Combating COVID-19 in Nepal

ProtoStar’s efforts to help fight the Coronavirus pandemic in Nepal has been focused on assisting the Humla District Hospital in setting up quarantine facilities, isolation wards, and an intensive care unit (“ICU”).  This initiative occurred in two phases: (1) $10,000 USD to purchase medical instruments and personal protective equipment (“PPE”) needed for a 30-bed quarantine facility and an eight-bed isolation unit; and (2) $22,000 USD to acquire non-invasive ventilators and other essential medical equipment to establish a new three-bed ICU.  Such a grant is assisting the hospital in its efforts to limit the spread of the Coronavirus and to treat patients with COVID-19, the disease that is caused by the virus.  This initiative is essentially a public-private partnership, as ProtoStar’s grant supplements the funding pledged by the Karnali Provincial Government.

Background

The Humla District

Nepal is divided into seven provinces, each of which in turn has various districts.  One of these provinces is the Karnali Pradesh Province.  The Humla District is one of ten districts in the Karnali Province.  It is situated in the northwestern part of Nepla, just south of the Tibetan region of China.  The Humla District is perhaps the most remote and poorest district in all of Nepal.  Its total population is estimated to be around 59,000 people.  It is the last district to be linked to the national road network, although construction is underway to connect the Karnali Corridor to Simikot.[1]  In order to reach Humla from the capital city of Kathmandu, one must first take a flight to Neplagunj in the southwestern portion of Nepal, stay overnight, and take a morning flight to Simikot.

Delivering health care to remote parts of Nepal, such as Humla, has always been a big challenge.  Because the villages are scattered throughout these rural areas, the nearest hospital is often a long distance away.[2]  In order to reach the many remote villages, the district hospitals would typically set up various outposts.  For some villages, the nearest outpost could be as far as a two-day walk.[3]  Moreover, these outposts have limited staff and supplies and thus could only attend to relatively minor injuries and illnesses.  Anything more serious would have to be referred to the main district hospital for further diagnosis and treatment.

Humla District Hospital

There is only one public hospital facility that serves the entire Humla District – the Humla District Hospital.  The hospital was established in the 1990s when Nepal extended primary healthcare facilities to more rural areas.[4]  It has fifteen beds for inpatient care, but lacks adequate medical equipment and supplies.  Over the years, it has set up 26 outposts.  As with many other districts in Nepal, the Humla District Hospital and its outposts are often underequipped and understaffed. 

Impact of COVID-19 on Humla’s Healthcare System

The COVID-19 pandemic has put additional stress on the already overstressed, under-staffed, and under-equipped healthcare system in Nepal generally and in Humla specifically.  A regional newspaper in Nepal recently observed that like many other countries, including even the U.S. and European countries, “Nepal’s existing hospitals are also desperately short of ICU beds and ventilators.”[5]  Noting that 12 people in Humla had already died of the flu in 2019, the newspaper pointed out that the Karnali Province (of which the Humla District is a part) lacks the resources to deal with the COVID-19 pandemic, writing:

Even though its government has announced an all-out effort to stop the spread of COVID-19, the Karnali Province is facing an acute shortage of doctors and medicines.  People in the province are going back to villages from urban centers, hoping to save themselves from infection.  But they get more worried when they get to the villages and find that even basic medical facilities are missing. . .  Although the district hospitals have set aside isolation rooms, they lack basic equipment to identify and treat COVID-19 patients.[6]

As with other nations, Nepal also faces the lack of reliable and accurate tests for COVID-19.  The Humla District Hospital had initially received a shipment of COVID-19 rapid test kits, but they turned out to be unreliable and inaccurate.  It has stopped using the rapid test kits and could only base its decisions on whether a patient is a “COVID-19 suspect case” or not.  The lack of reliable and accurate tests may explain why the number of “official” COVID-19 infections and deaths reported by Nepal has been relatively low.

Phase I: Quarantine Rooms and Isolation Wards

To limit the spread of the Coronavirus and provide better care for patients with COVID-19, the Humla District Hospital has put in place various measures, including setting up quarantine and isolation units to separate the suspected COVID-19 patients from the nonCOVID-19 patients.  Dr. Tashi Anjuk Lama, Humla’s Medical Superintendent, wrote:

A key challenge is the additional manpower, equipment and infrastructure required to deal adequately with the situation thus preventing the pandemic from getting out of hand.  [Humla] District Hospital is planning not only for the short-term but also focused on the control measures needed for the longer-term.  We are trying our best to tackle this pandemic taking every measure to prevent the spread of this virus in this remote place of Nepal.  At the same time we are also focusing on treating the COVID-19 cases by setting up 8 bedded isolation ward and strengthening laboratory facilities in this remote place.

The Humla District Hospital concluded that its 15-bed facility did not have enough space for quarantine rooms and isolation wards.  Accordingly, it is temporarily leasing two lodges about a kilometer away: one with 30 rooms for COVID-19 quarantine units and another with 10 rooms for isolation wards to treat suspected COVID-19 patients with mild- to moderate symptoms.

Medical Devices and Personal Protective Equipment (PPEs)

Towards this end, ProtoStar made a $10,000 USD grant to the Humla District Hospital in May 2020, so it could purchase the following items for the quarantine rooms and isolation wards:

Multi-Parameter Patient Monitor (2). This machine is a vital piece of equipment that every hospital must have.  It provides multiple information about the patient, including body temperature, heart rate, pulse rate, respiration, carbon dioxide levels, etc. – hence the term “multi-parameter.”

Oxygen Concentrator (2). This device delivers a high concentration of oxygen to patients who are not getting enough oxygen in their blood streams because of respiratory difficulties, such as those caused by COVID-19.  The device filters the surrounding air, compresses the oxygen, and delivers it to the patient.

Semi-Autoanalyzer (1). This is a diagnostic equipment that performs tests on blood, serum, plasma, cerebrospinal fluid, and urine samples.  The availability of a semi-autoanalyzer would allow the hospital to quickly and accurately make certain diagnosis on premises, rather than having to send the samples to a laboratory in Kathmandu and wait days or perhaps even weeks for the results.

Coulter Counter (1). This apparatus is used primarily for counting red and white blood cells.  Again, having this device on premise would drastically reduce the amount of wait time for lab results and allow the hospital to make a proper diagnosis quickly and efficiently.

Infrared (IR) Thermometers (5). Infrared thermometers are an obvious essential tool in dealing with COVID-19 so that the hospital could instantaneously detect whether a patient walking into the hospital has a fever and monitor the temperature of those who are already admitted.

Personal Protective Equipment (PPE). The hospital has a shortage of PPE and needs to maintain an adequate stockpile to protect its own healthcare workers.  The need for an ample supply of PPE to protect all of the doctors, nurses, and other healthcare providers is well known and cannot be overstated.  These are the brave individuals who are risking their own health (and those of their families) to save others.

Phase II: Intensive Care Unit

In December 2020, ProtoStar committed an additional $22,000 USD to assist the Humla District Hospital in setting up a new three-bed ICU.  The hospital needed an ICU for both COVID-19 cases and other serious illnesses.  The ICU will also have utility beyond the pandemic.

It is remarkable that the Humla District Hospital has been functioning for so long without the capacity to treat intensive care patients, but must refer them to hospitals in the capital city of Kathmandu.  It is almost unimaginable how a patient needing ICU care could even survive such an arduous trip – a trip that, as discussed, typically requires taking a flight from Simikot to Nepalgunj and another from Nepalgunj to Kathmandu on decades-old, small propeller airplanes that are constantly tossed around by the often severe turbulence over the mountainous terrain.

Accordingly, the Humla District Hospital urgently needed to set up an ICU.  ProtoStar’s grant was used to purchase basic medical equipment and supplies for the ICU, as well as one or more non-invasive ventilators.  The grant did not include the invasive ventilators, which is far more expensive and which the hospital is requesting from the Nepal Government.  (The difference between invasive and non-invasive ventilators is discussed below.)

Utilization of the quarantine and isolation facilities since they were established at the hospital in May has been relatively high.  The hospital saw about 23 patients with COVID-19, all of whom were placed in the isolation wards.  Of those 23 cases, one took a turn for the worse and was referred to a better equipped hospital in Kathmandu.

By December 2020, Nepal had, according to data compiled by The New York Times, approximately 249,244 confirmed cases of COVID-19 and 1,716 reported deaths that were attributed to the Coronavirus.  However, as discussed earlier, it is generally believed that the actual numbers in Nepal may be substantially higher because of several factors, including the shortage and unreliability of COVID-19 testing, general lack of access to an already inadequate healthcare system, reluctance of many villagers to seek proper medical attention, and a generally inefficient system of medical reporting.

In order to treat COVID and non-COVID patients in the ICU, a hospital needs not only invasive ventilators, but also emergency equipment and supplies, as well as adequate staffing.  The Humla District Hospital had already requested that the Karnali Provincial Government provide about $85,000 USD for ICU training and to purchase invasive ventilators and an arterial-blood gas (ABG) analyzer.  The hospital asked ProtoStar to fund the supplemental medical equipment and supplies needed to operate the ICUs properly, as well as one or more non-invasive ventilators.  As with ProtoStar’s prior $10,000 USD grant in Phase I, this grant was also a de facto public-private initiative.

ICU Equipment

High Flow Nasal Cannula.  ICU patients in severe respiratory distress have an inspiratory rate that is very high.  Under these circumstances, a traditional nasal cannula would not be adequate because it does not deliver a high enough flow of oxygen to meet the needs of the patient in distress.  A high flow nasal cannula is a heated and humidified system that can deliver oxygen at much higher flow rates and can be adjusted to precisely meet the respiratory needs of the patient.

BiPAP and CPAP Machines.  BiPAP stands for Bilevel Positive Airway Pressure, which means that it can deliver pressure for both inhalation and exhalation.  BiPAP is distinguished from CPAP or Continuous Positive Airway Pressure, which delivers a single pressure to the back of the throat to keep the airways open.  Both are typically used for sleep apnea and a variety of chronic respiratory illnesses, such as COPD, and are now being used also for COVID patients with serious breathing difficulties.  They are used only when the patient is able to breathe on his own.  The BiPAP and CPAP machines are considered non-invasive ventilators because they require only a breathing mask, which covers the patient’s nose and mouth.  They are different from the invasive ventilators, which are used when the patient has extreme difficulty breathing on his own.  The invasive ventilators require the patient to be intubated, anesthetized, sedated, and in some severe cases placed in a medically-induced coma.

Multi-Parameter Patient Monitor (MPPM).  As discussed above in connection with Phase I, the MPPM is an important piece of equipment that monitors a patient’s vital signs, and the hospital should have one MPPM for every bed.  ProtoStar’s grant in Phase I increased the number of MPPMs from three to five for its eight-bed isolation wards.  The hospital requested an additional MPPM for its three-bed ICU.

Olympus Microscope cx 23.  This biological microscope will enable the hospital to examine patients’ specimens onsite and make diagnoses quickly and efficiently.

Blankets, Mattresses, Bed Sheets, and Pillows.  Extra mattresses and bedding are, of course, needed for the ICU beds.

Patients Waiting Room Long Chairs.  The hospital needed a couple of long chairs in the waiting room for family members and friends of the ICU patients.

Nebulizer Machine, Breathing Mask, Nasal Prongs.  A nebulizer turns liquid medicine, such as albuterol (for asthma), steroids, and antibiotics, into a fine mist that could be inhaled.  As COVID-19 is a respiratory illness, a nebulizer is an efficient way to deliver needed medication directly into the lungs.  The mist may be inhaled using either nasal prongs or a breathing mask specifically designed for the nebulizer.

Personal Protective Equipment (PPE).  PPE is an ongoing need for these brave frontline healthcare professionals who are risking their own health and lives (and those of their families) to save others.

ProtoStar’s COVID-19 Relief Fund for Nonprofits

The Humla District Hospital clearly met the criteria for funding from ProtoStar’s Relief Fund for Nonprofits, as it is a governmental facility with net assets of well less than $250,000 USD and net revenues of less than $100,000 USD in 2019.

Social Impact

The Humla District Hospital is the only hospital in a district with a population of about 59,000 inhabitants.  It goes without saying that the life of each and every one of those residents is precious and invaluable.  Moreover, once the travel restrictions are lifted, visitors will start coming to Humla again for such activities as trekking, academic research, and pilgrimage to circumambulate Mount Kailish.[7]  The hospital needed to have adequate equipment in the event it had to isolate or quarantine any person suspected to be a COVID-19 case and, if necessary, provide them with proper treatment in the ICU.

This grant assisted small nonprofit organizations during the COVID-19 pandemic and furthered ProtoStar’s interest in Socioeconomic Justice.

 

[1] Kunga Hyolmo, “Simikot to Get Connected to National Road Network Soon,” My República (December 21, 2019).

[2] Rebecca Solnit, “Medical Mountaineers: Delivering Basic Care to the Remote Himalayas,” The New Yorker (December 14, 2015).  This article discussed Dolpo District, which “is as materially poor as it is culturally rich.”  That characterization is an apt description of Humla as well, perhaps even more so.

[3] Jocelyn Poweson, “Life and Livelihood in Remote Nepal,” Nepali Times (September 28, 2018) (describing the village of Maspur in Humla).

[4] Dr. Babu Ram Marasini, “Health and Hospital Development in Nepal: Past and Present,” Journal of Nepal Medical Association (Vol. 32:  306-311) (2003).

[5] “Nepal and coronavirus: Does the Country Have a Long-Term Plan to Deal With Pandemics?”, The Annapurna Express (March 24, 2020).

[6] “Corona in Karnali: A Case of Missing Doctors and Drugs,” The Annapurna Express (March 26, 2020).

[7] Mount Kailish, located just to the north of Humla in Tibet, is sacred to several religions: Bön, Buddhism, Hinduism, and Jainism.  See Robert Thurman & Tad Wise, Circling the Sacred Mountain: A Spiritual Adventure Through the Himalayas (Bantam Books 1999).  Trekking from Simikot is one of several ways to get to Mount Kailish.