Nepal should rethink approaches of combating Covid-19

We are not nearly testing enough number of people to know where we are on the curve. There’s a chance that the infection is already rampant.

In 2016, non-communicable diseases (NCDs) contributed to 66 percent of the total deaths in Nepal. For the United States, this number stood at 88 percent and for OECD countries it was 87 percent. It is a feature of the developed world that NCDs be their greatest challenge and a feature of ours that children in remote villages like Jajarkot die every year from communicable diseases such as diarrhea. When our country cannot even at times provide access to adequate amount of Jeevanjal and paracetamol, it would be quite naïve to expect them to deliver a vaccine efficiently and uniformly—if and when that arrives.

Until then, and even after that, given an effective vaccine—depending on the country of origin—need only be 50 percent effective, cases will continue to be seen. This brings us to the issue of lockdowns and the basis of it. The daily press briefing from the Ministry of Health and Population provides us with different types of statistics with which an individual could inform their judgment. The only problem is that, statistics without proper interpretation merely takes the appearance of facts and comes without the benefit of it. The general consensus is that a lockdown isn’t a feasible long-term solution. But nevertheless, lockdowns, if strictly enforced, might help prevent overcrowding of valuable health care resources. Over the next few months, our governments—and that is plural given that we are a republic—will have to go back and forth when it comes to easing and tightening restrictions. But there is this danger that such decisions will be guided by total number of additional cases alone. This does not come as a surprise as the total is always the most easily comprehensible statistics available and it is the politicians’ wisdom making the decision. When putting statistics into context, a good starting point is analyzing data in proportions or ratios. Now the MOHP does provide a few of those—some directly, some requiring derivation—but they are seldom emphasized, or rather they take the backseat to other headline worthy numbers. One of such proportions is the percentage of total tests that come out positive.

We could easily deduce this number for the nation from MOHP data, but this is only helpful for smaller administrative regions, namely provinces, districts or grouping of districts—Kathmandu, Lalitpur and Bhaktapur—for instance. One of WHO’s guidelines regarding easing of restrictions advises governments to ensure that the rate of positivity be less than five percent for two consecutive weeks before reopening. Let’s forget about the WHO threshold for a bit to focus on why the percentage of positive tests makes an important metric. Not only does this number suggest the relative risk of getting infected with the virus, it also helps us know if adequate number of tests are being carried out. In order for the positivity rate to be low, either the number of infections would have to be low, and/or the number of tests would have to be high. This means that if a good proportion of tests from a particular place comes out positive, even though it might look scary, chances are that the number is a result of limited testing. Positivity rate is one of a few other important metrics that can help our leadership make better decisions. This brings us to the issue of implementation and assessment of policies being undertaken.

The problem with our country’s approach is that we never set a target with which we could measure our performance. We went on implementing strategies with no clear goal in sight. It is obvious by now that the total number of cases is not going to approach zero even after a good few months or, more likely, a year or two. The number doesn’t even have to be zero, aiming for a total number of cases to be under a certain margin at this point—with how the testing is going forward—is pointless. Additional cases are going to pile up. We are not nearly testing enough number of people to know where we are on the curve. There’s a chance that the infection is already rampant—especially in a highly dense city like Kathmandu—and taking 10-15k tests nationwide daily merely reveals catch up statistics. And this is where it gets tricky. Over the past few months we have been hearing demands for more testing—and we can all agree with the legitimacy of such demands. But how much is more? Nobody knows the answer to that. And virtually no “expert” wants to venture an estimate—like the ones in other countries have.

Under these circumstances, we could either copy the WHO guidelines verbatim—which would most likely see us fail given our circumstances and efficiency track record—or we could make adjustments to it based on our demographic variables, health care resources and administrative/testing abilities. This would still require experts to step up, and CDOs—positions which should have been long rendered obsolete—to step aside when making decisions.

The number of tests that come out positive is just one metric that is used in conjunction with a few others—percentage of hospital beds that are unoccupied being another important one. But, in any case, all statistics should come with a disclaimer about what it does and does not show. There’s no hope for social media to adhere to these guidelines but mainstream media venturing beyond the superficial stats to add a paragraph should not be that big of an ask.

At this point, emphasizing on additional and total cases without providing any context will mainly serve to spread panic, and using them to inform judgment will see us locking down into perpetuity. And since we already used that strategy for a good few months—with no avail—sustaining it further, without any relief package will call for a big sacrifice from the country’s most economically vulnerable. Besides, there are factors that might make lockdowns not nearly as effective as one would ideally want. We cannot enforce a lockdown like China and we are not spread out like advanced countries in the West—not even houses can maintain the six feet social distancing rule let alone the people. Kathmandu, for instance, is one of the most densely populated cities in the world—with many private buildings literally leaning on each other.

You can see people interacting in neighborhoods for different reasons—some professional, some personal. On top of that, it would seem as if every person either knows someone, or knows someone who knows someone who has a pass and is moving around places. To make things more challenging, festival season is fast approaching and we belong to a culturally diverse nation and observing many of the traditions require social gatherings. And no matter how much anyone tries to impose righteous decision making, it is naïve to expect that faith and devotion will fall back into retreat for long. It is perhaps time to reconsider our strategy based on our social, cultural and demographic realities. But in any case, we will need to set targets, not in the form of adjectives but in the form of numbers. The right numbers.