Hoping for the best while preparing for the worst has been the theme of all medical institutes around the world, especially in counties that are yet to be hit by the dreaded tsunami of overwhelming COVID-19 cases. We have 191 positive cases 153 of which are in the hospital being treated and 33 have recovered. Fortunately, there have been no mortalities till date.  The current statistic may not look dreadful given the large numbers that we are exposed to daily these days. Before the cases reached 100, most Nepalese wondered, sometimes boastfully, why the cases are not spreading like wildfire. People went on record, crediting our culture of greeting with Namaste instead of a handshake, eating with hand instead of a spoon – which necessitates handwashing at least 4 times a day, the hygiene hypothesis, the fact that our country has only one international airport, and the universal coverage of BCG vaccination in Nepal. There are too many biases and heuristics at play here, but somewhere inside, I want to believe that at least some of them are true.
The Sukraraj Infectious and Tropical Disease Hospital (STIDH) in Teku, Kathmandu has been designated by the Government of Nepal (GoN) as the primary hospital along with Patan Hospital and the Armed Police Forces Hospital in the Kathmandu Valley. The Ministry of Health and Population (MoHP) has requested the 25 hubs and satellite hospital networks across the country – designated for managing mass casualty events – to be ready with infection prevention and control measures, and critical care beds where available. The Government is allocating spaces for quarantine purposes throughout the country and some sites have already been populated by migrants who recently returned from India. 
We have seen healthcare systems that are multi-fold advanced than that of our crumble when faced head-on with this illness. After working in the healthcare system of my country for 2 years, I am convinced that it will take a miracle for us to deal with this pandemic.
I have seen what preparations we are striving towards and what portion of it has been achieved. We are struggling to reach our preparation goals. That is not nearly as frustrating as the fact that many countries whose baseline was our goal have failed terribly. Today keeping the theme of workarounds rather than complaints about things outside of our circle of influence, I am presenting to you some preparatory works being done at Beltar PHC, a peripheral center located in one of the most affected districts, Udayapur, of Nepal. 
Credit, where credit is due: We have done 17878 RT-PCR, and 58546 RDT to find 191 positive cases till May 12, 2020.  We came up with a protocol and are also gradually updating it to meet the contemporary need. Funny word that contemporary is, especially now that no information gets to age before a new one replaces it. Speaking of temporary, a very recurring theme these days, there are temporary shelters made at every ward level in Beltar. People returning from abroad are kept in isolation for 14 days there. We run a temporary fever clinic at the PHC and refer suspected cases to higher centers for the COVID-19 test. We don’t have rapid diagnostic kits at the PHC yet. Our PHC with 26 staff has received 13 disposable PPEs that we have had the privilege of reusing. There is an Interim reporting form for suspected cases of COVID-19 (based on WHO Minimum Data Set Report Form) which can be downloaded and filled from the MOHP website. 
Lockdown was announced in Nepal on March 24, 2020. Excerpt from WHO Director-General’s opening remarks at the media briefing  on COVID-19, 25 March 2020 says this: “Asking people to stay at home and shutting down population movement is buying time and reducing the pressure on health systems. But on their own, these measures will not extinguish epidemics. The point of these actions is to enable the more precise and targeted measures that are needed to stop transmission and save lives. We call on all countries who have introduced so-called “lockdown” measures to use this time to attack the virus. You have created a second window of opportunity. The question is, how will you use it? There are six key actions that we recommend:
- Expand, train and deploy your health care and public health workforce;
- Implement a system to find every suspected case at the community level;
- Ramp up the production, capacity, and availability of testing;
- Identify, adapt and equip facilities you will use to treat and isolate patients;
- Develop a clear plan and process to quarantine contacts;
- Refocus the whole of government on suppressing and controlling COVID-19.”
In Nepal, there has been documentation of protocol for various aspects of the pandemic; PPE for each level of care has been decided, need to scale up the testing recognized, and even the support for Solidarity trials discussed. The protocol designed to tackle COVID-19 recognizes that different strategies for the rural and urban areas are necessary. The response to outbreaks in remote and rural areas where containment may be easier though assistance more difficult vs. outbreak in urban locations where containment is likely more difficult, but treatment and assistance likely to be easier.
The mist of immediate threat followed by the rubble of destruction it causes keeps us blind to the problems lurking in the background. As big and dangerous, if not bigger. Especially when you know nothing even vaguely similar to CARES-Act is being prepared for dampening the direct and indirect economic impact of the epidemic. Add to the fact that the American government’s CARES-Act already faces various criticism—that gives birth to anxiety for even the most seasoned economists. That is looking at just one domain of the post epidemic future. Healthcare might be crippled, social structure tossed over, politics somersaulted and people stripped off their faith. That may give rise to a jigsaw too complicated to attempt. It is high time we start thinking about solving some of those puzzles now.
1. Corona Info. Ministry of Health and Population. Accessed May 12, 2020. https://covid19.mohp.gov.np/#/
2. COVID-19 Nepal preparedness and response plan (NPRP) draft. April 9. Accessed May 10, 2020. https://www.who.int/docs/default-source/nepal-documents/novel-coronavirus/covid-19-nepal-preparedness-and-response-plan-(nprp)-draft-april-9.pdf?sfvrsn=808a970a_2
3. Reporting form for COVID. Accessed May 12, 2020. http://edcd.gov.np/resources/download/reporting-form-for-covid
4. Situation reports on COVID-19 outbreak, 25 March 2020. WHO | Regional Office for Africa. Accessed May 12, 2020. https://www.afro.who.int/publications/situation-reports-covid-19-outbreak-25-march-2020