As Nepal deals with a growing number of COVID-19 cases and prepares for an influx of citizens returning home from abroad, it is imperative that rational, humane, and effective public health measures are implemented to ensure minimal suffering and loss of life while preventing further spread of the disease in the country. In an effort to reduce the risk of community spread of COVID-19, the federal government has mandated that local authorities quarantine Nepalis returning from abroad for 14 days. Public health policies and measures against a disease, during a pandemic or otherwise, are useful --and ethically and morally justifiable-- only if they reduce death and suffering, not exacerbate them. Quarantine—an important disease control measure -- involves physical separation of people exposed to a contagious disease to see if they become sick during the disease incubation period. However, at the local level, resources and technical expertise needed for the proper implementation of quarantine are lacking and therefore, the quarantine facilities may inadvertently be helping to spread the virus rather than control it. With the expected surge of migrant workers returning home across rural Nepal, the challenges of implementing an effective quarantine system will be even greater. Therefore, at-home self-quarantine for the returnees may be the most viable, effective, and humane option for minimising needless suffering in inadequate facilities while limiting disease transmission and deaths. Over 5 million Nepalis are working abroad primarily in India, Malaysia, and the Middle East. The COVID-19 outbreak in these countries and the collateral impact of the disease is creating substantial health and economic security risks for Nepalis there. As of June 3, 2020, the reported COVID-19 rate in Qatar, where about 400,000 Nepalis work, was 2,214 cases per 100,000 people. In India, where 3-4 million Nepalis work, the reported COVID-19 rate was 16 cases per 100,000 people. More specifically, Mumbai and Delhi-- where many Nepali migrants work-- were reporting the highest COVID-19 rates in India at 200 and 140 cases per 100,000 population. If 100,000 Nepalis returned home from these cities in India, we may expect about 100 - 200 individuals would either have an active infection or show evidence of a past infection. The risk would be lower if they were returning from other parts of India. If 100,000 Nepalis returned home from Qatar, about 2,200 would currently have or have had COVID-19. The policy of quarantining Nepalis returning home from other countries implies that these individuals were exposed to the virus and need to be quarantined to prevent them from potentially transmitting the virus to others in the community. However, only a small fraction of them are likely to be infected. Holding tens or hundreds of individuals in inadequate quarantine facilities together, however, is a recipe for COVID-19 outbreaks to occur in these facilities. Congregate settings are one of the highest risk categories for COVID-19 transmission and there is evidence to suggest that the transmission in Nepali quarantine facilities may already be occurring. Those outbreaks eventually will likely spill over into the general population. Currently, the quarantine facilities in Nepal are mostly holding Nepalis returning from India. So, how is it possible that the COVID-19 rate in these facilities is more than 2-times over what is observed in the COVID-19 epicenters in India? There are three possible explanations for this observation: First, it is likely that testing rates are low in Mumbai and Delhi, and therefore, the reported incidence rates are likely underestimates. Second, it is possible that people are picking up the infection in route back to Nepal. The third and most plausible explanation is that the individuals are getting infected in the quarantine facilities in Nepal. Even if all three explanations are true, transmission of the virus in the quarantine facilities is counter to the intended purpose of a quarantine regimen. This calls into question the utility of having these facilities that may be spreading the disease and risking lives. In addition, the inadequate quarantine facilities are likely putting people at risk of other diseases, mental health stress, and other unnecessary trauma and suffering. Therefore, instead of gathering people in inadequate quarantine facilities, the better option may be to facilitate their journey home where they can self-quarantine. In addition, provide them information on methods to keep their family safe and healthy during their quarantine period. At the local level, if necessary, provide individuals a place to sleep if their home situation does not allow for physical distancing. Instead of mandating people live in difficult quarantine conditions that are likely ineffective and may also be causing more harm than good, trust the individuals and allow them to self-quarantine. Most people are sensible, responsible, and reasonable. They will make the right decisions while observing self-quarantine; they will take the necessary precautions to protect their families and communities. And, if you know anything about living in rural Nepal, everyone in a community will be aware of someone who had just returned from India or abroad, and no doubt, people will know to keep physical distance from those in self-quarantine. Again, public health policies and measures are useful, and ethically and morally justifiable, only if they reduce death and suffering, certainly not exacerbate them. The current quarantine policy towards migrant workers returning home to Nepal does not meet this test. Therefore, it may be time to rethink the policy and replace it with a more effective and humane self-quarantine-at-home measure, especially in rural areas.
(Born in Baitadi district, Madhav P. Bhatta, PhD, is a Professor of Epidemiology and Global Health at Kent State University College of Public Health, USA.)