1 The Battle Continues - COVID-19, Leprosy, Lockdown and Fear … (and other tropical nasties)

Front-line Mission Hospital Work

From the entire grateful team at Lalgadh Leprosy Hospital & Services Centre, Nepal Leprosy Trust (LLHSC/NLT), Nepal - & Dr Graeme & Meena Clugston – Medical Director, and Nursing Advisor 24 June2020

Facebook: www.facebook.com/nepal.leprosy Website: www.nepal-leprosy.com

Dear Church Family - all you saints, loved ones, dear friends, Warmest greetings and yes-indeed - love - from all of us here at Lalgadh Leprosy Hospital!

(a) GREETINGS… with masks up (b) GREETINGS… with masks down.

Recognize our Staff Nurses in their new PPEs? ... (L-R) Sulochana, Meena, Dr Krishna, Anita BK, Urmila, Durga, Panina, Anita-IPD Manager

1. First things first - Health, Well-being, Prayer-Support Firstly - all of us here at Lalgadh Leprosy Hospital hope, pray, and trust that ALL OF YOU dear friends are truly safe and well. Thankyou so very much for your prayers, your concerns, and the wonderful support you provide for the patient care, mission work, and the safety of the team here at Lalgadh Hospital. Please continue doing so in these difficult times…. It means a HUGE lot to us all. Please let us know if you would like us to pray for you or your loved-ones or family, your church… or whatever is needed. God is good and faithful, and we know experience the joy of answered prayer. 2. Upping our defences against COVID-19 here at Lalgadh Leprosy Hospital This is a challenging, disruptive, totally unprecedented time … a pandemic of global seismic dimensions … something we’ll tell our grandchildren about for years to come. A mind-blowing experience for us all at this busy hospital. With the growing risks, hospital defences have been further strengthened against COVID-19. A boom-gate has installed about 20 metres inside the hospital gates. This ensures everyone – patients, visitors, staff – all have to stop and go through the Fever(temperature) Clinic, and wash their hands. Moreover everyone entering the hospital grounds is required to wear a face-mask. Clinical staff – paramedics, nurses, doctors, laboratory staff - all who deal face to face with patients, have been issued with PPEs (Protective & Preventive Equipment) of increasing quality and protectiveness … although it has been difficult to find their availability (getting easier now with stocks from China) and purchase them. This includes such PPEs as: N-95 masks, gowns, goggles, face-shields, gloves, caps and boots.

Wow!... Here the battle intensifies! … with COVID-19 rates rising daily across Nepal especially here in Province-2 … and the stresses and difficulties of Nepal remaining in tight lock-down … and the stigma and cruel behaviour arising from fear, rumours and ignorance, eroding the harmony of local communities.

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(a) Everyone entering must wear a mask. (b) Fever Clinic at the gate

After the front gates - The bamboo-boom-gate: Only lifted for those wearing a mask and checked at the Fever Clinic

Infection control has been stepped up. The hospital walkways get spray-disinfected with Na-hypochlorite (bleach) solution every second day. Hand soap dispensers and alcohol-based hand sanitizer dispensers have been installed for both patients and staff. All the wards have been whitewashed and are regularly cleaned. Drains cleaned and soak pits dug and other COVID-19-defence steps have also strengthened. And so far – although we worry about asymptomatic transmission, especially in new patients who are admitted - we have not seen any cases of COVID-19 transmission in the hospital.

(a) Dr Krishna in his PPEs running his outpatient clinic. b) Two of our Staff Nurses (Sulochana & Urmila) in new PPEs with Dr Krishna behind

3 3. In the thick of it in Province-2 - with Nepal’s worst rates of both leprosy and COVID-19 … plus other nasties.

Lalgadh Leprosy Hospital is situated in Dhanusha District – one of the 8 Districts comprising Province 2 which runs along the border with India. It is LLHSC’s official “catchment area” for leprosy. It is the poorest, most populous province of Nepal, with 6.01 million people. It is the worst affected province for leprosy, for COVID-19, and for a number of other diseases and indicators of poverty…

The nearby border with India is still bulging with hundreds Nepalese migrant workers who were working in India, have lost their jobs and are now stranded on the Indian side trying to cross back into Nepal. There were hundreds of thousands some days ago, but the government is now cautiously allowing them through. All are supposed to go to quarantine centres for 2 weeks, but these are inadequate. Many returnees lack food and water. Most of the rapidly rising new COVID-19 infection cases in Nepal are from returnees from India. Some are also from overseas – mostly returning workers from Middle East countries and Malaysia. The Nepal government is starting to repatriate about 40,000 of these. But the process is deliberately slow, as quarantine facilities throughout Nepal are inadequate and poorly set up. COVID-19 case numbers are rapidly rising throughout Nepal every day. Today (24 June) total numbers of confirmed cases in Nepal stand at 10,728. Province 2 has by far the highest number of confirmed COVID-19 cases – currently 39.4% of all Nepal’s COVID-19 infections. Of course this is a serious underestimate, as PCR-testing is still very very limited, and equipment and supplies have failed in many centres. Leprosy rates and numbers are also highest in Province 2. This province has 34% of all Nepal’s current leprosy cases. It has 36.2% of Nepal’s annual new leprosy cases - by far the highest rate of anywhere else in Nepal.

5.80 %

39.50 %

3.30 3.30

27.30 %

16.00 %

4.80

14.98 %

34.07 %

7.80

3.85

25.00 %

3.95

10.30 %

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

45.00

50.00

Province 1 Province 2 Province 3 Province 4 Province 5 Province 6 Province 7

COVID-19 LEPROSY

PROVINCE-2 WORST AFFECTED: COVID-19 CASES and LEPROSY CASES -Both as % of national registered totals - Data by Province - Nepal (22 June 2020)

%

India

China (Tibet)

4 Here are some additional colourful data to further the dismal picture of Province 2… • Province 2 has the highest number of poor Nepalis – more than 2.5 million people of Province 2 are multidimensionally poor,

representing 35% of all poor Nepalis according to the recent 2018 government report (Multidimensional Poverty Index – MPI). • Province 2 has the lowest female literacy rates (38.8%) in Nepal.. • 35% of children in Province 2 don’t even start school • A large proportion of the Province 2 population is Dalits (“untouchables”) – many face discrimination. • Malnutrition and many other disease rates in children are amongst the highest in Nepal • Social injustice, gender bias against women, child marriage, stigma and discrimination are endemic in the population

And now, on top of all this … the monsoon has started…. (see below)

4. Keeping ablaze the light of our double (integral) mission - “salt & light” for the world … compassionate service & Gospel outreach

This work is only possible because of God’s amazing grace and His enabling, and because of our lovely partnership with you. Lalgadh Leprosy Hospital is a front-line Christian mission hospital - one of the world's busiest leprosy hospitals (see below). There are three main programme arms - Hospital Services, Community Outreach, and a Training Programme. Underpinning and transcending all we do here are two mission objectives which we pursue here with all our hearts and souls:

1. Serving people affected by leprosy and other marginalized, sick, disabled and needy people, by providing compassionate preventive, medical, surgical and rehabilitative health care, combined with community outreach and social support;

and 2. Bringing the Gospel of Jesus and His saving love, through both loving word, action and example to an awfully poor and needy

population where Christianity is mostly unknown (only about 1% of the population)- trying to "shine like stars in the universe in a dark and crooked world as we hold forth the Word of Life"

We manage huge and increasing patient numbers every year - although COVID-19, and lockdowns, and fear, have all severely reduced patient numbers since March 2020. Leprosy and now COVID-19 are both rampant in the border regions of Nepal and north India. We have only 6 doctors and 13 nurses and 96 inpatient beds. Leprosy patients are mostly extremely poor - at the bottom of the socioeconomic "wood-pile". There is a high proportion of Dalits (untouchables) in the villages all around LLHSC. All services for leprosy patients at LLHSC are free, and we want to keep it that way as a Christian service. Every year for the past 12 years, patient numbers have been increasing – both leprosy and other diseases. Here are last year’s outpatient consultation patient numbers. There are almost no other leprosy hospitals worldwide that cope with such numbers as 12,726 leprosy patients. However, this year (2020) our patient numbers have already dropped dramatically – because of the ongoing COVID-19 lockdown.

Hospital Services soldier on - with some anxieties and extra precautions - Outpatients, Inpatients and Diagnostics Services Some of our staff are understandably anxious. Mostly because of the uncertainties of who, amongst the stream of daily patients might be infected or not. The worry is that possibly asymptomatic carriers of COVID-19 might enter amongst our patients, without detection at the hospital gate fever-clinic. However, rules are strict now at the gate with everyone entering having their temperature taken, washing their hands, and wearing a mask. Still… it’s a bit scary!

5 There is an additional anxiety for some staff – for those who live in the local village - The stigma and sometimes open hostility they face from fearful local neighbours because of their working at LLHSC, adds to their stress. Daily outpatient numbers - patients of all types - are running at about 110-140 per day at the moment. Normally at this time of year when the monsoon is beginning, we treat 700 or more patients a day. When the lock-down is relaxed we expect numbers to rise. With the monsoon flooding, water supplies become contaminated, and the diarrhea season and other water-borne and related diseases increase (typhoid, parasites, cholera, hepatitis, skin-infections, malaria, dengue-fever, lymphatic filariasis and Japanese encephalitis). And always our staff are “on edge” trying to determine who might have COVID-19. All this keeps us all daily dancing on our diagnostic toes! Inpatient Care We have in practice divided our hospital wards into two sections – the main wards with leprosy inpatients - hospitalized with severe complications of leprosy, whom we are sure do not have COVID-19 infection; and the 10-bed Isolation Ward plus one or two other wards, for new admissions. These latter beds are for new admissions, whether with leprosy or other diseases – since they are of uncertain COVID-19 status. it is for them that our nurses and doctors dress-up in full PPEs (masks, goggles, face-shields, caps, gowns, gloves, boots) for their treatment and care. We do our best to keep these two groups separate, because many of our leprosy patients are immunocompromised, especially those on high doses of steroids for Leprosy Reactions. Inpatient care remains busy… Here is a glimpse of Ward-Round time

Ward Round patient care

Over the past month there have been 40 – 50 hospitalized inpatients being cared for each day, including 3 - 4 children. The lock-down has decreased inpatient numbers - normally at this time of year the hospital is full with over 90 inpatients.

6 Currently some 80% of these inpatients are leprosy patients – needing hospital care for grossly infected leprosy-related ulcers, disintegrating feet or hands, or with severe Type-1 or Type-2 Leprosy Reactions needing high doses of steroids. Additionally there are 5-10 non-leprosy patients with a range of diseases – jaundice, kidney disease, diabetes, tuberculosis etc .

(a) Three of our teenage inpatients – Shova, Neelam and Ruby (b) We are struggling to rescue Neelam’s right foot which has a badly infected

ulcer that has destroyed some footbones. Neelam already has a below-knee amputation for her left leg.

Neelam

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Ward Round pics … holistic care … not just leprosy lesions - Dr Ananda checks up on an ear infection

5. Three Demons are playing havoc with people’s lives across Nepal - COVIS-19 infections, the Lockdown, and Fear When all this is over, and despite the rapidly increasing numbers of COVID-19 infections, it may well be that the other two demons – the lockdown and fear – will have taken a greater toll on life, death, and livelihood of people, than the morbidity and mortality from COVID-19 infection. For example… Lockdown Effects:

• Immunization of children and mothers’ services reduced • Measles epidemics already occurring • Antenatal care and hospital deliveries reduced reduced • Those needing hospital, care find it too difficult to get through the lockdown to reach hospital • Sick folks wait until disease is severe • Income for hundreds of thousands of daily wage earners stopped • Malnutrition rates increasing • Increase in non-communicable diseases • Those with disabilities are especially vulnerable • Children’s education and school progress damaged for this year • Family conflict, suicide, domestic violence, violence against women increasing

Fear, Stigma, False Rumours, Cruelty, Inhumanity: There are rising numbers of reports of deaths and distress cause by fear, stigma, ignorance, rumours, plain cruel inhumanity. A man from our local village died yesterday in a hospital up near Kathmandu. He did not have COVID-19 infection … but people thought that he might have. He was quite ill but was refused treatment at hospital after hospital here in Province-2. He got sicker and sicker. He made his way up to Kathmandu but police would not let him past road-blocks into the city to hospitals there - instead he was admitted to a COVID hospital on the edge of Kathmandu valley. He died a day later of liver and kidney failure and dehydration. He did not have COVID infection. Another lady died yesterday - a young guy who resented people from the local quarantine unit sharing a water tap, connected electric wire to the tap. A lady came to wash and drink in the early morning – was electrocuted and died. Our own staff face some hostility in the local village here. Health workers elsewhere in Nepal are chased, sometimes beaten, because they work at hospitals whether or not they deal with COVID infections. Landlords refuse to allow them to return to their rented accommodation. And there are many stories daily of stranded Nepalese workers, returning from India, barred from entering their villages – stranded, destitute, without food or water. Fear prevails across the country. There are many health, morbidity and mortality casualties – and much physical and mental suffering – resulting from fear, stigma, rumours, ignorance, and inhumanity. This may have a greater negative impact on the people of Nepal than COVID-19 infections, or the lockdown. Our efforts to combat these inhumanities are outreaching to the community with facts, reason, unity… and compassion, love and hope for those affected by COVID-19, and enormous gratitude to our staff who courageously carry on despite stigma and hostility. Despite these challenges – the risk of COVID-19 infection, the negative effects of the lockdown, and the fear that causes hostility and cruelty - we still have pregnant mothers coming for delivery (much wiser than risking home-births during the lockdown), and seriously ill patients many of whom should have come earlier for diagnosis and treatment.

8 Busy busy hospital work continues each day

(a) Baby Laxmi – normal delivery by Staff Nurse Ankita and team (Meena, Anita, Panina); (b) 3.1 Kg and healthy – being checked by Anita

(a) Ultrasound services with “Janet” - our amazing new Siemens machine. This inpatient with jaundice; (b) Oh dear - massively dilated intrahepatic

bile ducts. Seems to show a cholangiocarcinoma (cancer of the hepatic ducts). Thanks to the ultrasound we have probably caught it early enough.

Today’s septic surgery – Dr Prakriti and Nurse Sulochana wearing full PPE-gear. This 55-year old man with an advanced infected leprosy ulcer eroding

right through his foot should have come to hospital much earlier. Couldn’t - because of the lockdown and no transport. Since he has only recently been admitted to our hospital we are uncertain of his COVID-19 status – so it’s full PPE gear.

9 Each Day has its many Happy Moments…

(a) Dr Krishna is happy at having received some free PPE sets – good quality gowns, masks, caps, goggles, gloves etc.;

(b) These ladies are hugely gigglingly happy - daily laughing/stretching exercises with Meena (on the walkway)

6. Community Outreach Programme Increasing numbers of people are suffering increasing deprivation, illness and hunger as a result of the national lockdown. LLHSC’s Community Programme recently received permission to venture out into the villages and remote corners of the surrounding Districts seeking out and bringing food relief packages to poor and needy folks. Leprosy-affected people are often especially needy because of disability, deformity and marginalization, and difficulty in fending for themselves… but there are also many other vulnerable people now – mothers, children, elderly, disabled, very poor, blind, disabled, ultra-needy. LLHSC has 112 Self Help Groups across the surrounding districts, each with 15-25 members – about 2,200 beneficiaries, with about 75% leprosy-affected and the others with disability or marginalized or “untouchables”. These groups have been alerting the LLHSC Community Programme staff providing information as to who and where are those who are most needy, vulnerable and suffering. So despite the strict lockdown, LLHSC’s Community Program commenced this much needed relief work. Of course Province-2 is huge, with 6.01 million people. But a start has been made with the more adjacent Districts – where leprosy is still rampant. With some humble seed-funds provided by IDEA-Nepal (43,000 NPR (= $351)) our Community Team started delivering food relief packages and a cash living-allowance to 25 identified poor leprosy-affected folks in Mahottari and Dhanusha District – all very poor, some blind, disabled, ultra-needy –struggling in the current COVID and lockdown situation. This was a small start… much much mucjh more needs to be pursued.

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Now a larger more far-reaching project has been developed and supported by the Sasakawa Health Foundation (SHF). Still as a pilot project, SHF has provided $14,400 for a 3-month (June-August 2020) project entitled “ COVID-19 Comprehensive Community Rehabilitation Project for Persons Affected by Leprosy in Nepal”. This is providing food relief packages to 600 families, and also includes advocacy on behalf of these folks to health and support authorities, plus community awareness on prevention of COVID infections. Needy struggling families are identified through 20 of LLHSC’s community Self Help Groups, who also partner in implementation.

(a) The old Landrover loaded-up for one of the relief trips into Dhanusha District; (b) Dauna Devi is 70 and a widow living by herself –

this relief bundle – rice, daal, cooking oil, salt, soap and face masks – will help her survive for a month.

Here are some of the leprosy-affected and other lonely, poor, disabled and needy – whom we love so much.

Emergency Relief Package for 600 needy families both

leprosy-affected and other vulnerable families

Items Quantity Unit

Rice 25 Kg Daal 2 Kg Oil 1 Liter Salt 1 Kg

Soap 2 Pcs Mask 5 Pcs

Total cost of each relief package: 1,935 NPR (= US $15.80)

Total cost for 600 families: 1,161,000 NPR (= $9,476)

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These are all leprosy-affected – (a) Sundai Tamangage 65; (b) Ramji with his daughter is blind (due to leprosy)

(a) Dhan Kumari is 76 and lives alone, but the other villagers keep an eye on her ; (b) Phulo Devi is 75 – a dear lady totally disfigured by leprosy

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(a) She is so very grateful for the food relief; (b) Our Community staff teaching village folks about COVID and its prevention – hand-

washing and masks 7. The monsoon had just started – rain, heat, humidity from June to end August - and the diarrhea season (& mosquitoes too) Happens every year at this time….the Eastern Monsoon sweeps up from the Bay of Bengal each year, across Bangladesh and north-eastern India, and hits Nepal at much the same time each year - it’s a bit early this year…. but here it comes! The happy bit – usually this is a joyful time for many villages across Nepal – the monsoon rains are essential for rice planting and transplanting. If the monsoon fails, rice planting fails, food shortage follows, and malnutrition, diseases and death rates (especially in children) rise. So the monsoon brings much happiness as many areas of Nepal still face food shortages during the year. The awful bit – If the monsoon is severe it brings excessive rains, flooding and landslides. This brings misery to hundreds of thousands, as last year, and in 2017. Last year (2019) the monsoon caused 161 deaths, 51,300 homes destroyed and 413,500 people displaced including 170,000 children. Crops and livestock worth tens of millions of dollars were destroyed.

At Lalgadh Hospital the monsoon season is the busiest season. In the past few years at this time we treat 600-800 outpatients each day…. and on Sundays – our busiest day - it can get up to 900 a day. It’s the time of years for an increasingly wide spectrum of tropical nasties. Apart from leprosy there is an increase in skin infections, typhoid, tuberculosis (MDR - the nasty multi-drug resistant type), dengue fever, diarrhoeal diseases, cholera, malnutrition, malaria, meningitis, elephantiasis, chest infections and much more.

13 But I’ll keep this monsoonal madness for our next newsletter when the rain, floods, landslides and diseases are at their height. Next newsletter dear folks! 8. Devotions and the Gospel

Although the lockdown has stopped our Church Services down in Lalgadh Village, and stopped our having our evening fellowship, prayer and Bible Study evenings – (Ladies’ prayer meeting on Mondays, Bible Study on Tuesdays, Men’s prayer meeting on Wednesdays, All staff fellowship on Fridays, Church of Saturdays) … we still have the following:

• On-line morning prayer - 7am-8am every morning – from Koinonia Patan Church Kathmandu • Daily 10-minute Bible Study – on-line. Going through the Letter of James at the moment ; • On-line church services on Saturday from Koinonia Patan Church, Kathmandu • Other on-line services shared by some of the staff (who enjoy services in English) include Church of Scotland Geneva, and

Whites Chapel in Dallas, and St Andrew’s Cathedral Sydney. Every morning devotions (20 mins) are held in the hospital wards. Run by the nurses taking turns, it includes Bible reading, singing, a short talk, and prayers. Many patients come and enjoy and join in even though most are Hindu. It’s a good Gospel sharing opportunity.

Morning devotions yesterday with our patients – Anita reading the Bible (this-morning Psalm 116: 1-9)

Morning Devotions with our IPD patients - Staff Nurse Panina leading the singing today

9. International Nurse’s Day 12 May 2020 It was International Nurse’s Day one month ago - on 12 May. Also Florence Nightingale’s 200th birthday. Of course this is a much-looked-forward-to occasion for our Nursing Staff. They still see the “Lady with the Lamp” as a model for their own dedication and compassion which they put into their caring for leprosy patients here. So we had a terrific lunch-celebration in our Inpatients’ Ward, with two fabulous cakes.

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12. THANKYOU: Historically, it has been Christians who seek out and care for the poor, abandoned, leprosy-affected, sick and needy, staying to care for such as these irrespective of danger and disease, even when others flee. Our staff stay here in Province-2 at Lalgadh Hospital – there are much safer places - because of their faith, commitment and calling …. to be Christian “salt and light” for the world - serving the leprosy-affected with compassionate care, and holding forth the Gospel light through word and action. As with our last newsletter, here again is the response of Martin Luther, writing in 1527 when the Black Death – bubonic plague - which wiped out a quarter of Europe’s population, hit his home town of Wittenburg. When the town mayor and his friends urged Martin Luther to flee to safety, as had most of the town’s hierarchy, he resolutely determined to stay, saying…

“I shall ask God mercifully to protect us. Then I shall fumigate, help purify the air, administer medicine, and take it. I shall avoid places and persons where my presence is not needed in order not to become contaminated and thus perchance infect and pollute others, and so cause their death as a result of my negligence. If God should wish to take me, he will surely find me and I have done what he has expected of me and so I am not responsible for either my own death or the death of others. If my neighbor needs me, however, I shall not avoid place or person, but will go freely."

Thankyou all, dear friends, for your prayers, love, support and encouragement. You are in our prayers too. God bless!

The Clinical Team – Lalgadh Leprosy Hospital & Services Centre Dhanusha District, Province-2, Nepal

Our nurses … and dear Florence – on International Nurses Day 2020

Lalgadh Hospital web-site: www.nepal-leprosy.com Lalgadh Hospital FaceBook: www.facebook.com/nepal.leprosy