Corona quandaries

Waking up on 25 April 2015, nobody could have predicted a Magnitude 7.8 earthquake would hit us at midday and cause such widespread death and destruction.

It’s March 2020, and there is something far more sinister than an earthquake breaking out across the globe. It is almost upon our country as we wait helpless and unprepared. Yet, before the current coronavirus outbreak engulfs Nepal, we are presented with the unique scenario of having things very much within our hands.

Given how quickly the number of COVID-19 cases is rising everywhere, fear and anxiety are very genuine responses. But we must be equally cognizant of the power this pandemic has bestowed on each of us. Trivial everyday decisions such as where we go, who we meet, who and what we touch are suddenly loaded with a new and far-reaching significance.

And yet fear, strangely, has not been the overriding emotion. In the past two weeks, I have observed a popular narrative take hold of the Nepali psyche - that we Nepalis have a stronger immunity as we have grown up exposed to harsh living conditions and all kinds of germs and bacteria.

What an arrogant, and frankly self-destructive, form of patriotism. It refuses to acknowledge how vulnerable we are against this current outbreak precisely because of our quality of life. Health experts have relayed clearly and repeatedly that chronic air pollution has a damaging impact on people’s overall health, which in turn makes them much more susceptible to more severe cases of coronavirus resulting in death.

Nevertheless, it is highly plausible that most of us are going to be just fine. We will probably get away with a slight case of snuffles and a runny nose for a few days. Some of us who contract the virus may not display even these symptoms. So why should we care?

As I sit to write down this article, the only person to have a confirmed case has recovered. But what does this mean in reality?

Based on the virus' spread patterns elsewhere, one confirmed case is an indication of several untested cases. In China, for instance, analysis of data in hindsight shows that every newly positive tested case actually was only one out of 27 cases that existed but hadn’t gotten tested. But China presents a better scenario than others, where testing took place rampantly.

In Nepal we only have a total of 2,000 testing kits, and so far all the other 571 tests performed have shown negative results. People who showed symptoms and dutifully headed to Sukraraj Tropical Infectious Disease Hospital in Teku have complained about not being tested, as doctors and nurses wait for more severe cases to show up.

When people don’t get tested for showing mild symptoms, it skews the numbers. In all likelihood, in places like Nepal, for every confirmed case, there will be much more than 27 unconfirmed cases. This is something we should keep in mind.

As non-tested people go about their daily lives, coming into contact with others, they are likely to spread the virus to others around them. It would spread from one person to two on day one, two to four on day two, four to eight on day four, eight to 16 on day five, 16 to 32 on day six, and so forth. In a matter of days, the number of cases would increase beyond our capacity to deal with them. That is how Italy reached from less than 20 confirmed cases on 21 February to a staggering 53,000 cases by 21 March.

Based on the progression of the outbreak in China, for every person that died there were actually 1,600 other people who had contracted the virus. Therefore, confirmed case counts are hardly reliable numbers to make simple, everyday decisions. The first death in Nepal will signal what has happened in reality: that the virus has spread far and wide.

Keeping this exponential growth in mind, and also keeping in mind the fact that most of us might come out of this unharmed, what should we really worry about?

Click on the image to play the GIF. Source: Flatten the curve

This graph presents two scenarios. The first (taller and narrower) curve shows what can happen if the growth goes unchecked. The numbers eventually decline but there is a sharp, quick growth preceding that. The second (shorter and wider) shows what happens when we flatten the curve. Even though the overall number of cases is the same in both scenarios, the second one shows the possibility of delaying onset of cases and stretching them over a longer period of time.

The straight dotted line that denotes any country’s healthcare system capacity puts both curves in perspective. Go up and down the first curve and a huge number of people get sick. This can so easily overwhelm the system that patients will receive inadequate care, allowing cases to become more severe, and increasing the likelihood of death. As resources and overworked medical staff find themselves strained, the capacity of the system to handle cases might also go towards breaking point. Go up and down the second curve and there will be a steady flow of patients to hospitals, but at a rate that is far more manageable for healthcare providers to handle. This way a majority of patients can have access to care, especially hard-to-get ICU beds and ventilators, over an extended period of time.

Italian doctor Fabiano Di Marc recounted the harrowing experience of having to decide which patients were to live and which were to die because there weren’t enough ventilators for all. He spoke with evident distress of how he had to choose a younger patient over an older one based on the former’s likelihood of survival. Italy has now reported more deaths than China, which indicates the situation tragically unfolded along the first curve.

Even in the best case scenario, where there’s an exceptional healthcare system in place, a pandemic can cause overload. In Nepal, we are more than acquainted with the inadequate infrastructure of our hospitals. No Nepali is under any illusion that the system will get an instant makeover and be able to accommodate all our needs as the crisis exacerbates. Any immediate decision made by the government can only make marginal changes and the rest of us can't make any meaningful interventions.

Additionally, there is an acute shortage of testing kits in Nepal and testing has been slowed also to make the limited supply last longer. The service is currently only available at the Teku Hospital, with an abysmally low rate at which tests are being conducted, especially given how the pandemic is rampant everywhere.

Examples from elsewhere show the more people get tested, the more effective efforts at containing the spread become. In the absence of testing, there is a greater probability for the virus to spread undetected and unchecked, leaving a larger population vulnerable to exposure.

To add to this, healthcare professionals stationed in hospitals are panicking because their protection has so far not been ensured. Doctors and nurses across hospitals in Nepal have neither been given protective gears nor protocols to handle cases as they emerge.

Efforts at Tribhuvan International Airport have also been frail and full of neglect. Ishan Mainali, a 21-year-old student who returned from New York via Doha to Kathmandu on 16 March, wrote a concerned Facebook post about his experience:

“We had to submit a self-declaration form declaring where we had traveled in the last 21 days and what symptoms we were having. The guy in front of me did not get the form/forgot it in the airplane and the police officer collecting it just let him go. Next, we did a temperature check where three health workers did a quick check of our temperature and let us go.”

More recently in China, imported cases have started to outnumber local ones. This means airports and airplanes have become risky contamination spaces. Our government’s decision to bar entry to all arrivals from 20 March has been drastic. Although it is one step forward in trying to contain the virus, it bars Nepalis stranded abroad from entering the country, which is in violation of their constitutional right. The government’s decision to contain the virus by banning arrival, rather than enforcing stricter quarantine protocols, is faulty and jeopardizes the safety of its citizens.

What about those who entered Nepal in the last month, long after cases started to surge all over the world, under lax testing? How many of those people has the government ensured are in self-quarantine?

While all the information above can be daunting to read and process, we must take stock of all the things that are beyond our control in order to work with what is in our control. And I cannot stress enough that a lot is in our control.

On Wednesday, 18 March, our government issued orders that signal it comprehends the gravity of the situation. Along with prohibiting entry into the country, authorities have indefinitely postponed the Secondary Education Examination 2076 and public gatherings of over 25 people have been banned. On 20 March, PM Oli gave his first official address on COVID-19, announcing the closure of all public and private institutions barring a few from 22 March onwards.

These are all measures that can help flatten the curve and contain an outbreak, but they need our support. Which brings us back to the power we hold in our hands.

As strange as it may seem, doing incredibly simple things can contain this pandemic. Washing hands properly with soap, not touching our face with our hands, coughing into our elbows are guidelines so simple that they are also easy to overlook. We are also expected to practice social distancing, cutting down on all non-essential travel or gatherings. In short, we are expected to stay at home and do less. Social distancing not only protects individuals from contracting the virus and thereby easing the burden on our healthcare system, it also reduces the chance of those with mild to no symptoms from infecting others who are more vulnerable.

When some of us go about our usual ways, it creates a false sense of normalcy, giving others the license to follow suit. But the more people cooperate, the flatter the curve will be. In fact, collective cooperation in practicing these incredibly simple measures by each one of us is the most effective way of flattening the curve.

But avoiding the inessential feels difficult in the age of urban culture, which, over a lifetime, promotes self-gratification by engaging in non-essentials. This is true particularly of the privileged classes who have the unappealing option of practicing social distancing instead of hitting cafes, restaurants, malls, concerts.

In the same society, there are also those for whom social distancing is not a viable option, whose daily meal comes from what they earn each day, and who might have to throw themselves into peril by continuing to go out and work. On their behalf, it becomes imperative for those with financial cushioning to sit on their couches and watch TV, eat, relax. It has to start from today.

Stories of people stockpiling toilet paper in the West may appear farcical, but that has not deterred Nepalis from running to the market and overbuying supplies. There is an underlying selfishness in this way of thinking, where care is shown only towards oneself or one’s immediate family, which in the long run becomes harmful for everyone involved. The bottom line is we cannot protect ourselves from this virus if we do not protect others.

In times like these, it is easy for the worst in us to spill out as we make hasty, selfish decisions. If the coronavirus has come our way as a lesson, perhaps one important takeaway is that we might want to shift our understanding of what that ‘self’ comprises, letting it expand beyond ‘me’ and ‘mine’ to encapsulate a larger whole, where thinking and acting on behalf of everyone’s best interest is, in fact, beneficial to 'me'.

This is the time to include, in this idea of self, all the elderly, those with compromised immune systems and fragile lungs, those with other illnesses who might get sidelined in the healthcare system as COVID-19 patients are prioritised, the healthcare professionals risking their lives to save others, the pregnant mothers, the disabled, the migrant workers working abroad who might get laid off, those working in the informal sector, and all those in our country who can afford neither medical bills nor social isolation.

The decisions we make right now - consciously or unconsciously, conscientiously or recklessly - will dictate what will unfold in Kathmandu and the rest of the country in the days to come. Each one of us is responsible for the outbreak in Nepal. Each one of us has the power to intervene.

:::::::