Lockdown and immediate priorities for COVID-19 in Nepal: a case for LMICs
By Shyam S. Budhathoki – Imperial College London, Lila B. Basnet – BP Koirala Institute of Health Sciences, Nepal and Pradeep Khatiwada – BP Koirala Institute of Health Sciences, Nepal
People undoubtedly had their plans for the spring. At the beginning of the global outbreak that started in China, only a few imagined it to take the current shape of the global pandemic. In Nepal, locked up at their abode, some cannot wait to get out, while others don’t really want to, enjoying their private sanctuary using the internet as a window to the outside world. Some are losing their nerves over the virus and others, instead, are more occupied with the ongoing Indo-Nepal border crisis, brutal caste-related acts of violence, and other regular political melodramas.
Initially, China adopted the strategy of shutting down a town for a certain period to isolate the virus in Wuhan, Hubei Province. Later, other countries urgently adopted the idea of locking down its inhabitants, hoping to prevent the spread. Lockdown is currently looked upon as the panacea to this pandemic by most countries, with world media questioning what the situation would be now if only lockdown had been imposed earlier.
Dangerous ‘one-size-fits-all’ trend
Like its terrains and time zones, countries also differ in demographic, economic, social, and cultural facets. China and Italy, with 13% and nearly 23% population over 65 respectively, were not unwise on imposing this severe restriction to extenuate the spread of disease and avoid overwhelming their health system. When the disease crossed borders, other countries started to employ the same strategy urgently. Nepal, with just 5.7% of its population over 65 and India with 5.18% over 65, has been under lockdown for more than two months, though differing from Europe and China in many aspects. This difference in age demographics vastly impacts the outcome of COVID-19 infection as mortality is seen high above the age of 55 years.
For low- and middle-income countries (LMICs), the relative benefits of lockdown may be more limited and are easily exceeded by the demerits. Besides the impending economic toll, countries with more than a quarter of population below the poverty line and an unrecorded number of daily wage workers, the problem is already visible. Lamentation of starved daily wage laborers with kids walking miles to reach faraway village homes reflects it all. With limited savings, many more are on the same course of impending doom. Also, with an urbanization rate of just 19.75% in Nepal compared to an average of 74% in Europe, strict lockdown may not be appropriate in this context.
The effectiveness of lockdown is itself in question. Many settlements lack taps and sewers. According to the latest estimates, 22% of people in urban areas (153 million people) lack access to handwashing in Central and South Asia. And nearly half of urban Bangladesh (29 million people) and 20% of urban Indians (91 million), lack basic hand washing facilities at home. People must gather to collect food, water and even to excrete it all. Cooking gas in Nepal is not supplied through a pipeline and neither is there a functioning home delivery system for essential goods. Even 16% of health care facilities lack hand hygiene facilities. Lockdown is not enough – large-scale testing, contact tracing, social distancing, and proper health care are all necessary to tackle this problem!
Mitigation measures in LMICs have not prioritized the poor when imposing lockdown. Low-income urban settlements of some of the big south Asian cities have high population densities and are potential COVID-19 hotspots . A single informal settlement in Mumbai, Dharavi has a population of more than 700,000 over just 2.1 square kilometers (Population density = 277,136/km2). With an average family size of 6.7 in Kathmandu – most living in a rented household sharing common drinking water tap, and toilets – lockdown is unworkable. With this level of infrastructure and overcrowding, combined with seemingly lackadaisical governance and infodemic, there is a grave need to introduce, implement, and strengthen newer options to complement the efforts of lockdown in Nepal.
The economic impact of COVID-19
To up the ante, there is another very different and much harsher reality waiting at the doors. Instead of foreign tourists flocking in to spend large sums of cash, Nepal will possibly have millions of now-unemployed nationals returning home from abroad. There are more than 3.5 million Nepalese currently living and working abroad, that’s one in every four households, whose employment and livelihood are at risk due to this pandemic. Take Qatar, for example, where 400,000 Nepalese youths are currently working, even outnumbering the Qataris themselves. Most international labor migrants from Nepal are in India, the Gulf region and Malaysia, employed in low wage work, like construction and domestic work. Remittance from them accounts for nearly 30% of the nation’s GDP, giving Nepal the fifth-highest remittances-to-GDP ratio in the world. It has already been estimated that Nepal will lose 145 billion Nepali Rupees of the remittance this year. As COVID-19 derails the world economy, nearly 500,000 to 700,000 Nepalese labor migrants are estimated to lose their jobs, with 2.5 million others in Nepal are estimated to be unemployed.
The Nepalese government was ordered by the Supreme Court and pressurized by employing nations to admit the estimated 35,000 Nepalese migrant workers in need of immediate repatriation. With reports of severely undermanaged and under-resourced quarantine set-ups, where social distancing is not possible, this risks spreading the virus to the country’s most vulnerable and isolated communities. There is a dire need for urgent alternative methods, strengthening collaboration with community-based organizations and public health experts.
A paradigm shift?
Recent evidence suggests that the eternal existence of this virus clearly mandates a paradigm shift. As a part of the world with the largest income inequality, a holistic approach encompassing every stratum of citizens should be sought. A lockdown for people in lower strata of society with ineffective preparation and blatantly wasting months after the pandemic was declared by WHO shows apathy and cruelty towards those sections of people who are considered manpower more than just humans. Constant preaching about staying at home and washing hands is not a solution. Just declaring the lockdown, deploying police on the streets and sealing the borders will not materialize the nonexistent houses, soaps or water for those without.
Looking at previous major pandemics, treatment alone was never the solution. The great European cholera epidemic was terminated by a public health movement run by community leaders over affected areas, spreading awareness of the importance of hand washing, hygiene, and boiling water. The same kind of intervention is what this situation demands, where people are taught proper hand washing techniques, use of protective gear with proper knowledge about household care of mild to moderate illness, and when to contact a hospital.
Leaving no one behind in the COVID-19 crisis
Guidelines inculcating best measures are put forward by health agencies in each country. However the implementation of these guidelines demanded adequate preparation and, for that, strong public health infrastructures pre-pandemic. The Nepal government has already spent nearly 10 billion Nepali rupees for mitigation measures during this pandemic. However, the annual budget announced for fiscal year 2020/21, with an increase by 31.8% in health sector, lacks a focus on rebuilding public health capacity.
Lockdown measures should not be taken as a one-size-fits-all solution. It is a mitigating measure while other preparations are to be made. And if nothing significant is being done while everyone is confined, what hope is there for the future? Authorities must listen to the people, even the smallest of news columns raising issues of basic struggles of people in lockdown, especially the poor migrant workers heading to their villages and families.
The real solution to the COVID-19 crisis lies again in the notion of ‘leave no one behind’.
