FRAILTY, THY NAME IS CORONA!

By Dr Shisir Manandhar

Cover Story

February 2, 2021

A novel pandemic that came to haunt us brought the world to a near standstill. But mankind never stood still and continues to battle to pull all our lives together!

NEVER STANDING STILL WHEN THE WORLD CAME TO A STANDSTILL

Covid-19 was never taught in medical college. Yet, our invincible health care system is bravely battling an invisible enemy that has brought the world to a near standstill. As the pandemic sweeps over the globe, the role of public health experts and epidemiologists have been integral in protecting our communities and keeping populations healthy. As an expert rightly said, “tackling a pandemic is the essence of public health so every action to address this pandemic is somehow connected to public health.”

Let’s get to know Dr Biraj Karmacharya (Ph.D, MPH), Associate Professor – Dept. of Public Health, Dhulikhel Hospital, Kathmandu University School of Medical Sciences – an eminent public health professional and epidemiologist who completed his MPH and Ph.D in Public Health (Epidemiology) training at UW through a Fulbright fellowship from Nepal. Dr Biraj leads the Department of Community Programs at Dhulikhel Hospital, Kathmandu University Hospital and has more than a decade of experience in developing rural community health programs and forging international collaborations for academic training and research in Nepal.

Dr Shisir Manandhar, Ph.D.
Research, Technology & Innovation
Manager

It is not very often that we get to meet a public health professional with a doctorate in Epidemiology. What was it that fascinated you to delve deeper into the core of this unique subject and choose the “road less travelled”?

I started my career as a medical doctor and pursued Bachelor of Medicine as well as Bachelor of Surgery. As a medical doctor, you basically treat a patient individually since traditional, clinical medicine deals primarily with diseases and people on an individual level. What got me thinking was how I would be able to maximize my impact on the lives of people. It was then that the whole field of public health drew my attention. Public health looks at a large group of individuals as a whole and this means, the entire population is your patient. I was at Seattle where I pursued my Ph.D in Epidemiology and Masters in Global Health at the University of Washington. I also studied Leadership policy and management.

I would like to state that epidemiology is the pursuit of truth. In epidemiology, we specifically delve deep into the disease and its pattern to arrive at the main determinants of disease in a population. I would say I chose a non-traditional career path. Though I was equally fascinated by clinical medicine, I studied tropical medicine because I felt it was a very good blend of public health and medicine especially since it deals with infectious diseases. I have travelled far and wide setting up rural health programs and though I was both a clinician as well as an academician, within a few years I drifted towards community health where I felt I could make a greater impact in improving lives.

 

What exactly is Public Health in layman’s terms? What is its origin?

Public health is the study of the health of a population.

Public health has been in existence since prehistoric times when there used to be epidemics. But, of course, as a dedicated science and discipline, it does not have a long history, especially in epidemiology.

The English physician, John Snow is considered the father of epidemiology and he played an integral role in solving the Cholera outbreak in London in the early 1800s. I’m sure you must have heard about this. In the course of around three weeks, over 600 people died. The scourge of cholera seemed unstoppable and, even, unpredictable. But one doctor – John Snow – set out to prove that he knew how cholera was spread. So, there was an entire field of epidemiology and health care back then as well.

Would you say Public Health is a multidisciplinary field where you have health science joining hands with management and even information technology?

Absolutely! In fact, in the last few decades public health has become a discipline that is truly multidisciplinary. For example, there is a whole field in public health where we talk about social determinants in health and for this you need people from different backgrounds – political, economic, cultural and so on. There are also new fields such as public health informatics and public health nutrition. So, there is a lot in terms of management, policy and law. I don’t think you will find any field that is not linked to public health.

2020 has been the year of the infamous COVID-19 where it has achieved rock star levels of fame all over the world. Why do you think such epidemics happen?

There is no single instance or situation when we can say that now we are all fine and free from epidemics. The relationship between Nature and man is dynamic. Human practice and behaviour is constantly changing because mankind is continually creating new structures, new systems and new entities. The way we evolve and our interaction with Nature has changed. So, there is a constant battle between human beings and Nature due to modernisation and urbanization. I am not saying this is the reason behind epidemics. But in such a dynamic state there is ample room for everything new, including new viruses, mutations and novel pandemics. The future is, of course, going to be tough. The essence to survival is how fast we can adapt ourselves to new threats and innovate to address the changes. Better the mechanisms we create to work unitedly, the easier it is going to be in terms of addressing a pandemic. I think the key thing is how fast we can adapt, innovate and collaborate. When Covid-19 arrived in Nepal, I immediately prepared my institution to address and manage the epidemic. I felt it was my duty to get involved at the national level and prepare everyone for this epidemic.

What is the greatest lesson we get to learn from the COVID-19? How has this pandemic shaped our homes and our lifestyle?

I think all major changes in the world, including positive ones, took place during times of major crisis. If you look back at history, every leap in the field of development took place when the world was in chaos and totally messed up. Being an incurable optimist, I feel even this Covid situation will change the world for the better. In Nepal, online education and online business has flourished and the changes we see here now would have taken another 20 years to impact the society, had it not been for Covid-19.

Moreover, Covid-19 has truly humbled people, making them realize that there is a limit to what we as humans can do. Humility and Humanity has returned. Of course, we have learned to place more importance on hygiene. There are now less instances of diarrhoea and other infectious medical conditions that result from lack of hygiene and increased social interactions.

Would you say we are self-sufficient to handle similar epidemics in the future or do we need more professionals as well as innovations in the health care sector?

I feel in our nation, we are not very well prepared to handle such emergencies. Earlier, we used to believe that such epidemics would not affect us. However, the Covid-19 situation proved to be a very good wake-up call for every country, even developed nations.

I was fortunate enough to work at the central government level during this epidemic and managed to get complete snapshot of the scenario. From what I have understood, we lack the capacity to generate, synthesize and interpret data. I will give you an example. During the past couple of months, we struggled to gather data on how many people entered Nepal through the borders and to trace each one’s current location. It took us weeks to sort out and gain access to that kind of information. So, in addition to having more professionals we also need to emphasize the need for innovations in data and communications.

What about nations who are reluctant to release date or information of their people due to security concerns?

Well, during the SAARS outbreak many nations were hesitant about revealing and disseminating data. But now, perceptions have changed with nations realizing the importance of information.

It is impossible to hide anything in our times now, so I do not see that as a problem in the coming days.

Do you feel data integration is another of our major focus areas?

Absolutely, no doubt about it. A few days back I was trying to integrate three sources of data in order to identify the major hotspots in the city as well as the areas that are most likely to be designated as hotspots in the days to come.

Here is what I did: I gathered the geolocation data of Covid positive cases in the city. Then, I used demographic data to figure out the population density in each city because the public health implication of a Covid positive patient living high up the hill is different from the implication of a patient who resides in the heart of the city. Finally, I made use of mobility data by reaching out to telecom companies. These professionals in the telecom sector shared data and showed us the geolocations where Covid positive cases were clustered. The data we receive is confidential but the impact such data has on public health is tremendous.

How close are we to discovering a vaccine for Covid-19? Has the vaccine stage got anything to do with the efficacy of its outcome?

When it comes to vaccines, there are well-defined protocols on when it can be used among populations. There are different stages to preparing a vaccine. The first stage takes place in the laboratory and it is the experimental stage. In the second stage, it is tested on animals. In the third, the vaccine is tested on a small group of people in a highly controlled environment. It is only after that stage we test it on the population at large. I am very optimistic that we will be successful in obtaining a suitable vaccine in the next few months and we will also be better prepared for future epidemics.

We would love to know about the reforms planned by Public Health to safeguard our community in a changing, evolving nation like ours. What are your plans for the community in Nepal as well as across India?

I have a very clear plan at least on what I want to do.  I think my own professional career will focus very much in terms of bridging the governance and the academia, it will be my major area of focus. Because whatever you see, the new innovations and knowledge comes from academia.  When you go into the governance sector in developing countries it is so sad to see that a tiny fraction of what the knowledge you generate is actually, used.  I feel very sorry that what is the use the whole time, energy and resources spent in academia; the scientific sector is not used for the good of the people.  If you get into the shoes of the government, it is not entirely their fault.  It is very easy to blame them.  The blame should be shared by academia too. Academia people do not get out of their box they are happy with their own publication profile, lectures and presentations. They are in their own ivory towers.  My focus will be to bridge these two, this will be very synergetic relationship for both. I think that is going to be my major focus. I do not have the answer to how am I going to do that yet but at least I know that will be the area I am working with. I did not talk about the private and industrial sector which I have not talked about today. It is not going to be easy, but I am very confident that is precisely what I am going to do.

Your interest in innovative health systems is very impressive. Is it completely technology-based or research-based?

Normally, when we use the term innovative the first thing that comes to our mind is technology and communications. What I mean is innovation in terms of approach. I will share an instance here. Traditionally, the health system in Nepal is run by the government and a few private players. No major study is being done on how to engage the communities to develop health systems. So, here is where the innovation comes. Here, we have a group of individuals we refer to as Female Health Volunteers. They are not health professionals but they have played an integral role in reducing maternal deaths in Nepal. There is a whole movement coming up as well with community health workers training laymen on basic health. So, when I say innovation, I mean in terms of approaches and in terms of designing the systems.

You are a role model for public health professionals and an Emerging Leader award recipient by the World Heart Federation. Do share your wisdom for those who have been inspired by you to carve their career in Public Health.

I would say ‘get out of our box’. In the coming days, the boundaries around different disciplines will become thinner. Earlier, we only had individuals designated or categorized as doctors, engineers, businessmen or industrialists. Today, epidemics have taught us to think beyond our own pre-conceived perceptions of the world. We also need to be humble enough to understand our own limitations and work as a team to achieve the impossible. The Healthovation team thanks public health professionals who worked tirelessly behind the scenes to keep the world’s population healthy

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