“We couldn’t do anything,” said Shrestha, a physician and professor at Dhulikhel Hospital and Kathmandu University Hospital.

In Nepal, which shares a long and porous border with India, Covid-19 cases are surging. As bad as official numbers are, the reality is likewise worse. Testing, particularly in rural areas, is limited, according to Dr. Aban Gautam, president of the aid organization Mountain Heart Nepal.

Dhulikhel Hospital has been conducting free community Covid-19 testing in an effort to help gain control of the situation. Their positivity rate is an astonishing 60-65%, Shrestha said.

In general, said Andrew Schroeder, Direct Relief’s vice president of Research and Analysis, Nepal’s overall test positivity rate of approximately 44% “means they’re really only testing symptomatic people…That will mean that things are much more widespread than anything you have data about.”

The country is experiencing approximately 296 cases daily per million people as of May 18, compared to India’s 231. “It’s now overtaken India in terms of all the key metrics per capita in the current Covid pandemic in South Asia,” Schroeder said.

None of the 150 beds that Dhulikhel Hospital has designated for Covid-19 patients is currently available, Shrestha said, and “there is a pile of cases waiting for a bed in our emergency room.”

That’s the case all over Nepal, according to Gautam. “The problem we are facing now is mostly lack of hospital beds, particularly ICU beds, because of the increasing number of cases,” he said. “We are even getting the news that people are dying in ambulances, trying to get a bed.”

In addition, oxygen is increasingly hard to come by, Gautam said. People who can afford to purchase oxygen concentrators are disproportionately likely to have access to them, making them an increasingly precious resource. “People are dying from lack of oxygen,” he said.

A Changing Pandemic

The providers and aid organizations interviewed for this story all expressed particular concern for rural communities, where testing, masks, and oxygen are harder to come by.

“It’s a very mountainous and remote country, and getting care out to people in the remote areas is really challenging,” said Arlene Samen, founder and chief visionary officer of the aid group One Heart Worldwide.

That means, also, that getting sick individuals to much-needed – and scarce – hospital beds has proven difficult. Mountain Heart Nepal has been providing medical assistance to people being airlifted to a hospital bed, Gautam said.

Although Nepal is currently on lockdown, Shrestha said Covid-19 is spreading rapidly from urban centers to rural areas, as people lose employment in the cities and return to their homes in the villages.

“This lockdown will not help to break the chain of transmission,” he explained. Instead, more testing – which encourages people to stay in their homes and to seek medical attention – is needed.

In addition, where Nepal’s first wave of Covid-19 was particularly devastating for older adults, Shrestha is seeing more patients of younger ages succumb to the disease. He described losing five patients, of ages ranging from 20s to 40s, that same day. “They don’t have other comorbidities,” he said. “They just lost their life [to] Covid-induced pneumonia.”

Responding on the Ground

A Direct Relief-charted aircraft departed for Nepal on May 25, carrying 860 oxygen concentrators, along with PPE and medications donated by a number of corporate partners to meet requested needs. The medical aid will be distributed to several Nepal-based organizations, including Dhulikhel Hospital, One Heart Worldwide, and The Covid-19 Crisis Management Center. These organizations will distribute the donated support to Nepali hospitals and health centers.

Direct Relief’s partners on the ground are mounting their own ambitious responses. One Heart Worldwide will distribute medications and supplies on behalf of Nepal’s Ministry of Health and Population to the districts most in need of support.

Samen, who has worked closely with the Nepali government for years, said that the current situation reminds her of the devastating 2015 Nepal earthquake. “It feels like there’s that kind of chaos and overload on the health care system,” she said. “There’s just so many people dying, and they don’t have a place to put them.”

In addition to testing, Shrestha said, Dhulikhel is providing Covid-19 care to patients at its 18 rural health centers, where the hospital has set up isolation areas. Dhulikhel is also working with patients who are recovering from Covid-19 at home, providing medical counseling and psychosocial support.

“We have 20 dedicated people who are working day and night” to help patients recovering at home, Shrestha said.

Direct Relief will contribute a grant of more than $100,000 to fund a new oxygen plant that Mountain Heart Nepal is building to provide a reliable oxygen source for nearby hospitals and communities.

But Gautam points out that Nepal needs help now, and the oxygen plant will be ready in about two months. Mountain Heart Nepal is responding directly to the crisis, distributing PPE and medical equipment – including Direct Relief oxygen concentrators – to hospitals, and providing schools and rural communities with masks.

The organization’s doctors are providing medical for patients while they are airlifted to hospital beds. Gautam explained that the process primarily involves maintaining oxygen saturation, monitoring vitals, and making sure patients are hemodynamically stable. And for patients isolating after a Covid-19 diagnosis, they’re providing mental health support as well as directing them to much-needed resources, including food. They’re also providing food, prenatal vitamins, and IV fluids to vulnerable Nepali communities.

“It’s really important that we focus on those things as well,” Gautam said.

Shrestha didn’t shy away from the terrors of the pandemic. “I feel helpless,” he said. “People are deteriorating and losing [their] lives.”

But he grows more adept at treating patients as Covid-19 wears on – and it’s taught him valuable lessons.

“This pandemic taught me to be a human, a good human,” he said.

The post On the Ground, Fighting Nepal’s Covid-19 Wave appeared first on Direct Relief.

From rural communities to urban cities, patients struggle to make routine appointments. Some can’t afford a vehicle, others live hours, if not days, from the nearest point of care. The distance–and lack of transportation–leads to delays in medical care, which for some, can be deadly.

On this episode of the podcast, we explore how transportation poses a barrier to care for patients around the world, from rural Nepal to the United States, and what the consequences are for those in need of chronic care.

Direct Relief provides many local health organizations, including Casa de la Amistad in Mexico and Mountain Heart Nepal, with funding to purchase vehicles and provide transportation services to patients and health care providers. The organization has also provided funding for mobile health units that can be deployed to communities without regular access to health care or after a disaster, including rural communities in the United States.

Transcript:

Chronic conditions like diabetes, heart disease and cancer require routine care and strict medication regimens. But sometimes, getting to the doctor is the hardest part.

Five months ago, Rosa Hernandez moved to Mexico City with her son, Andry, who has been undergoing chemotherapy since being diagnosed with leukemia last year.  “La verdad ahora sí, necesitamos estar cerca del hospital,” she said.

Before the move, Rosa’s in-laws helped drive Andry to and from his appointments, but the constant travel became expensive and time consuming. Now, they’re living at Casa de la Amistad.

“My name is Leonardo Arana and I’m the general director of Casa de la Amistad Niños for cancer in Mexico.”

Casa de la Amistad is a full-fledged support center for pediatric cancer patients and their families.

“They will come to Casa de la Amistad here in Mexico city and we will take care of everything. We will take her of the medicines, housing, and transportation, which is very important,” explained Arana.

According to a study by the American Association for Cancer Research, 38% of cancer patients in Mexico report transportation as a barrier to timely care.

Most cancer treatment centers are located hours if not days from rural communities. For those undergoing consistent treatment—like chemotherapy–the distance is a problem.

“Cancer needs to be treated in years, over years. That that’s the way it has to be. So if you bring somebody once and then you don’t give them the possibility to go back they will die.”

Across the globe, in Nepal, a rural population experiences similar challenges. “In Nepal, healthcare facilities are mostly concentrated in urban areas,” explained Dr. Aban Goutam, the founder of a non-profit health care organization, Mountain Heart Nepal, that The group transports doctors and nurses into rural communities to provide healthcare services.

“Mostly the rural villages are located on hilly or mountainous reasons,” he said, “and they consist of smaller health care clinics or community hospitals with limited treatment options.”

On average, it takes Nepal’s rural population more than 2 hours to get to a clinic for basic care. And 92% don’t have a vehicle they can use to traverse the distance. Most walk, bicycle or rely on the public bus. “In many villages, when the mode of transportation is by foot, this often results in delay of treatment.”

While delays can be fatal for those with emergent medical needs, chronic conditions are just as deadly when neglected. In Nepal, getting diagnosed with diabetes or heart disease before it becomes an emergency is rare. Without consistent treatment at the onset, chronic conditions escalate.

For example, unmanaged diabetes can lead to poor circulation and nerve damage, putting patients at risk for developing ulcers and wounds in their limbs.

“These patients with diabetes, the wounds, they do not heal and it takes a long time to heal. So for those people in rural areas, they are mostly farmers, so they have to work and they’re not, they do not consider it as important.

If patients delay care, these wounds can become severe enough to require amputation. Goutam says it’s not uncommon for those with diabetes to lose legs and feet. And, survival rates after amputation are low.

“There are some studies which have highlighted that people with diabetes and have their feet amputated did not live more than five years. So that is more deadly than, uh, cancer.”

In the United States, transportation also poses a barrier to care.

In 2017, nearly 6 million people delayed medical visits because they didn’t have a way to get to their doctor. And according to a study published in JAMA Network—a peer reviewed medical journal–a lack of transportation is associated with a higher number of emergency department visits among Americans.

But in some places, primary care is right around the corner – thanks to the community health center.

“We have clinics in neighborhoods, hence the name and so many, many of our patients walk to our clinics.”

Dr. Charles Fenzi is the CEO and Chief Medical Officer of the Santa Barbara Neighborhood Clinics – a network of federally qualified health centers in Santa Barbara County, California.

“We’re in the neighborhood and we provide transportation. In fact, that’s written into our contract with the, with the Feds.”

Under the Public Health Service Act, federally qualified health centers are legally obligated to provide enabling services. These are services that break down barriers to help patients access care. Transportation is one of them.

If a patient needs to use a driving service to get to their appointment, the health center pays the fee.

For the most part, Fenzi says transportation isn’t a major problem for patients because they ensure it’s not.

That’s the model of community health centers, he says.

This transcript has been edited for clarity and length.

The post Sometimes, Getting to the Doctor is the Hardest Part appeared first on Direct Relief.

More than 670 deaths have been reported thus far, and millions have been displaced or significantly affected. Many are still missing, including children.

Dr. Ravikant Singh, founder of the nonprofit Doctors for You, recalls making his way to a village in Bihar, one of the poorest states in India. A baby who had been delivered that morning had spent hours still attached to the placenta – there was simply no one available to care for mother and child.

Throughout the region, houses and even entire villages have been submerged. “Even in higher-up places, many villages in Bangladesh are underwater,” said Iftikher Mahmood, founder of the HOPE Foundation for Women and Children of Bangladesh.

For people living in affected areas in India, Nepal, Bangladesh, and Pakistan, the difficulties have just begun.

Immediate dangers

It’s the start of monsoon season, a yearly seasonal change that causes the majority of South Asia’s rainfall to occur over just three months in the summertime. A new storm arriving Thursday is expected to blanket 90% of India with rainfall – which could, in turn, cause additional flooding, rising rivers, and landslides.

Each major storm can have devastating effects that continue for months or even years after the initial burst of rain and flooding – long after the news cycle has forgotten it.

More immediately, many people in flood-affected areas, particularly in India, are still cut off from most contact with the outside world, making it difficult to deliver aid.

Food supplies have been damaged and water in flood-affected areas has been contaminated with sewage and other unsanitary material. That means many people are currently going without food, clean water, or access to medicines. If they get sick or are already dealing with chronic conditions, there’s no one to care for them.

Organizations like the HOPE Foundation’s field hospital, Mountain Heart Nepal, and Doctors for You have responded by setting up medical camps in flood-affected regions, making their way to isolated villages to treat patients, and providing everything from clean water to soap to people living in overcrowded facilities and makeshift shelters.

They’re already treating injuries and snakebites, along with diarrhea and skin diseases – both complications from contact with contaminated water.

Looking ahead

They’re also gearing up to address the serious, often deadly diseases that can follow a storm or flood. Cholera, which spreads rapidly when people drink water contaminated by the disease, is a visceral fear.

“After the flooding…we saw lots of standing water,” said Dr. Aban Gautam, president of the aid group Mountain Heart Nepal. Standing water attracts mosquitoes, greatly increasing the potential for malaria, dengue, and other vector-borne diseases.

Crowded conditions in shelters and camps can cause respiratory diseases like pneumonia to spread quickly. And people with chronic conditions like diabetes and hypertension are less likely to have access to the vital medications needed to manage their conditions.

All of these are compounded by malnutrition, already a risk for the largely poor population affected by the storm. “Since they belong to low socioeconomic groups, they are vulnerable,” Dr. Gautam said.

He explained that many of the people affected are subsistence farmers and members of lower castes. (Indian society is stratified into strict layers determined by status and occupation. Members of some low castes, as well as those outside the caste system, have famously been called “untouchables.”)

In Nepal, Dr. Gautam said, people are slowly returning to their homes. “People are starting to rebuild,” he said. But that doesn’t mean that life will return to normal anytime soon.

For one thing, the threat of disease won’t disappear. Dr. Gautam is concerned that he’ll see outbreaks of cholera, diarrhea, and vector-borne diseases in Nepal in the coming weeks.

Economic impacts

But in addition, monsoon season has a profound impact on South Asia’s agriculture and, by extension, its economy. “Such a large number of people are so dependent on this intensively seasonal rainfall,” said Sunil Amrith, a professor of South Asian studies at Harvard University.

“If the monsoons are late, or if they fall short of normal expectations, or they are in excess, they can ruin a harvest, and in a predominantly rural country, that really matters.”

Many of the people in this region are rural farmers for whom a bad harvest is devastating. “The whole family depends on income from livestock and from farming,” Dr. Gautam said. In the wake of the storm, livestock have been drowned and paddy fields destroyed.

Highlighting the situation

Direct Relief has responded by providing requested medical supplies and an emergency cash grant, helping aid organizations in the region set up medical camps, travel to flood-affected areas to provide services, and distribute urgently needed medical supplies.

The organization has aided in other disasters in the region, including Cyclone Fani, which hit northeastern India earlier this year, as well as heavy floods in Nepal in 2017 and in Kerala, India in 2018.

Dr. Singh explained that frequent disasters cause “donor fatigue,” in which people are less likely to help out when faced with repeated requests for donation.

To compound matters, Dr. Singh said, “the local media is not giving much attention, or maybe they don’t want to highlight the situation on the ground.”

There may be an explanation for the relative lack of media coverage in the region and elsewhere. “In some sense, I suppose, one might call it an ordinary disaster,” said Amrith. “It’s almost as if these things are expected in South Asia, under the radar.”

“A force that governs the world”

And the future may be more volatile – in part because of climate change. “The monsoon has become more prone to extremes,” Amrith said. Both the where and when have become less predictable: monsoon rains have been falling in unexpected places, and heavy rains are interspersed with longer dry periods.

Amrith said that monsoon seasons have always had a profound – and variable effect – on South Asian economic and cultural life. “The monsoon is portrayed as a force that governs the world” even in centuries-old literature.

“But they really are changing,” he added. “They’re becoming much more unpredictable and much more dangerous.”

The post Widespread Flooding Has Devastated South Asia. It’s Only the Beginning. appeared first on Direct Relief.