On Monday, Dr. Rajeev Shrestha watched as a 24-year-old patient deteriorated, then died in emergency care. His Covid-19 results had just come back positive earlier that day, after his mild flu-like symptoms began to worsen abruptly.

“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.