Going into lockdown is the correct decision and a critical first step that the government has taken. This will help flatten the curve of infection. The focus should now be on preparing and equipping its warriors

“Night gathers, and now my watch begins. It shall not end until my death.” This is the oath that the Night’s Watch, the military order that shields the realms, takes in the popular series Game of Thrones. When the hero of the Night’s Watch, Jon Snow, recognises a new dire threat to all humanity, he tries to warn the Queen about the monsters marching to destroy the mythical realm of Westeros. But she would not believe him. So, he ventured into danger to capture and bring a monster directly before the Queen. But she ignored it. Months later all of Westeros was burnt to ashes.

“Pledge myself to dedicate my life to the service of humanity.” This is Nepal Medical Council’s ethical code of conduct that every physician pledges by. It is also a code that I abide by as a Nepali emergency medicine doctor taking care of COVID 19 patients in the United States. With the unprecedented rise of the COVID 19 pandemic, the medical community in Nepal and around the world is shocked, but not shaken. Doctors and nurses witness enough horror during our training to be prepared for anything. Yet despite this bravery, there are some realities about Nepal’s current health system capacity that should scare all of us.

Nepal’s current ICU capacity is truly frightening. Even by the most optimistic estimates, we should expect 10 per cent of Nepal’s people to contract COVID 19. If just 1 per cent of the infected require ICU beds and ventilators (and it is likely to be many times more), that comes to 30,000 ICU beds and ventilators -- more than 30 times our current capacity.

There are very few medical providers in Nepal. According to 2017 World Bank data, there are only 18,000 physicians in a country of 30 million people. And in the three years since 2017, even if we estimate that Nepal created and retained 2,000 physicians every year, which is 24,000 physicians, or barely 0.9 physicians per 1,000 people.

While the government is working to increase Nepal’s ICU capacity, and frontline providers prepare to work night and day, there is another threat looming that scares us most--the lack of personal protective equipment (PPE), that is, masks, gloves and gowns. Whether in the US or Nepal, we are bound by a pledge, a pledge to dedicate our lives to ser ve humanity. And healthcare frontline providers are doing their best to protect their patients. However, that becomes impossible when we can’t protect ourselves.

Westeros burnt down because the Night’s Watch fell. Our frontline medical workers are the Night’s Watch of Nepal. I work in one of the busiest emergency departments in the US, and we do not think our supplies of PPEs will get us through this crisis. Doctors and nurses in Nepal are already making their plea in the social and national media that they need PPE, the bare necessity for protection from COVID 19. Some have already resorted to using their scarves and handkerchiefs to protect themselves.

In Italy, 20 per cent of responding healthcare workers were infected---20%. Italy is one of the richest countries in the world with one of the best healthcare systems and supply chains. If things do not improve rapidly in Nepal, far more than 20 per cent will be infected for lack of PPE. The overstretched, thin balloon of Nepal’s healthcare system will burst if our healthcare force goes down at this rate. The Nepali government needs to find ways to make, get, borrow and buy PPE now.

In the last few days, hospitals in Nepal have become forced into drastic measures by increasing the hours worked by interns, medical officers and residents. In some frontlines, they are being asked to work more than 48 hours straight without rest or sleep. Then, the frontline healthcare workers are asked to quarantine themselves for the next 14 days. This method will not work, and it will only cause physical and mental breakdown of these healthcare workers. Ultimately, we will have no one left to guard the wall. Instead, focus should be placed on obtaining and using appropriate PPE.

HAPSA is a nonprofit organization that seeks to improve the quality and affordability of health services in rural Nepal. Our innovative model enhances government health services by fostering community participation and directly supporting health facility staff.

Nepali medical professionals have known the reality of COVID 19 hitting Nepal, after all, we lie in the middle of the two most populous countries in the world---why would the virus skip us? Going into lockdown is the correct decision and a critical first step that the government has taken. This will help flatten the curve of infection. The government should now focus its resources on preparing and equipping its warriors.

All of the Nepali people can aid in this fight as well. How? By (1) staying inside, (2) meticulously washing hands (for 20 full seconds, with soap and water), (3) avoiding going to the hospital if possible, especially for mild symptoms, and (4) if you have masks and gloves, consider donating them to local hospitals.

This is all our fight, and Nepal’s Night’s Watch needs you. We need you to help us slow the spread of this virus as much as possible. Can you imagine sending the Nepal Army to battle without body armour? Right now, your doctors, nurses and other hospital staff are fighting the biggest war of our generation. Let us not follow the same fate that befell Westeros, or that which is falling upon other countries that struggled to take timely and decisive action. Let us help protect Nepal’s Night’s Watch, so that it can do its absolute best to save Nepal.

Dr. Ramu Kharel, MD, MPH, is the Founder of HAPSA, and a Nepali Emergency Medicine Resident at Emory University with a Masters of Public Health degree from Harvard University.