In recent months, a multitude of voices have raised the alarm about the covid-19 crisis in Nepal, imploring wealthy nations like the US to provide immediate vaccine aid. These calls to action from groups like Nepal Rising, the Covid Alliance for Nepal, and others contributed to the Biden administration’s decision to send seven million vaccine doses to South and Southeast Asia in June 2021.¹ This was a small step forward in the battle against global vaccine inequity, but falls far too short. 

The situation in Nepal remains dire, despite the somewhat increased availability of vaccines. A few weeks ago, the country was reporting more new weekly cases and deaths as a proportion of its population than India, which itself had the world’s second highest case numbers in absolute terms.² While cases have dropped from a peak of almost 9,000 new cases a day on 12 May 2021, excess mortality from covid including underreported cases exceed 37,000, and daily cases remain high. Nepal’s healthcare system is simply unable to cope with the volume of sick and suffering patients, and facilities continue to experience widespread shortages of oxygen and other essential supplies.³ A major challenge is that the true extent of the covid-19 situation is largely unknown, as the number of confirmed cases is significantly lower than actual cases due to limited testing capacity.

While it seems a crushing second wave peaked in some areas, such as in Kathmandu, in other parts of the country cases had been on the rise. And while some remote districts, such as Mustang, have received sufficient vaccine doses for its population, others such as neighboring Dolpa, remain under-resourced when it comes to both testing capacity and vaccine access. Official coronavirus case numbers primarily represent urban areas, where laboratories are concentrated. A lack of systematic testing and contact tracing, coupled with the unavailability of data from regions still witnessing high levels of community transmission – like those on the Indian border – continue to obscure the true toll of the pandemic.⁴

Less noted are distressing reports from Nepal’s mountainous districts where earlier this summer rural municipalities were witnessing highly symptomatic villages, in which “at least one person in each household is ill with flu-like symptoms,” as reported by the ward chair of Dho village in Dolpa. These remote settings lack access to PCR tests, and nationwide lockdowns hinder symptomatic people from travelling to the nearest laboratory. In response to the high testing demand from rural regions, a few weeks ago, the Ministry of Health and Population (MoHP) distributed rapid antigen tests in remote and rural areas – the proportion of cases detected by these tests increased from 0.4% on 25 May 2021 to an alarming 25% on 8 June 2021.

The catastrophe in Nepal also requires that we pay greater attention to the social epidemiological factors and inequalities that characterise, and are exacerbated by, the pandemic. Recent studies in Nepal have already highlighted the socioeconomic shocks of “lockdown” measures,⁵ increases in reported cases of domestic violence against women and girls,⁶ families experiencing hunger,^7,8 a surge in mental health distress,⁹ and deleterious impacts on maternal and child health.¹⁰

The most vulnerable and marginalised are surely suffering in greater proportion, with WHO recommended protective measures for masking, hand washing, isolation and physical distancing to slow the spread of covid-19 often unfeasible, especially for those in rural settings: people living 6-10 in modest village homes are unable to “isolate” or physically distance; masks are unavailable in local markets; soap for handwashing is expensive; water must be carried on the backs of humans and animals. Meanwhile, agricultural and other livelihood rhythms must go on, despite the collective awareness of the virus and its modes of spreading. Plowing, irrigation, and harvest are communal activities, and the urgency of ensuring food for coming seasons takes precedence over sheltering in place. The ravages of summer monsoon rains and their impacts on homes and other infrastructure have further challenged people’s capacities to prioritize or abide by such protective measures.

We must put our eyes and ears to the ground and be attentive to these dynamics if we are to stem the spread of the virus. And we must develop more feasible, contextually congruent recommendations along with providing the necessary supplies and resources to enable them. Widespread mask distribution is one low hanging intervention; increased testing at facilities is a more difficult but necessary focus, as is contact tracing at the municipal level; considerations around what safe and human shelter in place policies should look like – especially for rural communities – are more challenging, but a similarly necessary focus.

Nepal’s healthcare system presents both significant opportunities and challenges to effectively respond to the pandemic. The country was in the process of full-scale decentralization just a few months before the pandemic hit. This governance transition saw the upheaval of personnel, reporting protocols, and chains of command, complicating the ability for local officials to respond. Yet, Nepal was able to marshal a thorough and equitable covid vaccination programme throughout all of its seven provinces with the initial doses it received.¹¹

Indeed, Nepal is uniquely situated to deliver effective responses to covid surges and ‘waves’, with an exceptional capacity to provide community-based services to even the most remote regions.¹² Central to this approach are 50,000+ community health workers distributed throughout every municipality in the country, and connected to local health posts or primary healthcare centres. Nepal’s renowned Female Community Health Volunteers (FCHVs) serve as the frontline, working in the communities where they live, able to dispel misinformation, and poised to connect individuals and families to facilities and referral care. FCHVs have been at the forefront of successful immunisation campaigns in the past,¹³ and, with the proper training, supplies, and support from government and non-governmental organizations, they and other frontline health workers can help bridge the gap between last mile communities and lifesaving treatment such as vaccines.

As of 17 August 2021, 8.3 million doses of the vaccine have been administered in Nepal, but only 12.2% of the country’s roughly 30 million people have been fully vaccinated.¹⁴ The delta variant is by now likely the dominant strain circulating in Nepal,¹⁵ and the newer ‘delta plus’ variant has already been detected.¹⁶ Meanwhile, several wealthy nations such as the US, Israel, and France, are preparing for a third booster of the vaccine for some groups. The WHO has rightfully called for a moratorium on the broad use of boosters by countries who have already used up more than their fair share of the global vaccine supply.

The cost of continuing to ignore the crisis in Nepal raises significant epidemiological and ethical concerns within and beyond the region. As the now popular saying goes, ‘no one is safe until everyone is safe.’ For this maxim to even approximate the truth, we need to pay closer attention to Nepal’s unfolding covid scenario and its concomitant syndemics. There are a range of cogent steps and learnings that will help mitigate a ‘third wave’ in Nepal.¹⁶ These will take some time to achieve and implement, and thus direct and immediate vaccine aid is needed at the same time.

David Citrin, Affiliate Assistant Professor, Departments of Global Health and Anthropology University of Washington

Tsering Wangmo, MPH candidate, Department of Global Health, University of Washington 

Archana Shrestha, Associate Professor, Department of Public Health, Kathmandu University School of Medical Sciences

Sienna R. Craig, Professor, Department of Anthropology, Dartmouth College

Katharine Rankin, Professor and Associate Chair, Department of Geography and Planning, University of Toronto

Galen Murton, Assistant Professor, School of Integrated Sciences, James Madison University

Competing interests: none declared.

 

1. Statement by President Joe Biden on Global Vaccine Distribution, 2021 June 03. Available: https://www.whitehouse.gov/briefing-room/statements-releases/2021/06/03/statement-by-president-joe-biden-on-global-vaccine-distribution/.
2. Irwin L. 2021. Nepal’s COVID-19 crisis swells as global aid funding slows. The New Humanitarian 2021 May 31. Available: https://www.thenewhumanitarian.org/news/2021/5/31/nepals-COVID-19-crisis-swells-as-global-aid-funding-slows.
3. Bhandari R and Ellis-Peterson H. A hopeless situation’: oxygen shortage fuels Nepal’s Covid crisis. The Guardian 2021 May 10. Available: https://www.theguardian.com/world/2021/may/10/hopeless-situation-oxygen-shortage-fuels-nepal-covid-crisis.
4. Dhital K. Nepal Covid-19 impact worse than official figures. Nepal Times 2021 May 30. Available: https://www.nepalitimes.com/latest/nepal-covid-19-impact-worse-than-official-figures/.
5. Sharma K, Banstola A, Parajul RR. Assessment of COVID-19 Pandemic in Nepal: A Lockdown Scenario Analysis. Frontiers in Public Health 2021 April 08. Available: https://www.frontiersin.org/articles/10.3389/fpubh.2021.599280/full.
6. Sharma N. In Nepal lockdown, a domestic violence spike. Nepali Times 2020 May 05. Available: https://www.nepalitimes.com/latest/in-nepal-lockdown-a-domestic-violence-spike/.
7. Adhikari J, Timsina J, Khadka SR, Ghale Y, Ojha H. COVID-19 impacts on agriculture and food systems in Nepal: Implications for SDGs. Agric Syst. 2021 Jan;186. Available: https://pubmed.ncbi.nlm.nih.gov/33191971/.
8. Nepal families face hunger as coronavirus crisis hits remittances. Al Jazeera 2020 30 June. Available: https://www.aljazeera.com/news/2020/6/30/nepal-families-face-hunger-as-coronavirus-crisis-hits-remittances.
9. Poudel A. Over 1,200 people killed themselves during 74 days of lockdown. Kathmandu Post 2020 June 14. Available: https://kathmandupost.com/health/2020/06/14/over-1-200-people-killed-themselves-during-74-days-of-lockdown
10. Ashish KC, Gurung R, Kinney MV, Sunny AK, Moinuddin Md, Basnet O, et al.. Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study. Lancet Global Health 2020 Oct;8(10):e1273-e1281. Available: https://pubmed.ncbi.nlm.nih.gov/32791117/.
11. Bhattarai S, Dhungana J. A million-dose success for Nepal: insights from Nepal’s national vaccine deployment plan against COVID-19. Journal of Travel Medicine 2021;28(4). Available: https://academic.oup.com/jtm/article/28/4/taab027/6154673.
12. Regmi K, Naidoo J, Pilkington PA, Greer A. Decentralization and district health services in Nepal: understanding the views of service users and service providers. Journal of Public Health 2010;32(3): 406–417. Available: https://pubmed.ncbi.nlm.nih.gov/19995811/.
13. Khatri RB, Mishra SR, Khanal V. Female Community Health Volunteers in Community-Based Health Programs of Nepal: Future Perspective. Frontiers in Public Health 2017 July 21;5. Available: https://www.frontiersin.org/articles/10.3389/fpubh.2017.00181/full.
14. Johns Hopkins University & Medicine Coronavirus Resource Center. World Countries Overview: Nepal. 2021. Available: https://coronavirus.jhu.edu/region/nepal.
15. Mallapaty S. India’s neighbours race to sequence genomes as COVID surges. Nature 2021 May 14. Available here: https://www.nature.com/articles/d41586-021-01287-2.
16. Nepal-Johns Hopkins University Covid-19 Vaccine Advocacy Group. How Nepal must prepare for 3rd Covid wave. Nepali Times 2020 August 14. Available: https://www.nepalitimes.com/banner/how-nepal-must-prepare-for-3rd-covid-wave/