COVID Pandemic: A Reflection of Critical Health System

It all started on 12 December 2019, when a case of pneumonia of unknown etiology was detected in Wuhan City, Hubei province, China. However, the source of the virus is still controversial. As the china set an example, WHO then announced the lockdown, is only effective measure so far in control of mass spread of COVID-19. As per the footsteps of China’s lockdown, Low- and middle-Income countries (LMICS) like Nepal started national wide lock-down, but without proper vision and action was taken suddenly. Initially, Nepal treated COVID-19 outbreak as a distant threat. When the first case (a student coming from China) was found in 2nd week of January, the case was isolated and treated in the hospital but no interest was shown to track the contacts that he had made with others. The local jokes around the ‘supposed’ strong immunity of Nepalese to the COVID virus even caught on with government officials, who declared the country a “corona virus-free zone” and assured tourists of it to boost tourism campaign. Due to the open border of Nepal and India, there were already COVID cases being imported unknowingly to Nepal. As India already had rise in cases and was under nationwide lockdown, the daily wages workers started returning to their home. In fear of lockdown due to corona virus and market price of goods getting higher, people in Nepal started stockpiling the essentials, long queues outside the stores, shops were seen which may have resulted in spread and now sudden rise of asymptomatic cases of COVID-19 may be the reason of that. There is no denying that lockdown may have halted the virus spread, but without adequate planning and enforcement, they have cause devastating damage in health and economy sectors.

Stigmatization
Stigmatization of corona virus has got outrageous in Nepal. It is real and has negatively affected the population in seeking and accessing care. Patients who believe they are stigmatized against COVID do not seek care; others think they will become sick, and hence entire family and society of affected are prejudiced against it. Instead of being treated as the heroes as they deserve, healthcare workers are being discriminated, harassed, and being bait for violence, mainly due to unfounded COVID-19 fears. Patients too are getting targeted, especially asymptomatic patients who got tested positive or was ordered to stay in home quarantine by health department. Health workers working in local hospitals and laboratories which are assigned as COVID pandemic hospital are facing difficulties finding food.

Testing
Testing for COVID, Rapid Diagnostic Test (RDT) and Polymerase Chain Reaction (PCR) these two tests processes are being widely used to test the corona virus patients. Earlier in countries like Nepal RDT was widely used to test corona virus as directive from the Nepal’s the Ministry of Health and Population. However, this strategy was based on the poor research evidence and the method gave frequently inaccurate results.RDT can show false negative results in patients for up to a week after infection because their body has not produced sufficient anti-bodies to get detected. It takes at least 6 days for IgM and 15 days for IgG to develop after nCoV enters the body of the individual through respiratory tract which is why rapid tests conducted in the early stage of infection gave more negative results even if the individual is actually infected from nCoV. Unfortunately, the negative result individuals were regarded as healthy and were sent back home with no proper quarantine or isolation or monitoring. According to recommendation from WHO for countries the PCR is recommended for the COVID-19 testing because RDT cannot detect new infections.  As per this recommendation, later health experts in Nepal also started to advocate for the use of the more reliable PCR on a wide scale of testing. But there is scarcity of PCR test kits and reluctance of the government to buy PCR kits only persuaded RDT testing and more possibility of missing out true positives or potential positives rising the fear and confusion among its citizens.

Equipment for Front-liners
Meanwhile, even people wearing KN95 (equivalent facemasks as N95) and PPE while going out in public, there is no awareness of social distancing. The virus now regarded as an airborne, and also thought to spread mainly between people who are in close contact through respiratory droplets produced when an infected person coughs or sneezes and thus social distancing would come into play. The only thing that front-liners rely on is PPEs to protect themselves and patients from being infected and infecting others. But scarcity and spurious products of this stuff is leaving frontline workers dangerously ill-equipped to care for COVID-19 patients in Nepal. With no proper secured supply, and the deaf ear turned by government officials, the risk to healthcare workers in countries like Nepal is real and pathetic. There are lack of industries in LMICS due to lack of capital and so to compensate these, governments must act quickly to setup industries and boost the production in order to meet the demand of supply, because importing everything in these times will not help in any case. Due to negligence of concerned authority, front-liners are obliged to use raincoats as PPE, single layer KN95 instead of N95, face shields homemade of lamination plastics. Private hospitals, due to lack of capital are unable or simply not interested to provide optimal care to their frontline workers.

According to the Ministry of Health and Population Nepal (MoHP) for every symptomatic case they have tested, at least one is asymptomatic case; the discovery was made in recent weeks after lockdown was partially lifted and as Nepal ramped up testing. According to the infectious disease experts the asymptomatic cases have very few chances of spreading the contagion as they are not likely to cough and sneeze like symptomatic but there are still cases of spreading the respiratory disease to others living in infective circle of asymptomatic COVID carrier. This has been misinterpreted however on different occasions even by the WHO. With the rise in number of asymptomatic patients the MoHP in Nepal has issued notice to hospitals that those who have asymptomatic patients (mild or no symptom) should be sent home under the direction of home quarantine; so that hospitals can treat cases of COVID-19 with severe symptoms. In some COVID-19 patients show signs of the disease within 14 days and some develop symptoms after 21 days or even later as controversy are still alive but unknown in Nepal.

Front-liners
For physicians, the clinics or consultation rooms in Nepal are small and closed with lack of ventilation. So physicians have instructed supporting staffs to ask patients and patient’s party to maintain social distancing (2 meters mentioned by WHO) which is too difficult to maintain in here. Patients are told to well sanitize their hands and with face mask on before entering the OPD cabin. One patient one visitor rule is strongly pushed (but difficult implementing) as the social structure is different in  countries like Nepal where there comes the whole family with the patient for consultation and the condition of the patient is more concerned to the family members than to the patient himself.

The health sector however has been thriving, and the health workers have been doing their best to fight this pandemic as well as care the patients suffering from other diseases (acute or chronic) as well as protecting themselves as far as possible. The role of the government in raising public awareness, implementing rules, and providing safety and security to the health workers should be the priority.  Hence, proper attention of concerned authorities is required as after unlocking the second wave of symptomatic cases are arising.

Twitter : @DrAyushChandra

Email: 121withayush@gmail.com