolpa, Humla and other remote districts, between 80-90% of PCR tests are coming back positive, and it takes a week to get results. Patients are either not isolating, or not following precautions.Kathmandu's doctor-to-patient ratio is 1:850, but in rural Nepal it is one doctor for every 15,000 people, and hospitals and medical staff there <a href="https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/" target="_blank" rel="noopener noreferrer">are already overstretched</a>.Close to 60% of all swabs collected nationwide are from Bagmati Province, with nearly half of them in Kathmandu Valley, says epidemiologist Lhamu Yangchen Sherpa. She adds: “There just aren’t enough tests and contact tracing is minimal, official total cases and fatalities are grossly underestimated.” <figure><img width="1497" height="746" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85a39c7e80680e067805jpeg.jpg" alt=""><figcaption> </figcaption></figure><figure><img width="984" height="519" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85a69c7e80680e067806jpeg.jpg" alt=""><figcaption> </figcaption></figure>Hospitals in Kathmandu Valley with roof helipads have multiple daily rescue flights, but even these facilities are <a href="https://www.nepalitimes.com/banner/we-knew-the-tsunami-was-approaching/" target="_blank" rel="noopener noreferrer">at breaking point</a> with patients being turned away. Understaffed and under-equipped hospitals in the districts do not stand a chance. Even where hospitals exist, many families avoid them for fear of being infected and take wrong medication from pharmacies.Case in point are recent deaths due to misdiagnosis across the country. <a href="https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/" target="_blank" rel="noopener noreferrer">Typhoid disease</a> simulates Covid-19 with similar symptoms, and the widespread Widal test is known to give false positives.“Covid patients are being prescribed antibiotics to fight typhoid, only to turn critically ill in a few days’ time,” says Buddha Basnyat of Patan Academy of Health Sciences. “This is the reason behind some of the latest Covid fatalities.” <figure><img width="1280" height="720" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85a89c7e80680e067807jpeg.jpg" alt=""><figcaption> </figcaption></figure>As in India, Nepal is beginning to see a slight bending of the curve for new infections, but health experts expect the fatality rate to remain high for some more time.  There were 190 Covid deaths in the past 24 hours and 6,543 recoveries. Of the total 8,305 new cases on Thursday, Kathmandu Valley accounts for 3,232 infections. 7,814 people are undergoing treatment in hospitals with 1,748 in ICU and 492 in ventilator support. “After the relentless patient pressure of the past month, we have seen a decline in those requiring admissions,” says virologist at Teku hospital Sher Bahadur Pun. “The virus has now infected a majority of people in the cities, and this combined with the lockdown means we may be getting to the halfway mark of the second wave.” <h2>2. Vaccines</h2> A prolonged lockdown is not the answer. If it was, the <a href="https://www.nepalitimes.com/latest/covid-19-numbers-slightly-down-in-nepal/" target="_blank" rel="noopener noreferrer">reduction in the number of cases and the positivity rate</a> this week would have been steeper. Even while the government tries to increase oxygen supply to hospitals, the only long-term strategy is to vaccinate at least 70% of Nepal’s eligible population.Doctors report a marked difference between the recovery of people who are vaccinated against those who are not. Says virologist Pun at Teku Hospital: “Except for a few rare cases, all patients in critical condition and those dying are the ones who for one reason or another had not been vaccinated.”But Nepal has run out of its vaccine stock, leaving 1.4 million people still waiting for their second dose of AstraZeneca Covishield in a lurch, after India banned its export, and the COVAX Facility could not supply its remaining 1.8 million vaccines to Nepal because of the global supply bottleneck.  <figure><img width="1440" height="1080" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85ac9c7e80680e067808jpeg.jpg" alt=""><figcaption> </figcaption></figure>The Nepal government and pressure groups in Nepal and the United States <a href="https://www.nepalitimes.com/here-now/nepal-needs-urgent-american-vaccine-support/" target="_blank" rel="noopener noreferrer">have strongly urged the Biden administration</a> to immediately rush some of its AstraZeneca doses to Nepal.Meanwhile, the UK, the US and Canada have authorised vaccines for use in children and adolescents, sparking outrage in the global public health community for prioritising an age group that is rarely critically affected by Covid-19. The World Health Organisation’s director-general Tedros Adhanom Ghebreyesus has urged rich countries to instead donate doses to the <a href="https://www.nepalitimes.com/latest/unicef-urges-g7-to-dispatch-vaccines/" target="_blank" rel="noopener noreferrer">COVAX Facility</a> for poorer states that have barely covered health workers and the most vulnerable groups. Speaking at the British Parliament last week, noted vaccinologist and the principal researcher of Oxford University’s AstraZeneca vaccine, Andrew Pollard, called the decision to inoculate children in wealthy nations ahead of high-risk groups in poorer countries “morally wrong.” Pollard has worked extensively in the region, leading research into the burden and transmission of typhoid in Nepal, Bangladesh and Malawi, and the impact of typhoid vaccine in these areas. He also runs surveillance for invasive bacterial diseases, and studies the impact of pneumococcal vaccines in children in Nepal.In Nepal, vaccination will grind to a halt this week after the current campaign to inoculate 300,000 people in the 18-59 age group with their second dose of the Chinese VeroCell ends.  <figure><img width="960" height="640" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85af9c7e80680e067809jpeg.jpg" alt=""><figcaption> </figcaption></figure><img width="960" height="640" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85b29c7e80680e06780ajpeg.jpg" alt=""><img width="960" height="639" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85b49c7e80680e06780bjpeg.jpg" alt="">Although <a href="https://www.nepalitimes.com/here-now/nepal-is-a-priority-for-vaccine-shipments/" target="_blank" rel="noopener noreferrer">Foreign Minister Pradeep Gyawali says</a> the government is in “final negotiations” for 2 million doses of Sinopharm VeroCell vaccines by June, there is no movement at the Ministry of Health. Ongoing talks to procure 8 million doses of <a href="https://www.nepalitimes.com/opinion/vaccine-geo-politics-and-sputnik-v/" target="_blank" rel="noopener noreferrer">the Sputnik V</a> have hit a production capacity snag in Russia. “We can implement lockdowns only for so long, the only exit strategy is vaccines. Science delivered, now our politicians must do the same,” says Buddha Basnyat, a physical at the Patan Academy of Health Sciences. “The Nepal government must procure vaccines using every diplomatic channel possible, and rich countries must realise that they are not safe until countries like Nepal are also vaccinated.” Activists have been trying to convince <a href="https://www.nepalitimes.com/latest/leading-public-figures-call-on-uk-government-for-oxygen-for-nepal/" target="_blank" rel="noopener noreferrer">the US government and Europeans</a> that Nepal has a lot of experience in successful vaccination campaigns against polio, smallpox, measles. It has over 50,000 female community health volunteers (FCHVs) reaching children with vaccines every year.  <figure><img width="1024" height="768" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85b79c7e80680e06780cjpeg.jpg" alt=""><figcaption> </figcaption></figure><img width="2048" height="943" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85ba9c7e80680e06780djpeg.jpg" alt=""><img width="1920" height="864" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85bd9c7e80680e06780ejpeg.jpg" alt="">Similarly, Nepal’s health system has amassed vast experience in maintaining the vaccine cold chain even in the remote mountains. It also has trained human resource overseeing DOTS (Directly Observed Therapy, Short-course) for tuberculosis management all over the country who can lend a hand in equitable distribution of vaccines in <a href="https://www.nepalitimes.com/latest/rural-nepal-fights-back-covid-19/" target="_blank" rel="noopener noreferrer">rural Nepal</a>.Says epidemiologist Lhamo Yangchen Sherpa: “It’s not too late, we can still use existing resources like FCHVs to better mobilise vaccination, conduct contact tracing, dispel any remaining vaccine hesitancy, and use public health professionals in prevention.”

It’s an Emergency

<figure><img width="1400" height="933" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110111156/636cd9779c7e80680e092ea0jpeg.jpg" alt=""/><figcaption>Photo: SONIA AWALE</figcaption></figure>Sabina Magar lost her job at a brick kiln during the Covid-19 lockdown. The 28-year-old, a single mother raising two young children, was faced with uncertainty. To make matters worse, she had a fever, began to lose weight rapidly and found herself constantly bed-ridden, without an appetite. When she started to cough up blood, she dragged herself to a hospital in her village in Piuthan. She was diagnosed with tuberculosis.Tuberculosis (TB) is a common ailment in Nepal. This perfectly curable medieval disease, still kills at least 6,000 Nepalis a year. TB is in fact the biggest infectious disease worldwide, with 10 million new cases and causing 1.5 million deaths annually.TB has been traditionally difficult to diagnose. Despite free screening and medications, poor people in rural parts cannot afford to visit health centres and hospitals in district headquarters, leading to gross underestimation of TB cases in Nepal.A 2018 survey by the National Tuberculosis Control Center revealed that close to 70,000 Nepalis contract the infection every year, much higher than previously estimated.The Covid-19 pandemic has further exacerbated the situation. Nationwide lockdowns and restricted mobility meant that in lack of screening, many people went undiagnosed and patients like Magar had harder time accessing free medications.Delayed diagnosis and subsequent treatment of TB translates into enduring health impact from permanently damaged lungs. This in turn increases their risk of contracting the coronavirus.On the flipside, safety measures taken to contain the spread of Covid-19 such as wearing masks and handwashing can significantly reduce tuberculosis infection as every other Nepali is a carrier.<a href="https://www.nepalitimes.com/banner/tb/">TB</a>, Sonia AwaleMagar could not take nutritious food to regain her health because of the lack of income, making her recovery difficult.On the other hand, the standard Observed Treatment, Short-course (DOTS) requires medical supervision of the administration of antibiotic treatment to patients. This is fraught with challenges because it means travelling long distance to the health centres during which patients can continue to spread the disease. People are also worried about being stigmatised as TB patients and hence visit distant hospitals, walking for hours along the abandoned forest trails.TB and Covid-19 also have a synergistic impact on economic conditions, mental health and social life. While the coronavirus is a new disease and spread rapidly by a virus, TB is one of the oldest diseases known to mankind and a ‘slow’ pandemic caused by a bacillus.TB and Covid-19 disproportionately affect women, children, elderly and people living below the poverty line.At the same time, the response to the pandemic has overloaded Nepal's under-resourced health system. It has set back years of hard-earned gains against other infections. So how do we guarantee free and easy access to TB services during a time of crisis?The national TB program aims to diagnose all people with TB and leave no one behind. The right to free TB treatment should not be compromised at any cost, as the early diagnosis and treatment of every TB case, protects us all.Understanding the multitude of ways in which the pandemic has affected TB diagnosis and treatment in Nepal is essential to repair the damage, bring services within the reach of all the citizens and rebuild a resilient health service for the future.The lessons that we are learning from the Covid-19 response, including monitoring and the surveillance system, is an important opportunity for TB programs to develop innovative technologies for socio-culturally appropriate and people-centric care.Nepal might be a role model in the community-based DOTS, but a more active case detection method is now required. Employing GeneXpert, a more accurate diagnostic tool and introducing drones as a form of TB telemedicine might be a start.TB, is often called a medical poverty trap or disease of poverty and is a life-threatening disease for people living below the poverty line like Sabina. Due to the difficulties in completing the minimum six months of daily drugs, people also have a higher risk of incomplete treatment that allows the disease to take severe forms.Sabina, fought with the disease for her two children and trusted the benefits of taking medicines which helped to regain her damaged health. Her case is a reminder to us that health needs of people is a priority of the community.The slogan of this year’s World TB Day on 24 March ‘The clock is ticking’ prompts us to act in solidarity to take for TB prevention, diagnosis and treatment. Each one of us is responsible to achieve a TB-free future for our children.<a href="https://www.nepalitimes.com/latest/tb-patients-in-limbo-due-to-covid-19/">TB patients in limbo due to COVID-19</a>, Devika AgarwalKritika Dixit is a researcher with Britain Nepal Medical Trust (BNMT) and a doctoral student at Karolinska Institutet, Sweden. <img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110111156/636cd97a9c7e80680e092ea1jpeg.jpg" alt="" width="115" height="113">

Tackling TB amidst a pandemic

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181152/636be9a79c7e80680e0878d1jpeg.jpg" alt="" width="995" height="659"/><figcaption>Photo: NEWS MEDICAL LIFE SCIENCES</figcaption></figure>As a physician, I am at the receiving end of a lot of questions from friends and relatives about the pandemic. While some want to know about their symptoms, most questions are about <a href="https://www.nepalitimes.com/here-now/why-nepals-covid-19-figures-are-deceptive/" target="_blank" rel="noopener noreferrer">whether the number of cases in Nepal is actually going down</a>.It is hard to tell. There a lack of tracing, testing is inadequate, and record keeping is unreliable. The media carries a daily tally that is based on government figures, and they show confirmed cases have now dipped to below 1,000 per day, almost half of them in Kathmandu Valley.The Ministry of Health statistics also show that there are about 250 patients in critical care, and some 50 of them require ventilator support. If these figures are to be believed, the death rate from Covid-19 does not seem to have decreased.More worrying are reports that <a href="https://www.nepalitimes.com/banner/bala-chaturdashi-and-covid/" target="_blank" rel="noopener noreferrer">Pashupatinath now sees 80 cremations daily</a> as opposed to 30 per day at this time last year. Are some of these unidentified Covid-19 ‘excess mortality’? It is all guess work, but this more than double increase in funerals needs to be accounted for.It is indeed possible that although some of the excess mortality is due to undiagnosed Covid-19, it could very well be that the <a href="https://www.nepalitimes.com/latest/covid-19-will-get-worse-before-it-gets-better/" target="_blank" rel="noopener noreferrer">winter death rate</a> has gone up this year because people with other pre-existing conditions like cancer, cardio-vascular diseases, diabetes or kidney patients needing dialysis are not visiting hospitals for treatment. These ‘indirect’ Covid-19 deaths could be a useful research project.Despite this, there are indications that young urban Nepalis are letting their guard down. The parties during the <a href="https://www.nepalitimes.com/here-now/tying-the-knot-during-covid-19/" target="_blank" rel="noopener noreferrer">wedding season</a>, unmasked crowds at Thamel’s indoor nightclubs and concerts and the throngs in Pokhara Lakeside and Sauraha show a <a href="https://www.nepalitimes.com/banner/concerts-rallies-and-crowded-malls/" target="_blank" rel="noopener noreferrer">‘what will be will be’ attitude</a>.An affordable and effective vaccine is still some way off. Wearing a mask, preferably a N95, which serves the dual purpose of protection from SARS-CoV-2 as well as Kathmandu’s air pollution, maintaining safe distance and frequent had washing with soap and water are our ‘vaccines’ for now.Japan has important lessons for us. So far, it has kept Covid-19 death rate at the lowest by far among G7 countries by strictly following guidelines including avoiding the ‘san-mitsu’ or the 3Cs: closed spaces, crowded spaces and close contact settings.<a href="https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/">We in Nepal will be lucky</a> if a <a href="https://www.nepalitimes.com/here-now/when-will-nepals-covid-vaccine-turn-come/">vaccination</a> arrives by mid-2021. Current vaccines like Pfizer and Moderna are out of the question because of their cost and the lack of capacity to maintain the very cold storage that they require.The <a href="https://www.nepalitimes.com/opinion/glimmers-of-hope-for-nepal-on-vaccine/">Oxford University Astra Zeneca vaccine</a> that the <a href="https://www.deccanherald.com/national/serum-institute-of-indias-covid-19-vaccine-not-to-get-nod-till-uk-authorises-astrazeneca-shot-931200.html">Serum Institute of India</a> is manufacturing appears to be our best bet because it is relatively inexpensive and only requires the regular 3-6o Celsius cold chain. The good news is that the Serum Institute of India is also studying other vaccines such as an <a href="https://www.livemint.com/companies/people/intra-nasal-covid-19-vaccines-will-be-far-easier-to-deliver-kiran-mazumdar-shaw-11603681291099.html">intra-nasal vaccine</a>, which can be stored at room temperature. If effective, this would be the answer for countries like Nepal.We are awaiting published results of trials of the <a href="https://www.nepalitimes.com/latest/nepal-to-test-covid-19-test-kits-from-china/">Chinese</a> vaccine, and that could also be the answer for developing countries like <a href="https://www.nepalitimes.com/latest/90-in-poor-countries-will-miss-covid-vaccinations/">like Nepal</a>. The Chinese have an impressive track record of making vaccines, and to combat infectious diseases. For example, the inexpensive <a href="https://www.nepalitimes.com/banner/mosquitoes-move-up-mountains-as-the-earth-warms/">Japanese Encephalitis</a> vaccine made in Chengdu helped control the deadly disease in rural communities throughout Asia.This Chengdu vaccine cost less than $5, in contrast to the $100 per shot encephalitis vaccines made by Western pharmaceutical companies. The Chinese <a href="https://archive.nepalitimes.com/news.php?id=18079">Hepatitis E vaccine</a> could prevent infection and save lives of pregnant women in the Subcontinent where the virus is a scourge due to poor hygiene.TherapiesAside from vaccines, research into treatment of Covid-19 is also making progress. For example, the Recovery Trial in the UK has convincingly showed that dexamethasone, a readily available and inexpensive steroid saves lives in the treatment of moderate to severe Covid-19 patients.In all this confusion regarding treatment, however, it is equally important to note what does not work. Drugs like hydroxychloroquin do not work in the treatment of this disease, despite its false efficacy touted by Donald Trump. The <a href="https://www.who.int/nepal">World Health Organisation</a>’s Solidarity research also showed that the expensive remdesivir drug that our government was at one time handing out freely to Covid-19 patients is not very helpful, either.Reliable diagnosis of Covid-19 is important, especially in countries like Nepal as there are many other infectious diseases that may at first present with fever and cough, like tuberculosis. The PCR (polymerase chain reaction) test still remains the gold standard for Covid-19, but they are expensive and may take a day or two for the results.Antigen tests are being carried out in Nepal and can give a quick diagnosis in symptomatic individuals within 30 minutes. But they are not as accurate as the PCRs. There are other commercial brands, and some may not be as accurate as others.New variantNews of the new variant of Covid-19 reported in England and South Africa and now spreading across the globe, sound alarming. It is interesting that this new variant was discovered in the UK where a great emphasis is given to finding its chemical constituents.One of UK’s prime institutions for this is the Sanger Centre near Cambridge, with whom we at Patan Hospital also collaborated to delineate a variant of typhoid organism mutation, helping establish a new treatment strategy for typhoid in the Subcontinent in 2016.The best way to handle the new Covid-19 variant is <a href="https://www.nepalitimes.com/opinion/a-covid-19-exit-strategy-for-nepal/">continued vigilance</a> about preventive measures, especially since the mutation gives the virus the ability to spread faster. It is best to be over-prepared than under-prepared to fight this wily virus.Masking up, safe distance and hand washing are our best course of action for us to stop the pandemic in 2021 and beyond.<a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/">Buddha Basnyat</a> is a clinical researcher at Patan Academy of Health Sciences and writes Dhanvantari, a <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/">frequent health column</a> for Nepali Times.

Buddha Basnyat

Staying safe in 2021 and beyond

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109191116/636beef44b0ad905ca02ef7ajpeg.jpg" alt="" width="1500" height="1125"/><figcaption>Photos: BNMT</figcaption></figure>Drone therapy for tuberculosis diagnosis in Nepal’s remote and hard to reach mountains has won at the <a href="https://tiaca.org/tiaca-press-release/pelican-biothermal-and-nepal-flying-labs-win-2020-tiaca-air-cargo-sustainability-awards/" target="_blank" rel="noopener noreferrer">2020 International Air Cargo Association (TIACA)</a> Sustainability Awards and will receive $10,000 in prize money as a start-up category winner.The winning project, <a href="https://www.nepalitimes.com/banner/nepal-tests-and-treats-tb-with-a-flying-pharmacy/" target="_blank" rel="noopener noreferrer">Drone Optimised Therapy System</a> (DrOTS) by Nepal Flying Labs links rural health posts with high-end diagnostic tool via drones to improve the accessibility of tuberculosis diagnostic tests.“In a year marked by a global pandemic which disrupted our industry, problem solving and forward-thinking companies like Nepal Flying Labs bring hope that air cargo can come out of this crisis stronger and more resilient,” says Céline Hourcade of TIACA, which celebrates and encourages outstanding industry initiatives driving sustainability in air cargo.Under DrOTS, drones fly from a central district hospital to health posts in the mountains to collect sputum samples and deliver both diagnoses and treatment to patients living in up-country villages. The samples are tested using a <a href="https://www.nepalitimes.com/banner/for-nepal-a-game-changer-in-tb-control/" target="_blank" rel="noopener noreferrer">high-end GenExpert kit</a>.If they are positive, patients are given DOTS (directly observed treatment short course) treatment using smart pill boxes, which keep electronic records of whether or not patients have taken the antibiotics regularly.The highly competitive award evaluated humanitarian projects based on three aspects of sustainability -- economic social and environmental -- as well as innovation and practicality of the applied solution. The winners were announced online on 10 December.The project had also won the prestigious industry award from the <a href="https://www.auvsi.org/industry-news/winners-2020-xcellence-awards" target="_blank" rel="noopener noreferrer">Association for Unmanned Aerial Vehicles</a> – the AUVSI XCELLENCE Award 2020 in Humanitarian and Public Safety category in October.The goal of this project is to assist Nepal’s Ministry of Health in generating data on <a href="https://www.nepalitimes.com/banner/tb/" target="_blank" rel="noopener noreferrer">tuberculosis</a> and support it in its efforts to reduce the prevalence of the infection. This perfectly curable medieval disease is the biggest infectious killer in the world today, more than HIV or malaria.https://www.youtube.com/watch?v=Xf4OpwoblRc&amp;feature=emb_logoWhile Nepal is a role model in the community-based DOTS treatment, which ensures index patients are taking their medicines, this alone will not suffice in the battle against TB, since a patient would often have already infected others in the household and workplace. Which is why active case finding and early treatment is the key.The first comprehensive national TB prevalence survey 2018-19 in Nepal showed that the burden of TB in Nepal is much higher than previously estimated. There are now known to be 245 TB cases per 100,000 people – which means there are 69,000 new cases each year. Some 6,000 people in Nepal die every year because of the infection while every other Nepali is a carrier of TB.“Tragically over 35,000 cases of TB are not due to difficulties reaching the basic health services. To accelerate progress towards the end of TB in Nepal we must increase efforts to reach remote and disadvantaged populations with high quality TB services,” says Maxine Caws, epidemiologist with BNMT. “The drone project project represents one such approach to solve this problem, and also has the potential to address many other health challenges facing rural populations of Nepal.”The DrOTS test flight was conducted successfully in Piuthan district in western Nepal last year. Since then, over 106 flights have been carried out, collecting and delivering more than 742 sputum samples, with a result of 26 positive cases from eight remote health facilities. The technology has also been used for TB control in Zimbabwe and Papua New Guinea.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109191116/636beef84b0ad905ca02ef7bjpeg.jpg" alt="" width="1500" height="1125"><figcaption>Locals wait for drone to arrive.</figcaption></figure><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109191116/636beefb4b0ad905ca02ef7cjpeg.jpg" alt="" width="1500" height="1125"><figcaption>Using the drone interface.</figcaption></figure>The drones weigh 9kg when empty and can carry another 7kg in a cargo hold designed to protect against biohazards; they can be airborne for 30 minutes. The craft flies at speeds of up to 1km per minute, and is controlled by a pilot at the take-off point who coordinates with a health worker at the destination.The DrOTS project is a multidisciplinary consortium of Birat Nepal Medical Trust (BNMT Nepal), DroNepal, Nepal Flying Labs, Liverpool School of Tropical Medicine, UK and WeRobotics, Switzerland working in partnership with the Nick Simons Institute, National Tuberculosis Centre, and Stony Brook University, USA.Says Biplav Pageni of Nepal Flying Labs: “We hope to scale our drone cargo technology to other rural locations and establish networks of medical cargo drones to help more people in the coming days. Drones are said to be the future of air cargo but I believe they are the present and we are using it to save lives in Nepal.”

Nepal anti-TB drone project awarded

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181148/636be7f69c7e80680e087831jpeg.jpg" alt="" width="1500" height="1125"/><figcaption>Photos: BNMT</figcaption></figure>Drone therapy for tuberculosis diagnosis in Nepal’s remote and hard to reach mountains has won at the <a href="https://tiaca.org/tiaca-press-release/pelican-biothermal-and-nepal-flying-labs-win-2020-tiaca-air-cargo-sustainability-awards/" target="_blank" rel="noopener noreferrer">2020 International Air Cargo Association (TIACA)</a> Sustainability Awards and will receive $10,000 in prize money as a start-up category winner.The winning project, <a href="https://www.nepalitimes.com/banner/nepal-tests-and-treats-tb-with-a-flying-pharmacy/" target="_blank" rel="noopener noreferrer">Drone Optimised Therapy System</a> (DrOTS) by Nepal Flying Labs links rural health posts with high-end diagnostic tool via drones to improve the accessibility of tuberculosis diagnostic tests.“In a year marked by a global pandemic which disrupted our industry, problem solving and forward-thinking companies like Nepal Flying Labs bring hope that air cargo can come out of this crisis stronger and more resilient,” says Céline Hourcade of TIACA, which celebrates and encourages outstanding industry initiatives driving sustainability in air cargo.Under DrOTS, drones fly from a central district hospital to health posts in the mountains to collect sputum samples and deliver both diagnoses and treatment to patients living in up-country villages. The samples are tested using a <a href="https://www.nepalitimes.com/banner/for-nepal-a-game-changer-in-tb-control/" target="_blank" rel="noopener noreferrer">high-end GenExpert kit</a>.If they are positive, patients are given DOTS (directly observed treatment short course) treatment using smart pill boxes, which keep electronic records of whether or not patients have taken the antibiotics regularly.The highly competitive award evaluated humanitarian projects based on three aspects of sustainability -- economic social and environmental -- as well as innovation and practicality of the applied solution. The winners were announced online on 10 December.The project had also won the prestigious industry award from the <a href="https://www.auvsi.org/industry-news/winners-2020-xcellence-awards" target="_blank" rel="noopener noreferrer">Association for Unmanned Aerial Vehicles</a> – the AUVSI XCELLENCE Award 2020 in Humanitarian and Public Safety category in October.The goal of this project is to assist Nepal’s Ministry of Health in generating data on <a href="https://www.nepalitimes.com/banner/tb/" target="_blank" rel="noopener noreferrer">tuberculosis</a> and support it in its efforts to reduce the prevalence of the infection. This perfectly curable medieval disease is the biggest infectious killer in the world today, more than HIV or malaria.https://www.youtube.com/watch?v=Xf4OpwoblRc&amp;feature=emb_logoWhile Nepal is a role model in the community-based DOTS treatment, which ensures index patients are taking their medicines, this alone will not suffice in the battle against TB, since a patient would often have already infected others in the household and workplace. Which is why active case finding and early treatment is the key.The first comprehensive national TB prevalence survey 2018-19 in Nepal showed that the burden of TB in Nepal is much higher than previously estimated. There are now known to be 245 TB cases per 100,000 people – which means there are 69,000 new cases each year. Some 6,000 people in Nepal die every year because of the infection while every other Nepali is a carrier of TB.“Tragically over 35,000 cases of TB are not due to difficulties reaching the basic health services. To accelerate progress towards the end of TB in Nepal we must increase efforts to reach remote and disadvantaged populations with high quality TB services,” says Maxine Caws, epidemiologist with BNMT. “The drone project project represents one such approach to solve this problem, and also has the potential to address many other health challenges facing rural populations of Nepal.”The DrOTS test flight was conducted successfully in Piuthan district in western Nepal last year. Since then, over 106 flights have been carried out, collecting and delivering more than 742 sputum samples, with a result of 26 positive cases from eight remote health facilities. The technology has also been used for TB control in Zimbabwe and Papua New Guinea.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181148/636be7fa9c7e80680e087832jpeg.jpg" alt="" width="1500" height="1125"><figcaption>Locals wait for drone to arrive.</figcaption></figure><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181148/636be7fe9c7e80680e087833jpeg.jpg" alt="" width="1500" height="1125"><figcaption>Using the drone interface.</figcaption></figure>The drones weigh 9kg when empty and can carry another 7kg in a cargo hold designed to protect against biohazards; they can be airborne for 30 minutes. The craft flies at speeds of up to 1km per minute, and is controlled by a pilot at the take-off point who coordinates with a health worker at the destination.The DrOTS project is a multidisciplinary consortium of Birat Nepal Medical Trust (BNMT Nepal), DroNepal, Nepal Flying Labs, Liverpool School of Tropical Medicine, UK and WeRobotics, Switzerland working in partnership with the Nick Simons Institute, National Tuberculosis Centre, and Stony Brook University, USA.Says Biplav Pageni of Nepal Flying Labs: “We hope to scale our drone cargo technology to other rural locations and establish networks of medical cargo drones to help more people in the coming days. Drones are said to be the future of air cargo but I believe they are the present and we are using it to save lives in Nepal.”

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109141132/636babf89c7e80680e077f08jpeg.jpg" alt="" width="1400" height="933"/><figcaption>Photo: NEPALI TIMES ARCHIVE</figcaption></figure>COVID-19 has made headlines every day over the past two months, but tuberculosis (TB) patients across South Asia have their treatment interrupted due to the lockdown.South Asia is a vast hub for TB. India alone had 2.7 million new cases and 440,000 deaths due to TB in 2018 — the highest in the world. Every year, tuberculosis kills at least 6,000 people in Nepal and every other person is a carrier of the microbe.The WHO has set <a href="https://www.who.int/tb/End_TB_brochure.pdf?ua=1" data-saferedirecturl="https://www.google.com/url?q=https://www.who.int/tb/End_TB_brochure.pdf?ua%3D1&amp;source=gmail&amp;ust=1593695520550000&amp;usg=AFQjCNHVd_kVz8K7Q1LZxUa_CWkwSdG7Vg">global targets</a> to reduce new cases of TB by 90% and deaths by 95% between 2015 and 2035. However, the fight against TB faces a setback of an estimated 5-8 years globally, due to COVID-19.The COVID-19 crisis has uncovered gaps in the present healthcare system in the Subcontinent. There is now a shortage of functioning sputum testing centres as well as DOT (Directly Observed Treatment Short-course) centres. Healthcare workers are also wary of going on-ground and carrying out tests and diagnoses.Migrant workers with TB, who are travelling away from their workplaces, are at risk of treatment interruption, which may lead to <a href="https://en.wikipedia.org/wiki/Multi-drug-resistant_tuberculosis#:~:text=Infectious%20disease,drugs)%2C%20isoniazid%20and%20rifampin." data-saferedirecturl="https://www.google.com/url?q=https://en.wikipedia.org/wiki/Multi-drug-resistant_tuberculosis%23:~:text%3DInfectious%2520disease,drugs)%252C%2520isoniazid%2520and%2520rifampin.&amp;source=gmail&amp;ust=1593695520550000&amp;usg=AFQjCNEkqQ32ZjQluu9UU_sZ8EeTipApXQ">multi-drug-resistant (MDR) TB</a>. Additionally, due to the stigma attached with the symptoms of COVID-19, people are now afraid to get tested for TB, which has symptoms similar to those of COVID-19.This can exacerbate the problem, as undiagnosed patients can infect many more. Those with lung injuries due to TB may be <a href="https://www.thetruthabouttb.org/coronavirus/" data-saferedirecturl="https://www.google.com/url?q=https://www.thetruthabouttb.org/coronavirus/&amp;source=gmail&amp;ust=1593695520550000&amp;usg=AFQjCNHh8d8TmjVl40wPRPytgXeQDPsiww">prone to more severe outcomes</a> if infected with COVID-19.“In India, health-seeking behaviour has completely changed after COVID-19. People think twice before seeking a doctor,” says Khasim Sayyed of TB Alert India. “We are expecting a very high number of patients across all DOT centres and outpatient departments once the lockdown is lifted, because the patients are afraid to get diagnosed right now.”A combination of strategies will be required to restore normal TB services, with the objective to reduce the accumulated pool of undetected TB patients. Here are some other steps that can be taken to strengthen both diagnosis and treatment:Diagnosis<ul><li>Governments should collaborate with non-profits and use technology to ramp-up active case-finding and contact tracing.</li> 	<li>Community health workers should conduct door-to-door sample collection.</li> 	<li>Health system should ensure diagnostic services for TB. Currently, most labs are being used for COVID-19 testing only.</li> 	<li><a href="https://www.nepalitimes.com/here-now/a-covid-19-game-changer-for-nepal/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/a-covid-19-game-changer-for-nepal/&amp;source=gmail&amp;ust=1593695520550000&amp;usg=AFQjCNEqv3e5bpooFbMQx594hHcms3j7uA">GeneXpert</a> test should be enabled for MDR TB cases as they are quicker and can identify if a person has resistance to the drug.</li></ul>Treatment<ul><li>Healthcare workers and non-profits should facilitate tele-counselling to sensitise family members about the possible side effects and severe symptoms of TB.</li> 	<li>The government, in collaboration with non-profits, should run a helpline so that TB patients can better manage severe symptoms or side effects.</li> 	<li>Health practitioners should leverage digital tools to diagnose patients and prescribe first-line treatment.</li></ul>Additionally, institutions must also work to safeguard healthcare workers from tuberculosis, as well as COVID-19, during any intervention. And as more private practitioners turn to digital facilities for diagnosis and consulting, there is a need to design solutions for marginalised communities.The projected numbers for TB highlight the urgency for a better intervention strategy. While the COVID-19 pandemic deserves attention and intervention, the response to it should not come at the cost of another disease. (IPS)Devika Agarwal has worked with TB Alert India, Ministry of Health and Family Welfare, Government of Delhi, and the non-profit Aaroogya. This story was <a href="https://idronline.org/managing-an-epidemic-within-a-pandemic/" data-saferedirecturl="https://www.google.com/url?q=https://idronline.org/managing-an-epidemic-within-a-pandemic/&amp;source=gmail&amp;ust=1593695520550000&amp;usg=AFQjCNGlN78X8O31tWoB2VkPn1rFIadjaA">originally published</a> by India Development Review (IDR) and has been reprinted under an arrangement with Inter Press Service (IPS).

TB patients in limbo due to COVID-19

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109121116/636b8c4d9c7e80680e06b2efjpeg.jpg" alt="" width="4096" height="2730"/><figcaption>Photo: BIKRAM RAI</figcaption></figure>With no proven <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNFhARSUb8HMQP_ZJgsaTmPoQDLWvA">cure or vaccine available yet for COVID-19</a>, various treatments with no proven benefits and potential deadly side-effects are being tried out on patients.One example of a desperate treatment measure is a New York City doctor carelessly declaring on primetime tv recently that COVID-19 pneumonia was similar to <a href="https://www.nepalitimes.com/latest/high-alert/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/high-alert/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNGuDq-Ti_uWGlw-rY-q1PpyQQO54g">high altitude pulmonary edema (HAPE)</a>, and he recommended high altitude drugs like Diamox for the treatment of Covid-19.Trekkers in Nepal are familiar with <a href="http://archive.nepalitimes.com/news.php?id=19693#.Xp-oJy8w0Wo" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/news.php?id%3D19693%23.Xp-oJy8w0Wo&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNGSLnJg3LMR2gIcZz9LMdKOvruqJA">Diamox</a>, a pill they take to acclimatise better when hiking at higher altitudes. There is no scientific basis that the drug will work, but this idea of very low oxygen (hypoxia) and pneumonia in both afflictions was appealing.To counter this some of us in Nepal and other countries have a forthcoming Opinion in the British Medical Journalcautioning against this rash treatment strategy using high altitude medicines. In medicine, doctors have to remember the maxim, Primum non nocere (‘above all do no harm’).But there are some silver linings <a href="https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNGtTkAInA3D5xIkzd65kTSfDvYESg">if Nepal escapes the worst of COVID-19</a>. <a href="https://www.nepalitimes.com/banner/tb/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/tb/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNGbOqrkOzN3uP_va7u0F-uhlxipaQ">Tuberculosis</a> rates, which are very high in South Asia (more than 400 per 100,000) could go down if people continue to use the masks since it will also mean that a tuberculosis patient will not spread the bacteria, not to mention other respiratory infections.Similarly, as more people get into the habit of washing hands with soap and water where available, the rates of diseases like typhoid and hepatitis A and E, caused by fecal oral transmission, will certainly be reduced.An average of <a href="https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNHn0HGje-Tq3pDeekYbQAbhZxJOwg">230 people used to be killed every month</a> on Nepal’s highways and streets. The lockdown has now lasted a month, and that is approximately the number of lives saved due to vehicles being off the roads.The importance of public health for both the rich and poor countries has been highlighted by the pandemic. Industrialised countries had thought they had been done with infectious diseases, except perhaps the odd HIV patient. This pandemic has given great pause to that argument. Developing countries which having tried to come to grips with pre-existing epidemics have used lessons learnt in dealing with coronavirus in prevention.The Indian state of Kerala for example, has done relatively better in dealing with COVID-19 partly because it utilised prior lessons from the Nipah outbreak a year ago. Other South Asian countries with robust public health infrastructure like Sri Lanka also have a better handle on the disease.They strengthened their public health system, and it has paid rich dividends. South Korea too had an outbreak of MERS Coronavirus in 2015 which was brought by a South Korean returning from Kuwait, but they were able to effectively control the spread, and have been dealing successfully (so far) with the novel coronavirus. Singapore had been doing well, but discovered last week that it had a blind spot in the migrant workers’ dormitories. It has now announced a ‘circuit breaker’ lockdown till 1 June.South Asian countries have had more time in preparing for the contagion, while they wait for a vaccine or drugs to treat COVID-19. Treatment trials are happening all over the world even as the patients and doctors await with bated breath (pardon the pun). In all likelihood, we will soon know if chloroquin works or not before we have a vaccine.Vaccines will be a game-changer against Covid-19, and competition is heating up because whoever makes this vaccine first will be the knight-in-shining armour. China, USA, UK are probably a few of the countries engaged in developing a vaccine, and among them are researchers at Oxford University Clinical Research Unit who <a href="https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNHKJgZ_d-vQIhZ5sdehQmMT7iWvHQ">collaborated closely with Patan Academy of Health Science</a> in a recent successful typhoid vaccine study.This Oxford University group lead by Professors Sarah Gilbert and Andrew Pollard are optimistic about producing a million doses of the vaccine by autumn. The vaccine will be eventually required not in the millions, but in billions of dosages. It also has to be affordable for countries like ours.For making vaccines promptly for neglected tropical illnesses, it is hard to beat the Chinese. When <a href="http://archive.nepalitimes.com/news.php?id=19220#.Xp-nMS8w0Wo" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/news.php?id%3D19220%23.Xp-nMS8w0Wo&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNEw-YGKhD3XomMEP736r5ileoWJ3g">Japanese Encephalitis (JE)</a> was raging in China and South Asia, it was the Chinese who tested, developed and made available the ‘Chengdu vaccine’ that revolutionised the prevention of the mosquito-borne disease. The earlier vaccine was expensive and only tourists in Nepal could afford it.Similarly, when <a href="http://archive.nepalitimes.com/news.php?id=18079#.Xp-m3S8w0Wo" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/news.php?id%3D18079%23.Xp-m3S8w0Wo&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNEndZvjwlu6D0uMBXFMGO9OgvSoXg">hepatitis E</a> was a scourge in China, the Xiamen Innovax Biotech came up with a vaccine in 2012 to protect vulnerable populations. Because there is no other commercial vaccine available against hepatitis E, it will be valuable in South Asia if the virus is rampant again and affect pregnant women with a fatal outcome.Nepal clearly needs to have a strong public health infrastructure in collaboration with a prestigious institute abroad to be able to tackle COVID-19 and other infections. Just like earthquakes, there will be more pandemics in future. Humanity needs to up its game in the control of emergent infectious diseases, and Nepal can make a small contribution by helping itself, especially by strengthening public health.Buddha Basnyat is a clinical researcher at Patan Academy of Health Sciences and a <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNFhARSUb8HMQP_ZJgsaTmPoQDLWvA">frequent health columnist</a> for Nepali Times.Prevention while searching for a cur

Prevention while searching for a cure

<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109121112/636b8bc79c7e80680e06b2c0jpeg.jpg" alt="" width="2000" height="896"/>Governments in industrialised countries must not ignore the plight of poorer nations facing the coronavirus pandemic, or the disease will not be brought under control.African nations report growing numbers of cases, and more and more infections are being detected in countries with endemic poverty in Asia as testing picks. There are growing fears that developing countries could soon see major outbreaks they will not be able to cope with.A potential paralysis of <a href="https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/" target="_blank" rel="noopener">already vulnerable healthcare systems</a> would not only have a drastic impact on public health, but could also push people further into poverty and deprivation. If developed countries in Europe and North America bring COVID-19 under control, there is a threat that the disease would rage on in developing countries, with the danger that it could spread back into places like North America and Europe.<a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/" target="_blank" rel="noopener">Nepal must hope for the best, prepare for the worst</a>, Buddha Basnyat and Sudeep AdhikariRich states must keep a focus on helping other countries with weak healthcare systems, despite the fact they are fighting their own battle with the disease.“High income countries are completely consumed with what is happening in their own states, but it would be good if they could give at least some focus to poorer countries,” Amanda Glassman of the Washington-based Global Centre for Development think-tank. “If things are not brought under control in less developed countries, it could come back to hurt developed countries later on.”But while there have been <a href="https://www.nepalitimes.com/latest/could-an-anti-tb-vaccine-be-protecting-nepalis/" target="_blank" rel="noopener">far fewer registered cases of the disease</a> in Africa, Asia and South America, many health experts believe that those numbers could very quickly rise dramatically. Some countries also face extra burdens of other endemic diseases, <a href="https://www.nepalitimes.com/here-now/epicentre-of-two-disasters-in-west-nepal/" target="_blank" rel="noopener">recent natural disasters</a>  or coping with large-scale refugee influxes.“Sub-Saharan Africa is already struggling with the Ebola virus and the locust invasion and associated famines. It now faces a third war against the coronavirus. In many countries, resources are stretched thin,” said Dan Steinbock of the Difference Group advisory organisation.South Africa has the world’s worst HIV/AIDS epidemic and it is not known how a major coronavirus outbreak may affect treatment for those with HIV/AIDS or outcomes if they are infected with COVID-19. In Latin America, where more than two thirds of people live in extreme poverty, doctors have already warned of the strain widespread coronavirus infections could put on hospitals and health workers.Any major COVID-19 outbreak could affect incidence, and treatment of other diseases in some African states, says Ambrose Talisuna at the WHO Regional Office for Africa. “We saw this with Ebola outbreaks in some African countries. There was a diversion of resources to the disease and the healthcare system couldn’t deal with the shock of the outbreak. People died of malaria, people couldn’t get treatment for tuberculosis.”There would also be serious economic problems. Not only would massive financial resources have to go into healthcare rapidly, but measures implemented to contain the virus’s spread, such as travel restrictions, business closures, quarantines, would very soon affect people’s incomes.<a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/here-now/ke-garne-attitude-kills-people/" target="_blank" rel="noopener">Ke garne attitude kills people</a>, Laxmi BasnetOne potential advantage some less developed countries may have in dealing with an initial outbreak is their experience with other deadly infectious diseases. In the Democratic Republic of Congo, a devastating Ebola outbreak has just been brought under control. Tests for COVID-19 could simply be added to existing Ebola screening on entry into the country.Some of the poorest in the world in Asia, Latin America and Africa, have begun introducing strict measures to try and halt the spread of the disease. These have included closing borders and lockdowns. While WHO has supported the use of such measures, they have been shown to have had an enormous economic toll with sectors such as travel, transportation, tourism and retail, among others, all seriously affected.“The <a href="https://www.nepalitimes.com/latest/what-nepal-can-learn-from-china-about-covid-19/" target="_blank" rel="noopener">draconian measures that China opted for</a> have been very costly. But all alternatives would have been much worse. The Chinese leadership had to choose between extensive economic damage in one to two quarters with probable virus containment, or far greater economic devastation coupled with drastic increases in cases and deaths,” explained Steinbock.But the costs cannot, and should not, be borne by developing nations alone, development experts say. While local governments can help businesses and individuals with measures such as tax relief, providing financial support through loans, and exemptions from health and social security payments, other countries have a role to play.This month the World Bank made $12 billion available in immediate support to help countries coping with the health and economic impacts of the global outbreak. The International Monetary Fund has said $10 billion could be mobilised in loans to low-income countries tackling the virus. On March 13 WHO and its partners launched the <a href="https://www.who.int/news-room/detail/13-03-2020-who-un-foundation-and-partners-launch-first-of-its-kind-covid-19-solidarity-response-fund" data-saferedirecturl="https://www.google.com/url?q=https://www.who.int/news-room/detail/13-03-2020-who-un-foundation-and-partners-launch-first-of-its-kind-covid-19-solidarity-response-fund&amp;source=gmail&amp;ust=1587206340290000&amp;usg=AFQjCNEFMIPH219XuGD5cfiwkL2SpBnokg">COVID-19 Solidarity Response Fund</a> which aims to raise funds from private and corporate individuals to contribute to global response efforts. Meanwhile, the Global Fund for HIV, TB and malaria is to allow some funds to be used for the virus response while the United Nations’ Central Emergency Response Fund global emergency response fund has made $15 million available.Over a month ago, WHO chief Tedros Adhanom Ghebreyesus launched a $675 million preparedness plan hoping to contain the crisis and pave the way to deter future crises. But that is less than 1% of the US 2020 military budget. In late February, the European Commission earmarked $124 million for the WHO response plan, but others have not proved as generous.Added Steinbock: “No matter how it is funded, experts agree that developing countries must be given whatever help is needed to contain the disease. If cases escape detection in poor countries, then it is more likely than not that weak healthcare systems, coupled with endemic poverty and social instability could result in a secondary epidemic with potential global impact.”IPS

A COVID-19 third wave in the Third World?

In the black and white photograph, General Wangdu smiles broadly in front of the dusty cactus garden in Kathmandu’s Annapurna Hotel. With an ill-fitting jacket and shaggy hair he looks benign enough, but this was the last leader of the Tibetan freedom fighters who led the resistance against the Chinese from their remote mountain hideouts in <a href="https://nepalitimes.com/here-now/comings-and-goings-in-mustang">Mustang</a>. Five months later, Wangdu was dead. Snapped in March 1974, I had only recently arrived in Nepal. How did I meet this legendary fighter? Possibly with his devoted camp follower, Lynne Klapecki, and probably in the Om Restaurant near Freak Street which was the preferred <a href="https://nepalitimes.com/banner/hippie-trail-nostalgia-in-kathmandu">hippie hang-out</a>. Om Lobsang and his brother Yeshe were <a href="https://archive.nepalitimes.com/page/earthquake-brings-back-memories-of-camps-for-tibetan-refugees">refugees from East Tibet </a>whose cafe offered a friendly welcome and<a href="https://nepalitimes.com/multimedia/momo-loco"> the best momos</a> - they became my in-laws after I married their eldest brother Tenzin, but that was a decade later.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025052403054_4573b34282b0f5395c007243d6bef12c7ba76bfd520419e994cdcea048d795a1.jpg" data-media-id="editor_4" data-image-id="2025052403054_4573b34282b0f5395c007243d6bef12c7ba76bfd520419e994cdcea048d795a1" data-rendition-name="original" width="1000" height="1583" loading="lazy" alt="The last days of the Khampa NT"> <figcaption>Photo: LISA CHOEGYAL</figcaption> </figure>  Wangdu’s English was enthusiastically rudimentary, but even riding around town with him on the back of an aging <a href="https://nepalitimes.com/here-now/kathmandu-s-new-motorbike-museum">motorbike</a>, he was a commanding presence. Always flanked by armed outriders, impressive scars marked his forearms and a pistol hung from the cord around his neck. A charismatic guerrilla leader, Wangdu was celebrated by his followers for his tough commitment and respected for his measured pragmatism. He seemed so young to have shouldered such a responsibility of command, leading hundreds of hardened <a href="https://archive.nepalitimes.com/article/nation/50-years-after-the%20raid-into-Tibet,1012#google_vignette">Khampa combatants </a>through what had been a particularly <a href="https://nepalitimes.com/news/heavy-snowfall-over-nepal-himalaya">brutal winter in Mustang</a>, the last bastion to hold out against the Chinese invasion of their Tibetan homeland.&nbsp; The freedom fighters of Tibet, known as the Chushi-Gangdruk, had emerged to resist the <a href="https://nepalitimes.com/editorial/territorialism">Chinese takeover</a> of Tibet during the 1950s. Estimated to be 80,000-strong at the time of <a href="https://nepalitimes.com/here-now/what-or-who-after-the-dalai-lama">the Dalai Lama</a>’s final escape to India in 1959, the sheer number of Chinese deployed into Tibet eventually forced the Chushi-Gangdruk to retreat to Mustang, From this high Himalayan stronghold, they continued cross-border raids on the Chinese People’s Liberation Army (PLA) throughout the 1960s.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025052403054_8a4a935ba25ae79dc3a63bb5c14626927020e5ec098093c45ccb9a5982e009fd.jpg" data-media-id="editor_10" data-image-id="2025052403054_8a4a935ba25ae79dc3a63bb5c14626927020e5ec098093c45ccb9a5982e009fd" data-rendition-name="original" width="1114" height="676" loading="lazy" alt="The last days of the Khampa NT"> <figcaption>Guerrillas known as the Chushi-Gangdruk emerged to resist the Chinese annexation of Tibet during the 1950s. Photo courtesy: MIKEL DUNHAM</figcaption> </figure>  Their Kathmandu base was a small discreet lodge in a back lane near Rani Pokhari. Sipping sweet tea from a blue mug with a chipped lid, I sat bemused in a corner of the Mustang Hotel room whilst Wangdu and his cohorts received a battered brown suitcase from their CIA connection, a tousle-haired American in a leather jacket. Heaved onto the dingy bedspread that covered the thin mattress, it was clicked open to reveal piles of neatly stacked dollar bills.&nbsp; I cannot think why Wangdu allowed me to witness this handover but I was clearly no threat, a newly arrived world traveller with no understanding of the stakes nor any Nepali or <a href="https://nepalitimes.com/multimedia/tibetan-music-in-nepals-sacred-valley">Tibetan language</a>. Despite armed guards in the corridor,Wangdu radiated confidence and bravado, and there was a practiced familiarity to the tense transaction. This deadly dance for many years had been funded by the Americans, tolerated by <a href="https://nepalitimes.com/here-now/the-kingdom-within-a-republic">Mustang’s residents</a>, and permitted by King Mahendra and the Nepali authorities who it suited to turn a blind eye.&nbsp; But Mahendra died in 1972, and times were changing. Richard Nixon’s ping-pong diplomacy thawed the cold war and signalled a fresh entente with China. Nepal’s yet-to-be-crowned <a href="https://nepalitimes.com/here-now/if-birendra-was-alive-nepal-could-still-be-a-monarchy">King Birendra </a>was under pressure to curb the irritating incursions against the PLA launched from the Nepali territory of Mustang. Keen to appease his northern neighbour, on several occasions the King summoned Wangdu for peace talks but, despite increasingly overwhelming odds, Wangdu refused to surrender.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025052403054_a8efd5cfb92cd997bd7cb74296a936fef46e2f7428f9cd642b03f1ac4ea11ecb.jpg" data-media-id="editor_14" data-image-id="2025052403054_a8efd5cfb92cd997bd7cb74296a936fef46e2f7428f9cd642b03f1ac4ea11ecb" data-rendition-name="original" width="1055" height="885" loading="lazy" alt="The last days of the Khampa NT"> <figcaption>General Wangdu flanked by two Tibetan resistance fighters in Mustang in the 1970s. Photo courtesy: MIKEL DUNHAM</figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025052403054_75969125a745847a2ef82b6fe8b9106c0b21a116d85b8efdf5d2ee89a347bb31.jpg" data-media-id="editor_15" data-image-id="2025052403054_75969125a745847a2ef82b6fe8b9106c0b21a116d85b8efdf5d2ee89a347bb31" data-rendition-name="original" width="1044" height="792" loading="lazy" alt="The last days of the Khampa NT"> <figcaption>King Birendra with General Wangdu (right in dark glasses) taken in 1974 possibly in Mustang after one of their few attempts at negotiation. Photo courtesy: RAJRNDRA KUNWAR</figcaption> </figure>  While I naively rode pillion around Kathmandu in the spring sunshine, Wangdu was in the midst of what turned out to be his final round of negotiations with the Nepal government. Refusing to cease hostilities with the Chinese, Wangdu must have suspected the cost of his decision, making his cheerful smile in the photograph all the more poignant and brave. It was only much later that I appreciated the significance of the moment. Wangdu had been sent to replace the first resistance leader in Mustang, Baba Gen Yeshe, a much derided corrupt character who stole money meant for his troops and exploited fleeing refugees by seizing their treasures. Baba Gen Yeshe never forgave Wangdu,and sought revenge in May 1974 by betraying him and his commanders to the Nepal authorities. Renewed Chinese incursions from the north, active PLA collusion with the Nepali forces under the new King, and treachery from within the Chushi-Gangdrukranks combined to seal their fate.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025052403054_e0987a7c90d76431b0d7d5e6115ebfe3dbda7ab939e5941e079c18d722e884c0.jpg" data-media-id="editor_16" data-image-id="2025052403054_e0987a7c90d76431b0d7d5e6115ebfe3dbda7ab939e5941e079c18d722e884c0" data-rendition-name="original" width="1400" height="769" loading="lazy" alt="The last days of the Khampa NT"> <figcaption>British television journalists George Patterson and Adrian Cowell embedded themselves with Khampa guerrillas and accompanied them from Tsum Valley on a cross border raid on a Chinese Army convoy in 1964. Photo: ESSAYS ON NEPAL / SAM COWAN</figcaption> </figure>  Mikel Dunham, renowned author of Buddha’s Warriors, writes: ‘It is possible that Wangdu was waiting for some cue from the Dalai Lama’s government-in-exile in Dharamsala, India. It is equally possible – during that last, <a href="https://nepalitimes.com/multimedia/the-human-cost-of-nepal-s-yarsa-gold-rush?fbclid=IwZXh0bgNhZW0CMTEAAR31-Cqw8oyIwMPzf_35e4Skr0ululJvLf3_vDkzHn-AYG2h8uPw2rqqErg_aem_tGVn5coY1-jA7fze_xqhew">desolate winter </a>– that he made the decision to go out in glory rather than admit defeat. Over the last fifteen years, Wangdu had experienced Tibet’s organized resistance being squeezed and shoved around by every conceivable outside force.&nbsp; First they had been pushed out of their own country by the PLA; then they had been refused sanction while on <a href="https://nepalitimes.com/opinion/borderlines/nepal-india-trans-boundary-bonds?fbclid=IwAR0PpJ5zUEbwdug3g_U3ar6FUugngRY0S8Tl2v_7wqzrsHmXWcXsKjvL4t4">Indian soil</a>; then they were abandoned by the Americans because, apparently, Nixon wanted to make friends with Wangdu’s mortal enemies, the communists; then they had been betrayed by the vampiric Baba Gen Yeshe – a Tibetan and, even worse, a fellow Khampa; and now, finally Wangdu’s army was being evicted by the Nepalis. One thing was certain: Wangdu was a warrior. To imagine Wangdu simply giving up and settling down in the pacific squalor of a <a href="https://nepalitimes.com/here-now/elderly-left-in-bhutan-refugee-camp">refugee camp </a>was unthinkable.’  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025052403054_8fc1ffef4ae751628b90ae781b66e11e51e4fdde2787207c9042efbee345ce49.jpg" data-media-id="editor_20" data-image-id="2025052403054_8fc1ffef4ae751628b90ae781b66e11e51e4fdde2787207c9042efbee345ce49" data-rendition-name="original" width="500" height="746" loading="lazy" alt="The last days of the Khampa NT"> <figcaption>The much derided Baba Gen Yeshe, the first Tibetan resistance leader in Mustang, who betrayed Wangdu for personal gain. Photo courtesy: MIKEL DUNHAM</figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025052403054_b1d833cdb00d3ac4416b844d8730475cd88c238caaaf8da69889a584eea229a3.jpg" data-media-id="editor_21" data-image-id="2025052403054_b1d833cdb00d3ac4416b844d8730475cd88c238caaaf8da69889a584eea229a3" data-rendition-name="original" width="500" height="656" loading="lazy" alt="The last days of the Khampa NT"> <figcaption>Aditya SJB Rana of the Royal Nepal Army whose team ambushed Wangdu and his cohorts at the top of Tinker Pass in Darchula, West Nepal. Photo courtesy: GAUTAM SJB RANA</figcaption> </figure>  By August 1974 the game was up. Wangdu and six of his exhausted party were killed on their horses by <a href="https://archive.nepalitimes.com/news.php?id=7270">the Royal Nepal Army</a> on the brink of escape. The officer in charge, Aditya SJB Rana, cleverly predicted their route into India after they failed to silence a police radio in Yari. A carefully laid ambush trapped them near the summit of the Tinker Pass in Darchula,at 5,000 meters the highest military operation of its time. Wangdu’s body was helicoptered to Kathmandu, and a big show made of the royal Nepal victory.&nbsp; The Tibetan armed insurgency against China had reached its end.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250524030520_3ff9c6fc85a65bc9a2c3afe9736d9f5f9413de752e790a5d9dca0981ea94f9b4.jpg" data-media-id="editor_23" data-image-id="20250524030520_3ff9c6fc85a65bc9a2c3afe9736d9f5f9413de752e790a5d9dca0981ea94f9b4" data-rendition-name="original" width="1136" height="702" loading="lazy" alt="The last days of the Khampa NT"> </figure>

The Last Days of the Khampa

Starting 17 September Turkish Airlines will fly daily to Seville, one of Spain’s major tourist draws. This is Turkish’s sixth destination in Spain after Madrid, Barcelona, Valencia, Malaga, and Bilbao. Seville is in the Andalusia region on Spain’s south coast with a rich Moor history. There are approximately 30,000 Nepalis living in Spain.&nbsp;

Turkish to Seville

The newly-formed Himalayan Art Council is set to launch Nepal’s National Art Protection Platform that seeks to preserve <a href="https://nepalitimes.com/banner/the-history-of-heritage">Nepal’s unique cultural heritage </a>using<a href="https://nepalitimes.com/here-now/artificial-censorship"> AI-powered tools</a>. The Council seeks to safeguard <a href="https://nepalitimes.com/banner/nepali-art-going-places">Nepali art works</a> from neglect, theft and counterfeiting as well as preserve existing artwork and celebrate living masters by giving them a cultural space to continue the <a href="https://nepalitimes.com/banner/sacred-survival">sacred art traditions</a>. "We are introducing a new digital platform designed to preserve, verify and elevate <a href="https://nepalitimes.com/banner/nepals-new-generation-of-alternative-artists">Nepal’s art for generations to come,</a>” says a statement from the Council, adding that the digital platform will use AI told for authentication and blockchain to keep track of works of art. Artists can now be protected by <a href="https://nepalitimes.com/multimedia/ayo-ai?fbclid=IwAR1uwmTVq4gUB70ljfRezjzukD9ArWXPuMnUikopeQ8PoiZMjicToPSwhKE&amp;=1">AI tools</a> that detect forgeries, identify their work even when unsigned, and ensure they receive proper recognition and credit. The archives will be searchable with translated inscription and interactive guides. Says curator Meena Lama: “AI and blockchains are tools that give us the power to detect fakes and identify unsigned paintings and track every piece. With these tools we can restore trust, secure authorship and give artists the dignity they deserve.”  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250514170544_2ab58f6313c0458f75114a692b0016bd9efb3b59d5f8f07f0da72e1e37b82f53.jpg" data-media-id="editor_6" data-image-id="20250514170544_2ab58f6313c0458f75114a692b0016bd9efb3b59d5f8f07f0da72e1e37b82f53" data-rendition-name="original" width="1300" height="1000" loading="lazy" alt="Artwork at the Traditional Art Exhibition at Patan Museum."> <figcaption>Artwork at the Traditional Art Exhibition at Patan Museum.</figcaption> </figure>  The Council is also holding an exhibition of Nepali cultural masterpieces with 50 historical <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/Buzz-the-art,671">thangka and paubha </a>by past masters and <a href="https://nepalitimes.com/review/between-the-sacred-and-everyday">contemporary works by current artists</a>. This curated collection is a living tribute to <a href="https://nepalitimes.com/here-now/when-yaks-go-so-does-culture">Himalayan culture</a> with economic depictions of deities, mandala and sacred narratives. The exhibition at <a href="https://nepalitimes.com/multimedia/a-portal-into-patan-s-past-and-present">Patan Museum</a> also provides an opportunity to meet painters and custodians of art and culture. Read also: <a href="https://nepalitimes.com/review/golden-deities">Golden deities</a>, Sewa Bhattarai ‘The exhibition is only the first step in a long journey to ensure that Nepali art is no just seen but fully understood, <a href="https://archive.nepalitimes.com/article/nation/Narratives-of-Faith-and-Memory-Remembering-the-Lost-Sculptures-of-Kathmandu-exhibition,987">protected and remembered</a>,’ the Council says. Artist Kailash K Shrestha of Artudio has spent decades promoting thankha and paubha traditions because of their beauty and devotional meaning. But he also says artists are underpaid, exploited and ignored. He adds, “AI and blockchain are not just buzzwords, they are powerful tools that can protect Nepal’s artists from fraud, verify authenticity and build a permanent record of provenance.” Traditional Art Exhibition Till 17 May Patan Museum

Digital protection for Nepal’s art

<a href="https://www.instagram.com/prabalgurung/" target="_blank">Prabal Gurung</a> left Nepal for New York in 1999 to escape years of bullying, sexism and homophobia, and to pursue his dream of becoming a fashion designer. He <a href="https://www.youtube.com/watch?v=KqN0VaoAI5w" target="_blank">realised his dream</a>, but did not escape discrimination and racism in the new world. Propelled by passion for fashion, Gurung overcame everything America threw at him. He has attained <a href="https://www.vanityfair.com/style/story/prabal-gurung-recalls-his-first-met-gala-when-zoe-saldana-was-at-his-side?srsltid=AfmBOooy-H0oGgxMit864FnW_Pmw8mUnV8rYrh-co-f6OyYK6m2ip5hP" target="_blank">fame and recognition</a> for his haute couture dress designs while remaining true to his Nepali roots, and is even more resolute in <a href="https://www.youtube.com/watch?v=dSmNauyzACk" target="_blank">fighting prejudice</a> in all its forms. Prabal Gurung’s newly-released memoir <a href="https://www.amazon.com/Audible-Walk-Like-Girl-Memoir/dp/B0DG11HCDQ?fbclid=IwY2xjawKZfpxleHRuA2FlbQIxMQABHuZcIJO2OXyXcRm1oq1iG6wzeoF7VJFrQ7GXOFI0YxuZZ4id_CNvSZSZZIna_aem_pG_mOKG73RTnYvN8JaC4fA">Walk Like a Girl</a> is a saga of harrowing abuse in boarding schools in Nepal and India, only finding himself facing a different kind of bullying in the US. He prevails over it all to be where he is today: an award-winning American fashion designer with his own label. Walk Like a Girl was launched last week in New York at a time when everything Gurung fought for — tolerance, inclusion and diversity — are in retreat in his adopted country because of a president who has espoused a culture of bullying. The book is a searing, raw exposé of how cruel and abusive people can be even at a young age in school. On the other hand, it also shows that there are generous, compassionate and open-minded souls out there. In his book, <a href="https://www.youtube.com/watch?v=K4le_uWX7YE">Prabal Gurung</a> calls out those who tormented and tried to hold him back (some of their names have been altered). The moral of his story is: resist, never stop believing in yourself, do not let others define you, never lose sight of your dream, and help those who have been kept out. “Walk like a girl” was a slur used by bullies back in school in Nepal and India for Gurung’s effeminate ways. He fought back then, and he is still resisting by turning those words into something to be proud of.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250519170544_4ffc9c3f565dd2cfa754d10b224816897b82bb31ebaee91b6d79d469fc96f14e.jpg" data-media-id="editor_6" data-image-id="20250519170544_4ffc9c3f565dd2cfa754d10b224816897b82bb31ebaee91b6d79d469fc96f14e" data-rendition-name="original" width="1000" height="1253" loading="lazy" alt="Prabal Gurung NT"> <figcaption>Prabal Gurung at home in Kathmandu in the 1990s.</figcaption> </figure>  “Living through it all was one thing, but writing about it is one of the hardest things I have done in my life,” admitted Gurung during the launch. “I broke down constantly during the six-year writing process.” He continues: “I did not want this to be a victim’s book. I did not want to burden my readers with my emotions. I wanted my struggle to be an inspiration for others facing what I faced. I am grateful to those who bullied me in school, they made me a stronger person ready to face the world.” Indeed, this book is a departure from his earlier one titled simply, Prabal Gurung (Abrams, 2019), which was a lush pictorial autobiography of his career in fashion. Walk Like a Girl is not a typical fashion book, it is an intimate tale of <a href="https://archive.nepalitimes.com/news.php?id=16997">Gurung’s travails and triumphs</a>, and how he willed himself to succeed. Prabal pays a lavish tribute to his mother Durga Rana. We find out she is a descendant of the first wife of the eldest son of Jang Bahadur Rana who was banished to Palpa in the late 19th century. Prabal’s father served in the Singapore Police and that is where he was born before the family returned to Nepal when he was four. Gurung relates with brutal honesty about the violence his mother endured from his father. Durga raises three children as a single mother in Nepal, and Prabal credits her for his fierce determination to resist patriarchy and injustice, which in time manifests itself in his hyper-feminine and subversive dress designs. Writing the book has been a cathartic experience for Gurung, who says he is now relieved of the burdens of his past. It no longer haunts him, and he does not have to prove anything to anyone anymore. Walk Like a Girl has life lessons not just for the <a href="https://www.instagram.com/p/DJmOcSgxdWz/" target="_blank">fashion industry</a>, but for every other profession. How can my job serve a greater cause? Gurung tells us his work is <a href="https://asiasociety.org/blog/asia/why-designer-prabal-gurung-doesnt-want-just-stick-fashion" target="_blank">bigger than just making clothes</a>, it is about making the world a better place because it could do with a lot of improvement.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250519170544_d75296ad8bfdc00d88935f40d23543c6fea3d4d6a10e61a99d6cfc6127f2ee5b.png" data-media-id="editor_10" data-image-id="20250519170544_d75296ad8bfdc00d88935f40d23543c6fea3d4d6a10e61a99d6cfc6127f2ee5b" data-rendition-name="original" width="1516" height="1000" loading="lazy" alt="Prabal Gurung"> </figure>  This story of chasing the American dream may sound familiar to many immigrants: knocking on doors for jobs, rejections, trying to survive from day to day on expensive rent, and dealing with subtle racism in white America. Gurung finds racism is rife, and he is often mockingly called ‘gaysian’. He writes: ‘There was a strong hypocrisy — this idea of independence felt like a marketting ruse … and for all the talk of feminism in America, these high society women were trapped by the patriarchy just like in Nepal and India.’ After a trek to the Khumbu region in 2013, Gurung is inspired to use the colours, palette and textures of Nepal for his collection exhibited on Manhattan’s 8th Avenue. A major buyer tells him bluntly: “Stick to making pretty dresses … if I need to see a collection like this, I could buy a copy of National Geographic.” The New York Times was equally dismissive: ‘The designer tries to draw connections between blistered techo-fabric used to construct it and the topography of his homeland, Nepal. But, at the moment, he has lost his map.’ One potential investor tells Gurung he cannot design for Americana because “you do not look American”. Gurung wants to use expletives, but restrains himself. After a fundraiser in New York for the Nepal earthquake in 2015, some belittled his effort, saying: “Here comes the saviour."&nbsp; Read also: <a href="https://nepalitimes.com/review/prabal-gurung-by-prabal-gurung">Prabal Gurung by Prabal Gurung</a>, Kunda Dixit The Gurkha DNA must be dominant in Prabal Gurung’s genes because he does not take such mistreatment lying down. When asked by a fashion publicist why he was designing clothes for fat people, he snaps back: “Because of people like you.” He joins the Black Lives Matter and #MeToo movements, launches the Shikshya Foundation charity in Nepal, and has powerful allies among celebrities who wear clothes he designed: Michelle Obama, Oprah Winfrey, Sara Jessica Parker, Kamala Harris, Deepika Padukone … it is a long list.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250519150556_48a5f4211991a23fa85b64bbd5377575ca7081d97309d7542035591dda5180fe.png" data-media-id="editor_12" data-image-id="20250519150556_48a5f4211991a23fa85b64bbd5377575ca7081d97309d7542035591dda5180fe" data-rendition-name="original" width="1114" height="1534" loading="lazy" alt="Being Prabal Gurung by design"> <figcaption>Nigerian novelist Chimamanda Ngozi Adichie wearing Atelier Prabal Gurung’s design for Met Gala 2025 in which the theme was ‘Superfine: Tailoring Black Style’. </figcaption> </figure>  “I don’t dress women to look beautiful, they already are,” Gurung says. “I try to bring out their innate strength and grace.” <a href="https://www.instagram.com/stories/highlights/17908766880140171/" target="_blank">Admirers</a> tell Gurung he makes it all look so easy, but he used to put up a strong facade to not show his own vulnerabilities in public. “I was closed because of my childhood experiences,” he says. “I was always on guard to defend myself because I never knew where the next punch would come from.” But in <a href="https://www.youtube.com/watch?v=PPVepzPA210" target="_blank">Walk Like a Girl,</a> Gurung comes to terms with his vulnerability, and bares his soul. It has not been easy, it took sustained will power and support from his mother, sister Kumudini and a circle of close friends. “I made unbelonging my power,” he says. “Nepal is where I still have my heart and soul. Nepal grounds you. It is where people go to find themselves. But I escaped.” Recently appointed vice-chair of the <a href="https://cfda.com/about-cfda" target="_blank">Council of American Fashion Designers</a>, Gurung says: “I can’t believe I am here, it feels like it is happening to someone else. Writing this book, the healing has finally begun.” <h2>‘Everything is better in color’</h2> The Met Gala was two weeks later, and my table was an example of everything I’d been fighting for all these years as my guests represented everything I believed in: dynamic, powerful, influential women who were unapologetically original and unabashedly graceful. I was grateful to Anna for inviting me to host and dress a table that reflected my ethos—and for her guidance in doing so. I was also aware of the privilege as one of the first-­ever Asian fashion designers—not just from Nepal, but from the entire continent— to get the opportunity to do so. That fact was not lost on me. I reached out beyond the expected Hollywood celebrities and well-­known socialites to curate a table of exceptional women who inspired me. I invited Deepika Padukone and Alia Bhatt for their first-­ever Met Galas, as well as Michelle Yeoh, Mindy Kaling, Camila Cabello, Ashley Park, Denée Benton, KiKi Layne, Quannah Chasinghorse, and Grace Elizabeth. Together we checked many boxes: Asian, Black, Latinx, and Indigenous, each woman undeniably chic and powerful, a dazzling array of skin tones and experiences that proved my decades‑in‑the-­making hypothesis: everything is better in color. Excerpt from Walk Like a Girl Viking © 2025 by Prabal Gurung  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250519170520_6b91d560e9f072c37d16876901058c073a51ffa05e7ad1b9461d19e1c9c28215.jpg" data-media-id="editor_16" data-image-id="20250519170520_6b91d560e9f072c37d16876901058c073a51ffa05e7ad1b9461d19e1c9c28215" data-rendition-name="original" width="1136" height="702" loading="lazy" alt="Prabal Gurung book details NT"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250519170520_345240c21be400e2ce2ec629b52bd82bb53890e5bd86fe95b48340d84b5f1748.jpg" data-media-id="editor_17" data-image-id="20250519170520_345240c21be400e2ce2ec629b52bd82bb53890e5bd86fe95b48340d84b5f1748" data-rendition-name="original" width="1136" height="702" loading="lazy" alt="Prabal Gurung book details NT"> </figure>  &nbsp;