The World Health Organisation, Country Office for Nepal, has been completely reorganised and repurposed in its response to the COVID19 emergency, under the new Incident Management System structure. WHO staff members in the Nepal office are in new roles as they prioritise the COVID-19 response, and at the same time, continue delivering on their pre-COVID-19 ongoing programs. Dr Sunoor Verma and Roshan S Nepal caught up with WHO Country Representative for Nepal Dr Jos Vandelaer for a quick chat. They talked about the recent change in the structure of the office, the accompanying challenges and the WHO's assistance to the Nepal government.
Excerpts:
To begin with, could you please share with us your professional journey?
I am a Belgian. I graduated from medical school in 1985 from Leuven University in Belgium. During medical school, we had a year of internship which I did in a north-eastern district of Zaire. It gave me the flavour of working in developing countries. So after I graduated, it was clear to me that I wanted to go back to developing countries. I first studied at the Institute of Tropical Medicine in Antwerp for a six-month course. After that, I started working with Doctors without Borders. I did several short missions in Africa and Latin America. While with the Doctors without Borders, I also worked in Thailand in refugee camps for two years. From there, I worked for three years for the International Organisation for Migration in Vietnam, working on medical processing the people who wanted to leave Vietnam and resettle somewhere else. In 1992, I did my Masters in Public Health from Harvard University. After that, I again worked for the IOM during the Bosnian War, where we had a programme to take the people who needed medical care outside the war zone. Then I worked for a year for the UNHCR as a consultant with Rohingyas in Myanmar. After that, I joined the WHO and worked in the Philippines, New Delhi, Myanmar and Geneva—always in immunisation. From Geneva, I moved to New York, working as the global head for immunisation for UNICEF. From there, I came here to Kathmandu. In short, for ten years or so, I worked in emergency, refugee, and migration health. For the next 20 years, I worked for immunisation. And now I am here!
As the WHO Representative, how have things changed for you since the activation of the Incident Management System? What are your three most significant challenges as the head of WHO in Nepal?
When we activated the IMS, it coincided more or less with the lockdown. So a couple of things happened at the same time—several WHO people started working from home because of the lockdown. And then the COVID-19 started taking everything over. When we decided on activating the IMS, it was clear to us that our typical office structure will not cope with the demands of the emergency. So the activation of the IMS meant the full capacity of the office was directed towards the COVID-19 response.
Structural changes, no matter how temporary or transitory, require quite some adjustments from everybody. Several people had to already go through the adjustment of working from home. But the IMS prompted the second adjustment where suddenly people had to do work in areas where they had no previous experience. Colleagues had to go out of their comfort zone and do jobs that they are not used to doing. When we activated the IMS, we then also asked many colleagues to be posted in government units which they did and still do
Therefore, on the challenge, also for myself, in a new structure, we are not used to doing things many of us usually wouldn't be doing.
Another challenge is that the COVID-19 overtakes everything. We work with the government in the long term on topics like non-communicable diseases, communicable diseases and immunisation and so on. These programmes in the fields have to continue. People still need to get immunised. Thus, field programmes continue to run in the background. But our primary attention needed to go to COVID-19. Balancing that out is another challenge. Finding a balance between a regular job and this new job under the IMS is a challenge applicable to each colleague myself included.
The third challenge is the fall-out of how a health problem suddenly starts driving everything else. There are economic impacts too. There are travel impacts, etc. Human beings are not just biological people and respond to a disease, but they also need to work. They also need to eat. They want to move around. Within the UN, we had a lot of discussions around the broader response. Participating in these discussions, I learned a lot on how to find a balance between what the health impacts here are and what other implications are.
You have repurposed your office under the IMS. What value does the IMS bring to your emergency response in Nepal?
We work in emergency response and preparation year in year out through a dedicated team—Health Emergencies Team (WHE). This relatively small team works closely with the Ministry of Health and Population (MoHP) to get the country ready when the disaster happens, such as floods and earthquakes. This emergency team works to ensure the country is much better prepared to respond to wherever an emergency happens. That goes with training health workers so that they know what to do when a disaster occurs. That goes with preparing hospitals so that they can take care of extra casualties. That goes with prepositioning supplies, setting up communications systems, etc. All this is part of the preparation to be ready when a disaster happens.
But with the COVID-19, it was so enormous worldwide. It was like a tidal wave that you saw coming but hasn't hit yet. It became pretty clear that if we wanted to be capable of supporting the country in reacting to the COVID-19 epidemic, that small emergency team couldn't do by itself provide all the technical assistance that would be needed — from surveillance, communication, to hospital preparedness, etc. This was new for everyone—the WHO, the government and other partners. While the brunt of the work falls on the government, the WHO is there to help with technical inputs and hands-on support.
Against this backdrop, the IMS gives us more bandwidth, both with knowledge and resources. It increases the capacity in the office. It allows us to do things that otherwise we wouldn't do if we only had a small team. It also allows us to be hands-on. As I mentioned, we have people working within the government departments. We have people working very hard in every province of Nepal, helping the provincial governments deliver an adequate response. The IMS also enabled us to respond to the actual needs of the rapidly evolving situation.
What challenges does the COVID-19 pandemic in Nepal pose for the WHO's operations in the country?
We have over 100 staff throughout the year, and our operations continue. But the focus has shifted to COVID-19. Now, for most staff, the COVID-19 is the priority. It does not mean that we no longer do not work on tuberculosis or non-communicable diseases. That is still going on. But the main focus now is on the COVID-19. Under the IMS, people will do COVID-19 work, but at the same time work continues around immunisation, for example.
Lockdown is a unique component of this pandemic. Countries around the world have had different approaches to lockdowns and their lifting? What is WHO's guidance on this? Has WHO compared the outcomes of the different strategies adopted by various countries on this?
The WHO provides advice to governments on possible ways to slow down the epidemic. In this epidemic, we initially start seeing some cases, and at some point, these cases begin infecting others much faster and the number of infected people goes up very quickly. The main problem is when this increase in the number of cases is more significant than the capacity of the health system to cope with this increased demand. You don't have enough beds, you don't have enough doctors and nurses, you don't have enough medicines, and you don't have enough ICUs, etc. What a lockdown does is, because people cannot move around quickly, they cannot infect each other that easily, therefore it slows down the curve. The purpose of that is to keep the curve, or the number of people infected by COVID-19, within the boundaries of what the health system can handle. That way, you don't have more number of patients than the number of doctors who can treat them or hospital beds or the ICU. That's what you try to do with the lockdown.
Many countries have imposed lockdown but often in many different ways. Some countries have taken it more strictly, other countries have been a bit less strict. Also important is at what point in time the lockdown started? If you started very early, then, of course, it's easier to keep the epidemic in check. If you already have many cases and impose a lockdown, it's too late to have a significant and quick impact. So there are different ways of doing the lockdown, and the timing seems to be important.
In countries where the epidemic has already hit in a big way, what we see is that indeed you have a quick relatively steep way up, it peaks, and it comes down. How high this goes up, or how steep it is, depends on several factors and lockdown is one of them. What we shouldn't forget is that people still interact and people still need to go out and buy food, etc. So in the interactions of the people, it is still vital that people keep a distance from each other, they wash their hands regularly, they have cough etiquette, go and see a doctor if they don't feel well, etc. These things are all critical. So is testing and isolating cases and contacts. But it is difficult to say what exactly the effect of each of these measures is. There is a variation between countries too.
The government has eased the lockdown. What precautions would you like to see the ordinary citizens take?
The easing up of the lockdown means the people are allowed to do things which they weren't allowed to do for the last three months. The natural reaction is the people want to go back to life before COVID-19 or before the lockdown. The advice to the people would be—don't do that!
The advice is to implement the same things that we have been saying over and over again, and that needs to be implemented with a lockdown or without the lockdown or with a loosened lockdown. Keep a distance of at least one metre with other people, wash your hands very regularly, cough in your elbow when you need to cough, should you fall sick, go and see a doctor, in public places you can wear a mask, etc. But you need to do these things more strictly after the lockdown is eased because there will be much more interaction among the people than during the lockdown. After the lockdown, people may go back to work or be in contact with friends. Therefore, it becomes much more critical for the people to do these things, like keeping distance, washing hands, etc. And I can't stress enough that an easing of the lockdown does not mean going back to life before the lockdown. On the contrary, it requires more self-discipline to protect yourself and to protect others.
Even as the lockdown is relaxed, the risk of being infected is still there. The virus is there. The virus has not gone. As long as the virus is there, there's always the risk of infection. But you can do your own things, you can protect yourself, and you can protect others. If you keep distance or wash hands, etc., you will automatically limit the chances of getting infected yourself or you giving the infection to somebody else. In other words, you make the life of the virus much more difficult, and that's what you want to do.
How will WHO Nepal operations change once the lockdown is lifted?
Our operations are not really linked to the lockdown per se. Our activities are geared towards dealing with COVID-19. Lockdown or no lockdown, we will continue to see COVID-cases going up. That is the natural history of the disease. We support the government in its response to the COVID-19 emergency. It is the IMS at the WHO that gives us the necessary knowledge, resources and bandwidth to be able to offer this support.
Loosening of the lockdown will not change that. We still need to provide extensive support to the people of Nepal and to the government of Nepal—both at the central and provincial levels. The IMS system will continue even if the lockdown is loosened. We will see how the epidemic goes. Depending on the evolution of the epidemic at some point in time, we may have to ask some people to work more in their traditional jobs. But it's too early to say when this happens, but initially, the IMS will continue.
How would you describe your partnership with the MoHP?
The WHO is a member-state organisation of which Nepal is a full fledged member. The WHO, at the country level, is a specialised agency in health and works very closely with the Ministry of Health in every country.
We are neither the Ministry of Health, nor are we the government of Nepal. We are an independent UN agency. But we work closely with the Ministry of Health with the same goals that they have to improve the health of the people. To achieve this, we develop in close consultations with the ministry a five-year plan. This ensures that our strategy aligns well with the priorities of the country. The relationship with the MoHP in Nepal has been going on for around 60 years or so.
In COVID-19 situation the modus operandi is pretty much the same. We are trying to provide assistance where the government wants us to assist the most. What we are trying to do is to strengthen the response that the government can give to COVID-19.