Illustration: Himal Southasian
Comment
A death in the family
A family’s loss, Nepal's weak public healthcare, and the stigma of COVID-19.
It was supposed to be a quick visit to the emergency room. The doctor would inject a round or two of saline drip, prescribe a few medications, and send us home – or so we thought. But my cousin, a seemingly healthy young man, who had up until that evening displayed no symptoms of being severely ill, never made it back.
Two days after being rushed to the hospital for what we had presumed was a minor ailment, my cousin, who had been living with my family since his father's death over two decades ago, passed away on the afternoon of 12 April. He was only 24.
His sudden death shocked all of us. While he had complained of a sore throat and had lost his appetite in the days preceding his death, there were no other signs to suggest he had contracted a life-threatening disease. There was no high fever, no dry cough, no breathing difficulty ﹘ symptoms of COVID-19 that one is told to watch out for.
As the nurse sprayed disinfectant all over us and we put on surgical gloves and masks, I wondered if I had risked my boyfriend's life by calling him to the hospital.
And so, we delayed taking him to see a doctor. We thought his sore throat could easily be treated at home. We reasoned that by taking him to a hospital, we'd be needlessly exposing him to the contagious COVID-19 that had shut the country down and wreaked havoc across the globe. We believed we were doing the right thing amid a pandemic by following the World Health Organization guideline: stay at home if you feel unwell; seek medical attention if you have fever, a cough and breathing difficulty.
Little did we know that my cousin's organs had been failing him for a while, the result of a delayed diagnosis of pneumonia. But it wasn't until his death certificate was issued and a report of his COVID-19 test released to the family that we could say with certainty what exactly caused his death.
Those 42 hours of hospital stay (including two transfers) and the long and excruciating wait for his COVID-19 test result exposed us to Nepal's failing healthcare system. It also gave us a firsthand experience of the stigma faced by those suspected of carrying the virus.
Postponed
On the night of the emergency visit, when I went to check on my cousin to make sure he had eaten his dinner, his stomach looked swollen. He said he had a bad pain in his stomach, all of his upper body was hurting, and he couldn't sleep. He had to be taken to the hospital, we thought. Since my cousin had shown no signs of being in frail health until that night, which was more than two weeks into the countrywide lockdown, the doctor on duty had trouble comprehending how a healthy-looking adult with no pre-existing conditions had experienced such a rapid deterioration of health.
"How long has he been sick? What happened to him? Are you sure he didn't have any fever?" The doctor threw a volley of questions at us, as nurses scurried across, fixing a nasal cannula on my cousin, whose blood-oxygen levels had dipped below normal. We were in the emergency ward at Alka Hospital, a private facility in Kathmandu, which had become our family's go-to medical centre, mainly due to its proximity to our home. Soon the nurses began handing out one list after another of things that needed to be bought and paid for.
After running multiple tests at the hospital lab, including a chest X-ray which showed a collapsed right lung, my cousin's condition was deemed critical. He was admitted to the ICU and placed on a ventilator shortly after. All this occurred within just over an hour of our arrival.
Anyone who has ever been hospitalised or undergone treatment at one of Kathmandu's private hospitals knows just how expensive healthcare can get.
And so, even though my cousin had no travel history, had not come in contact with anyone who had tested positive for COVID-19 and had been asymptomatic, he was suspected of being infected by the virus. And by association so were we. My brother and I were asked not to leave the hospital premises and to inform our family at home to stay put. My boyfriend, who had joined us later, couldn't leave either. As the nurse sprayed disinfectant all over us and we put on surgical gloves and masks, I wondered if I had risked my boyfriend's life by calling him to the hospital.
We spent much of the night waiting outside in the visitors' area, googling "sepsis", "survival rate for patients on ventilators", "asymptomatic COVID-19 patients", "pneumonia", debating whether to inform the rest of our family about my cousin's condition. Every now and then we would hear his name announced over the hospital PA system, which meant one of us needed to go to the ICU, where a nurse would hand us a list of supplies that had to be bought from a pharmacy downstairs. At other times, it was a list of tests that needed to be performed and paid for. During one of those calls, contradicting their own previous instructions, we were told by a nurse to head to the National Public Health Laboratory, one of centres authorised to conduct COVID-19 tests in the capital, to fetch a collection tube for my cousin's test swab.
The National Public Health Laboratory was not the most organised. Although we were told by nurses at Alka that the national lab was running a 24-hour operation since the pandemic hit, it took my brother and my boyfriend over half an hour of walking around the empty facility before they encountered a staff member to assist them. The staff member, according to my boyfriend, looked for the collection tube inside a few boxes littered across a dishevelled storage room, and after a few minutes, told them he couldn't find what we needed. They returned empty handed, and the swab collection was postponed to the next day.
Debilitating costs
Anyone who has ever been hospitalised or undergone treatment at one of Kathmandu's private hospitals knows just how expensive healthcare can get. Even at Alka, which is less expensive than other premier private hospitals in the city, we had spent nearly NPR 80,000 (USD 650) in less than 24 hours. On one of the many runs we had to make to the pharmacy, I noticed with surprise an order for three N-95 masks, which I learned were for the nurses. I did not understand why we were required to pay for protective gear for the medical staff. Shouldn't a for-profit hospital be expected to take care of its employees?
Despite what may have been written on the certificate, news that he may have been infected by COVID-19 had spread far and wide in our close-knit Tibetan community.
The following day we decided to transfer my cousin to Mediciti, another private hospital in the outskirts of the city where we believed he would receive better care under more experienced doctors. Established in 2017, the hospital, which has investment from Upendra Mahato, a Russia-based businessman with allegations of illicit offshore investments, has quickly risen to the top of the ranks in terms of private care.
We had first considered taking my cousin to Patan Hospital, a public hospital which was designated one of the treatment hubs for COVID-19 by the government. But the hospital, we were told, had no spare ventilators. Lack of resources has long been an issue with Nepal's public healthcare system which has been wrecked by mismanagement, corruption and red tape. According to a spokesperson at the Ministry of Health and Population, there are 840 ventilators in the country, 146 of which have been allocated for COVID-19 patients in hospitals designated as treatment hubs. Even if all the ventilators in the country were working, Nepal would only have around one ventilator per 36,000 people. In comparison, India has one ventilator per 27,000 people, while the US has one per 5000.
The transfer to Mediciti seemed near impossible at first. To start with, as my cousin was an intubated patient, he had to be transferred via an ambulance equipped with a portable ventilator, available to only a handful of expensive private hospitals. Since there were suspicions about his being infected with COVID-19, the medical personnel involved in his transfer would need to be fully geared in personal protective equipment (PPE). Finally, the facility that we wanted to transfer him to needed to agree to having him in as a patient. After multiple frantic phone calls to friends and relatives, we were finally able to arrange for his transfer. A close friend worked at Mediciti, and she helped us secure an ambulance and an admission. One of the doctors there later told my friend, "If you hadn't known the patient personally, we would never have considered taking him in."
Despite the high costs of treatment at a facility like Mediciti, where we ended up paying over NPR 200,000 (USD 1700) in hospital bills for less than a day's stay, many in Nepal are forced to choose private care because of the gross inadequacies of public health facilities. Beds are often unavailable and machines dysfunctional. Perhaps no better institution illustrates this than Bir Hospital, the country's oldest.
The hospital, most of whose patients are from low-income backgrounds, has earned a notorious reputation for regularly referring patients to private healthcare providers, owing to a lack of resources. According to a Kathmandu Post profile of the hospital from August 2019:
Given that this is the state of a major public hospital in the capital, one can only imagine how bad things are at facilities outside urban centres. While there are some excellent specialised public hospitals, they are few and far between. Meanwhile, government spending on health in Nepal continues to remain low. In 2019, the government allocated only five percent of its annual budget to the health sector. Due to the state's low spending per capita on health, more than half of the total healthcare spending in Nepal is paid for out of pocket by patients themselves.
In the absence of a well-functioning public healthcare system, the private medical industry has flourished. In Kathmandu alone, there are over 900 private healthcare providers, many of them small clinics. As a result, non-government healthcare spending in the country exceeds government spending by more than four times.
Under the shadow of COVID-19
My cousin died a day after he was shifted to the second hospital. According to his death certificate, the immediate cause of death was septic shock with multiple-organ-dysfunction syndrome. The underlying cause: community acquired pneumonia with parapneumonic effusion. In lay person's terms, he died from failure of multiple organs, caused by pneumonia gone bad.
An hour before my cousin died, a pulmonologist treating him called us for a counseling session, and said that his team would not be able to administer CPR on my cousin in case his heart stopped. This was the advised protocol when treating COVID-suspected patients, he said. Regardless of whether CPR could have resuscitated my dying cousin or not, it seemed cruel to me that a mere suspicion of the disease was enough to withhold from him any last attempt to save his life.
Should we be self-isolating? Should we ask relatives not to come to our place? Should we even be trying to get monks to come to our place to perform last rites?
It would take another 24 hours for us to receive his report for the COVID-19 test. And so despite what may have been written on the certificate, news that he may have been infected by COVID-19 had spread far and wide in our close-knit Tibetan community. Even my relatives in Canada had begun receiving calls from acquaintances enquiring about the cause of his death.
We first realised just how fearful our neighbors were when a local shopkeeper refused to enter our house and left the drinking-water jar at our door. This happened the day after my cousin had been hospitalised. Politely, he explained, "I will not come inside since I am wearing shoes." That didn't stop you from entering other times, I thought to myself. While we knew that people were being cautious, and the rational part of me commended them for practicing social distancing, emotionally I felt hurt at being treated like an ostracised. In a moment of frustration, I texted the doctor who was coordinating my cousin's COVID-19 test: "Please tell them he has died and can they be more urgent with their work."
Should we be self-isolating? Should we ask relatives not to come to our place? Should we even be trying to get monks to come to our place to perform last rites? These were questions running through my mind as I waited for his report and began to plan his funeral.
Deep down, more than concerns about the infection, I feared the impact it would have on my aging aunts if no one from the extended family showed up for his cremation. That they would not be able to handle the trauma of having no monks present there to perform funeral rituals. And that we would have to mourn his death, alone, without any friends and family by our side.
According to Tibetan Buddhist traditions, a deceased person's birth sign and death details are sent to a lama soon after their death, who then makes calculations of the appropriate cremation time and lists the pujas that need to be performed for the dead to be reborn. My cousin's cremation was scheduled for 15 April 2020, three days after his death. To us this meant more time for funeral preparation, more time to prove to people he hadn't died of COVID-19, and a hope that, if the test results came back in time, we could organise a proper funeral.
The National Laboratory published Tseten's COVID-19 test report a day after his death; he had tested negative. Over 130 people showed up to offer their condolences at our house on the morning of his funeral. Another 40 visited his cremation site. Since then relatives and close family friends have been trickling in, with offers to help in the kitchen, to prepare butter lamps that need to be lit for 49 days, and to console my aunts who had been his guardians.
Most of them have no masks on.