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COVID-19 spirals out of control in Nepal

Surging caseloads, spiking mortality rates, and supply shortages threaten one of India’s neighboring nations.

National Geographic


Just before midnight on Sunday, Anup Bastola—chief consultant for Nepal’s Ministry of Health and Population, lead doctor at Sukraraj Hospital in Kathmandu, and the man who identified Nepal’s first-ever COVID-19 patient a year ago—felt, for the first time in his career, completely helpless.

Sukraraj transformed Sunday from an overloaded hospital into a nightmare of triage. Bastola arrived home from duty only to learn that six more patients were failing—six more for whom he could not find ventilators or ICU beds.

“These patients, they are fighting for their lives,” said Bastola over the phone. One of them was trying to breathe 56 times per minute, like a marathoner approaching the finish. “They will fight for one or two days. But they need ventilators. And tomorrow, the number who need ventilators will increase.”

India’s crisis shows how oxygen is a vital medicine not everyone can access. Bastola and his colleagues at Sukraraj led the Nepal healthcare system in treating Swine flu in 2009 and the dengue outbreaks of 2016, 2017, and 2019. They were the primary line of defense during the cholera outbreakthat followed the 2015 Gorkha Earthquake, and the first to treat cases during Nepal’s first wave of COVID-19. But none of those crises prepared them for this one.

“This is not like the last wave, okay?” said Bastola, his voice straining with emotion. “It’s really a disaster this time.”

Surging deaths and supply shortages

The world is watching India, where last week alone the government reported 27,157 deaths from the virus. But on Sunday, Nepal surpassed India’s per capita death rate—and mortality rates continue to spike. The 88 deaths in Nepal on Sunday represented a 52 percent increase over the previous daily high. On Monday, the figure jumped again, to 139 deaths, and on Tuesday to 225 deaths.

In response to India’s devastating COVID-19 wave, tens of thousands of migrant workers have fled north across India’s 1,100-mile open border with Nepal, bringing highly contagious strains of the virus with them. Nepal depends upon its wealthier neighbor to the south for nearly all medical resources. Now, with India strapped for supplies, Nepal is facing desperate shortages of oxygen, ventilators, and other critical equipment.

“The basic requirements for the hospitals, the basic requirements for the health workers, cannot be addressed right now within the country,” said Samir Adhikari, joint spokesperson of the Ministry of Health and Population. Describing Nepal’s health system as “paralyzed,” he said “right now, health authorities are helpless.”

Nepal currently has only 1,127 ICU beds, 1,555 high-dependency units (adjacent to intensive care), and 453 ventilators for its population of 29 million—fewer per capita than India. The country does not have the resources to produce its own oxygen, and it has not received oxygen shipments for more than two weeks due to border closures and India‘s crisis. Some hospitals are now unable to make use of their already insufficient bed capacities due to oxygen shortages.

“Compared to India, our situation is much worse right now,” said Roshan Pokhrel, chief specialist for Nepal’s Ministry of Health and Population. “Our health system has gone down. We cannot take more cases.”

Yet there are so many more cases to take. The daily caseload continues to increase, reaching a record 9,483 on Tuesday—and officials say these numbers gravely underrepresent the current rate of infection.

“Most people don’t want to get tested, because they know there aren’t beds available,” said Bishwo Shrestha, lead consultant of the COVID-19 management team at Kathmandu’s Star Hospital, where people waited more than six hours in crowded holding areas last Tuesday for PCR tests.

“Every alternate family I know is COVID positive right now,” said another doctor, estimating based on reported symptoms rather than test results.

The share of tests that are coming back positive has continued to increase and now stands at 50 percent nationwide, more than double India’s peak rate. With care becoming unavailable even to those who need it most, testing will likely continue to stagnate, and the number of positive tests will increasingly underestimate the true number of Nepalis with COVID-19.

Viral strains spread quickly

In Kathmandu, where infection and death rates are currently highest, the hallways and courtyards of hospitals are turning into emergency wards. Doctors are telling desperate callers to stay home.

“All the beds are packed,” said Bastola. “Every emergency room is full now. I get a lot of calls for ICU beds. My answer is, ‘I don’t have any.’”

“This is a war-like situation,” said Shrestha, who is now receiving roughly 300 calls per day from people searching in vain for available hospital beds. “I got a frantic call from one consultant radiologist looking for a bed for his sister. The sister died in the ambulance. And he says his sister died in the ambulance because I couldn’t pick up the phone. The situation is like that.”

Health officials and doctors attribute the severity of this second wave in part to the mildness of the first. Nepal imposed a strict four-month lockdown last spring and summer; while fewer than 2,000 Nepalis died from the virus in 2020, the economic costs of the lockdown proved crippling.

“I often think I will die of hunger before corona kills me,” an unemployed mountain porter told the New York Times in November.

“The experience of the previous wave created rumors that health workers were just crying wolf, and that the situation is not so bad,” said Adhikari.

Since the last wave—which peaked from mid-September to mid-December—public precaution has lapsed to dangerous lows, according to doctors and health officials. In mid-April, as cases in India were spiking, Nepal’s former royals—King Gyanendra and Queen Komal—along with more than 50,000 Nepali pilgrims traveled to Haridwar in Northern India for Kumbh Mela, a Hindu festival that attracts millions. While there, the former king and queen caught COVID-19.

“When they returned home, they brought the virus with them,” said one official.

Health experts say the virus strains now spreading through Nepal appear significantly more contagious and deadly than those of the last wave. While Nepal doesn’t have the capacity for frequent sequencing, the B.1.1.7. strain from the U.K. has been found, and officials are certain that the B.1.617 strain—which the World Health Organization classified Monday as a global “variant of concern”—has made its way from India, as well.

“Initially, what we had seen was one or two family members infected,” said Pokhrel, referring to the last wave. “But now, the virus is infecting all family members and leaving only one or two behind.”

Doctors are also reporting more infections of young and otherwise healthy patients now than during the last wave. Although most healthcare workers in Nepal have been vaccinated, many fear getting sick on the job and dying without care.

“You are always exposed,” said Nil, a physician who asked to withhold his full name so his family wouldn’t worry. “You are so afraid if you cough a single time on duty. ‘Maybe I will not see tomorrow. Maybe something will happen overnight.’”

On the brink of disaster

So far, Kathmandu Valley—the site of Nepal’s capital and international airport—has been hit hardest, but health officials fear the spread of the virus to rural areas, where medical resources and testing facilities are even more scarce than in the capital.

Nepal is now on the brink of an unprecedented disaster that can only be mitigated by foreign aid, according to doctors and health officials.

“The number of COVID cases is increasing,” said Bastola. “Mortality will increase because of unavailability of ICU beds and ventilators. We don’t have any idea where to send patients, or what to do next.”

“The people who got tested yesterday will worsen after about one week,” said Adhikari. “And after one week, if we do not have capacity to manage the worsening cases, these people will not get any support from any hospital or health workers. That means they will die.”

Doctors and officials say that next steps should include shipments of oxygen and ventilators, aid with healthcare financing, and the development of a telecommunication system to allow healthcare workers to advise those who are caring for sick family members at home.

The Ministry of Health and Population submitted a request Monday to international development partners for seven oxygen generation plants, 900 ventilators, and 300 makeshift hospital and screening tents, along with other critical equipment. They also asked for 7,000 body bags to be delivered within the next 15 days.

“There is a real battle going on in Nepal,” said Bastola. “International collaboration is needed now.”

Dear Patients / Colleagues,

National Geographic documents heart wrenching stories from ordinary Nepalese families to those of the health care workers who are having to cope with a health crisis, the like of which has never been seen before in Nepal whilst the focus of the world's attention is on India, it's much richer and populous cousin. There is another much greater humanitarian crisis gathering pace from an unstoppable tsunamic wave of Covid infections in neighboring Nepal.

Recently, Nepal has surpassed India's per capita death rate-and mortality rates continue to spike.

The situation in Nepal has been greatly exacerbated by the tens of thousands of migrant workers who have fled North across India's 1,100 mile open border with Nepal, bringing highly contagious strains of the virus with them. Nepal faces severe shortages of oxygen, ventilators and other critical equipment.

The National Geographic article outlines just how desperate and precarious the Nepalese health care system is with only 1,127 ICU beds, 1555 high dependency beds and 453 ventilators for its population of 29 million people. Furthermore, Nepal does not have the capacity or resources to produce its own oxygen and has not received any oxygen shipments for more than two weeks.

The Kathmandu Valley has been the hardest hit where it currently has the highest infection and death rates by comparison to the rest of Nepal. Hallways and courtyards of hospitals have been turned into emergency wards. Doctors are advising patients to stay at home since there is nowhere to put these ill patients. Health workers often describe these conditions as a ‘war like situation’.

Health experts say the virus strains now spreading through Nepal appear significantly more contagious and deadlier than those of the milder first wave of pandemic infections. Another exacerbating problem is that Nepal doesn't have the capacity for frequent genomic sequencing of the virus and therefore has major problems in keeping track of the variants affecting its population.

Fortunately, most of the Nepalese health care workers have been vaccinated but doctors are now reporting more infections in young and otherwise healthy patients during the current wave of infections.

The article reports many heart-breaking stories from the ground of families affected by COVID, unable to find medical assistance and unable to gain access to hospital care whilst on the other side of the glass looking through the window of health care, the doctors, nurses and paramedical workers struggle to cope with an overwhelming health crisis, the like of which they have never faced before, trying to cope in the face of adversity and provide care as best they can. The final cry of the Nepalese is that “there is a real battle going on in Nepal where international collaboration is needed now.”

This is an emotive 10 minute read about a forgotten people by an otherwise distracted world.

Doctor Donald Greig


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