Reimagining quarantine

Even after nearly two months of lockdown, Covid19 cases are on the rise in Nepal. Given that testing is low, even by the standards of more populous countries in South Asia, there is a good chance that the prevalence of covid infections in the country might be higher than what the data suggests. Recent cases have mostly been found among migrant workers who travelled back from India and the individuals who came in contact with them. The news that random tests in Bihar have detected Covid19 cases in one out of four returnees from Delhi should be alarming. Nepali migrant workers who have already arrived or are en-route have travelled with this very population, meaning that Nepal is looking at a similar prevalence risk in returnee migrant workers from India. There are also thousands of migrant workers in Gulf countries and Malaysia, where transmission is widespread, who are facing dire circumstances and are keen to return. As per government estimates, more than 35,000 migrant workers are in need of repatriation. One way or another, many migrant workers currently stranded in these countries will need to be repatriated. If Nepal is to contain the spread of the virus, it needs to take these circumstances into account and plan promptly.

The method Nepal has so far adopted has been to quarantine returnees at the local level, with local governments tasked to maintain quarantines. One of the objectives of the lockdown, meanwhile, has been to impede community transmission. However, these are mere add-ons to the more important task of testing and isolating Covid19 infectants. Nepal has so far failed in that regard, with testing that has been dismally low. We can only hope from the current federal government that they will get their act together and increase testing capacities.

Currently, this system faces an additional burden. Quarantine facilities at the local level are becoming the new hotspots for Covid19 transmission, especially as more migrant workers are arriving from India and being accommodated in these spaces. Under the context of larger governance apathy, local governments had done well to increase quarantine facilities across the country. Currently, the facilities set up in the country include 63,773 beds where 21,623 suspected are being quarantined. It is safe to predict that some of these facilities are not properly managed as is testified by reports from Banke, Kapilvastu and Rupandehi. Even if some facilities at the local level are better equipped, they are unlikely to be able to handle a large influx of migrant workers. This will put a lot of administrative strain on the quarantines being run at the local level.

Consider the provisions laid out in the quarantine standards issued by the Ministry of Health and Population (MoHP). They are very unlikely to be met in quarantines run by most local governments even when running well below optimum capacity. According to the standards, the human resource required to run a quarantine for 100 people include at least one MPH/MD in community medicine, a medical officer, a health hostess, a paramedic, a lab technician, a pharmacists, two paramedics and an ambulance driver to run a 24 hour ambulance service, a sanitation supervisor and five sanitation officers for waste management, a security personnel, a plumber, an electrician–the list goes on. Most local governments are equipped only with paramedics and community health workers. Even for other essential workers working without protective equipment, there is a great risk of exposure to the virus, and most will refrain from working in a quarantine facility unless the financial difficulties they face are dire. Unavailability of essential workers will put a great burden on community health workers.

On top of that, there needs to be infrastructure set up for toilets and bathrooms, clean drinking water, and regular food supply, among other things. These are not only financially unsustainable, but administratively challenging for the duration of the pandemic. Given this, if any of the guidelines are not followed, it puts occupants of the quarantines and, through health and other essential workers who come in their contact, the entire community at risk.

Alternatively, local governments can focus their Covid19 containment measures to safer home quarantines. The central government is yet to make protocols for home quarantine and the ways in which local governments are to handle it, and it is already getting too late. The benefits of quarantining at home far outweigh those of public quarantines. For starters, the number of people coming into direct contact with infected individuals will greatly decrease. An average rural household in Nepal comprises 4.8 members. This number is much lower compared to that of a fully functioning quarantine facility. Secondly, it will reduce fiscal and administrative burden on local governments. Resources can be redirected towards enforcing effective home quarantines and transporting critical patients to nearby hospitals through ambulances.

However, home quarantines might not be effective if Covid19 infected individuals do not observe strict quarantine guidelines and end up infecting family members who in turn infect others in the community. This could be involuntary when an individual household shares a small living space. While this is a valid concern, it is one that can be dealt with, especially by spreading awareness on the probable risks of Covid19 transmission. Returnees can be given pamphlets that specify the risks and ways to effectively stay under quarantine at home. There is a risk, nevertheless, that individuals may violate domestic quarantine. However, it is safer to assume that individuals and communities are far likely to observe quarantine on their own than in an unsafe and poorly managed public quarantine facility.

In order to make this shift, all governmental and non-governmental organisations must relay accurate information about the risks posed by Covid19 and the protocols returnees ought to follow to effectively quarantine themselves. This might not be accepted by some local governments where the risks of transmission are still low and returnees are flowing into facilities at a manageable pace. If local governments are provided with both options, they can decide which way to enforce quarantine, based on local needs and circumstances. For now, one thing is certain; relying solely on the method public quarantine is not only unsustainable, but counterproductive. 

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