The cost of the vaccine is still to be worked out. But the idea is to have a mechanism based on solidarity and not on market forces.

Dr. Jos Vandelaer is the Former World Health Organisation Representative to Nepal, a post he held for five years since his appointment in 2015. Dr. Vandelaer began his career in 1986 working in emergencies in Sierra Leone, South Sudan, Surinam and Thailand with Medecins Sans Frontieres, an international humanitarian medical non-governmental organisation known for its projects in conflict zones and in countries affected by endemic diseases. Later he worked in migration and refugee health for the International Organization for Migration (IOM) in Vietnam and Croatia and Bosnia-Hercegovina and for United Nations High Commissioner for Refugees (UNHCR) in Myanmar. Since 1996 Dr. Vandelaer has worked in the field of immunisation and has held related positions with WHO in the Philippines, Myanmar and India. Prior to taking up his current position, Dr. Vandelaer was the Chief of UNICEF’s Global Immunisation Program, based in New York, USA. He led UNICEF’s headquarter’s Immunisation Team of about 20 professionals and was responsible for strategy development, program management, and coordination. In an interview with Avant Shrestha of B360 Dr. Jos Vandelaer talks about his time as the Country Representative of WHO to Nepal, the organisation’s work in the country, and his thoughts on the impact of Covid 19 on Nepal’s healthcare system and the economy.

As the Country Representative to Nepal, what were your key responsibilities and what kind of changes have you seen in Nepal in terms of health infrastructure over the past five years?

I arrived here in July 2015 which was just after the earthquake and during a time when the country was in full reconstruction and recovery phase. Following the devastating earthquake, the country got hit by the border closure which took care of the latter half of 2015. It was a very difficult year. So, my job in Nepal started in an environment where we had just begun to recover from the earthquake and once again, we were hit by the economic problem because of the border closure. But I realised and it is often the case in Nepal that Nepali people are very resilient and they were able to come out of such tough times and then life continued. My work here has been, on one hand - along with my team - helping and establishing development issues, and on the other hand, assisting emergency preparedness and emergency response. Our work here basically has been focused on a number of health-related issues.We have a very strong support in immunisation which has been exemplary for about 20 years already. We have various teams that work on communicable diseases like tuberculosis, malaria, leprosy and HIV. Then we have a team working on non communicable diseases, as that has started to become more important because it mostly attributes as a lifestyle disease. Plus we have teams working on environment issues, maternal health issues, emergencies and emergency preparedness. It’s important to know about WHO that we are not a donor as such. We are only a technical agency, and we mainly provide technical assistance. Yes, we do assist financially but we are not a donor in the traditional sense of the word. I am happy to say that over these five years we have achieved quite a number of things. These achievements of course are always in support of the government and support of the country. Nepal has experienced a shift in the last five years. We have achieved quite a number of things like trachoma elimination and control of rubella. And that has been building on our past presense. So, it has been a very interesting journey because from a public health point of view, we have had a very broad engagement with the government in particular, and with the people of Nepal.

You have been WHO’s Country Representative to Nepal for over five years. How would you describe your experience?

Well I can simply say that I have faced a new situation every day and learn something new every other day. And personally for me that was an important part of my job. As the representative, I have to represent the organisation with the donors, the government and with our various partners. But there’s also an important managerial aspect to it. We have a large team and managing a large team requires a lot of technical expertise. So bringing that all together on one hand requires more of the managerial effort and on the other hand, maybe more of the representation side which makes this job an extremely interesting one. And as I said about working in Nepal, every day there is somebody who tells you something that you didn’t know, either about the country or about a technical aspect of this job so it has been extremely interesting.

In your opinion, how prepared are we to feel the full brunt of the Covid 19 virus if the situation gets worse?

I think we have to see this as one epidemic. And it is very often difficult to divide it up in phases or waves. Because whatever preventative measures we are currently applying we will have its repercussions later on. So it’s not like you prepare differently for first wave and again prepare differently for the second wave. No matter what stage this virus is in, we have to continue to be cautious. So instead of being prepared for the second wave, we have to ask ourselves, how prepared are we in general for Covid 19. There are two aspects to this. The first point being; in all countries we have seen that this is a disease that makes it very difficult to be fully prepared for. The second point is that this is a ‘new disease’. For example, when Covid 19 was first detected, we knew very little about this disease and gradually we started to understand a little bit more about it and we started to understand that the disease is not as bad in younger people compared to elderly. As the virus progressed, we started to learn more about it and the global guidelines changed accordingly. For example, during the initial stages, many claimed that there was no need for a mask, and then at some point the guidelines was changed and deemed that masks are crucial and very important to stop the spread of the virus. So, it’s fair to say that we are operating in an environment that is new for everybody and regardless of how the virus is spreading everybody has to very cautious, follow the guidelines, and take preventative measures.

How do you view the kind of preparation Nepal has undertaken since the virus was first detected in the country?

I think given that context of what has happened in the world and in Nepal, we often focus on the problems. For example, we often hear stories of people not being able to find a hospital bed or people not getting the right treatment. However, a lot of positive things have happened as well. As a good example, I always refer to the testing capacity. In the beginning, we had just one laboratory and now we have 40 plus laboratories. A lot of investment has been done there and not just monetary investment, but investment in new resources and supplies as well. Saying that, I believe there is still a need for testing capacity to be increased. Similarly, the capacity of isolation beds for people who are infected has been built. And I realise that there is a lot of nervousness going around about the fact that we are going to be overwhelmed when infection rates surpasses our health care system’s ability to treat them. It has happened in a number of countries where there were more patients than actual hospital beds. We have to see how the epidemic develops. But in our part, we have increased the health sector’s infrastructure to handle this disease. The number of beds, medicines, medical equipment like oxygen tanks and PPEs has been scaled up. Laboratories and research centers and medical personal training have been scaled up over the last months. I believe the case investigation and contact tracing needs to be further improved. However, they are slightly more difficult because it requires a lot of manpower and requires a lot of people going out. In addition, the private sector and the medical colleges have been brought in, which shows that there is an ongoing flexibility in the reaction and the need to keep the spread under control. And these are the work that is going on in the background which gets very little attention but is actually a key element of the response. Lastly, as the infection rate increases, people recover at the same time as well. Every death in the country is one too many for sure. But if you compare it to the global average, the case fatality rate is much lower in Nepal. Partially this maybe because the population is a bit younger. We also see many asymptomatic cases in Nepal. We don’t fully understand why this is the case. But there are lots of efforts and works going on in the background in regards to fighting this disease and getting better prepared that I believe has helped so far in keeping the death rate low.

Previously you have emphasised on public private partnership and collaboration to contain the spread of Covid 19 in the country. How has the WHO been interacting with the public or the government to manage this pandemic?

Our mandate is to support the Ministry of Health in every country throughout the year; not just for Covid 19. However, for Covid 19, we basically had to repurpose the whole office during the time when the first lockdown was announced. We assist and collaborate with the government in the area of logistics, guidelines, training and communication. To do so we have directed our resources and manpower to research how to mitigate the spread of Covid 19. And the personnel we have assigned in the Ministry of Health or the Department of Health work hand in hand on a daily basis with their governmental counterparts to respond to this pandemic. So it was an extra pair of hands that we put into the Ministry and into the Department of Health and in other places where the government would require assistance. In addition to all our efforts in fighting Covid 19, there is still the need to focus more on the continuity of traditional health services and the essential services. Yes, there is a pandemic going on but we should not neglect the health services that were being carried out pre-Covid 19.

The government was under immense pressure to ease the lockdown. Do you think it was the right decision?

This is a very difficult question. When the lockdown was set in motion, what you are basically trying to achieve is to try to prevent further spread of the virus; to limit the number of people getting infected. Furthermore, by doing this you make sure that your healthcare system doesn’t get overwhelmed; for example, trying to make sure that you don’t have more cases than you can actually treat. With the lockdown, people are restricted to their houses and this is an attempt to slow down the spread of infection a bit over time. So eventually when the infection rate is at its peak, we would have a relatively lower peak and the infected people can have better access to treatment because the healthcare is not overwhelmed. That is one of the reasons why the lockdown was a necessary step. However, a lockdown in itself is actually forcing people to behave in a certain way. During the lockdown, people were cautious about their surroundings and took preventative measures. If people do that properly, we can avoid lockdowns. The issue is people are not really self-disciplined, not just in Nepal but everywhere else in the world. So, we have to continue to follow the guidelines of keeping social distance, wearing masks and so on. However, if such methods do not seem to be really working then the government has to step in. And again, with the lockdown there is no ‘one size fits all’ policy. Various economic and social aspects need to be considered before a lockdown is implemented. But then, of course a full lockdown is not a long term solution. People do need to work; people do need to go out, and people need to earn a living. So that is the difficult balance the government must make. From a health point of view, we have to consider that people have other aspects to life than purely preventing to be infected. And so if a lockdown is implemented for extended period of time, at some point, you have to weigh psychological and mental health side of the lockdown as well. The government should be able to balance all the factors. The economic aspect, the social aspect, the psychological aspect, the health aspect, that is what the government needs to do. And there is no right answer to that. These are all very difficult decisions and these decisions are the ones the government needs to take in order to reduce the spread of the virus and keep people safe.

How do you view the impact of Covid 19 on the economy? What kind of preventive measures can we apply at the workplace as we move forward in this new normal?

Covid 19 has definitely had an economic impact in the country and it certainly has affected businesses. Due to the lockdown there is no transport, people could not go out, they couldn’t buy anything, they couldn’t go to work, companies can’t sell anything, and workers couldn’t earn anything. When the lockdown was lifted, there was some breathing space for the economy and businesses could start getting back to normality. Of course, there are a couple of sectors that are still affected, particularly cinemas, where there has to be larger group of people. But the main problem of lifting the lockdown and business resuming again is that we have the tendency to think that just because businesses are open the pandemic is over which obviously is not the case. For example, what we tend to behave in a manner similar to pre-Covid times when we see that the shops and restaurants open for business. Such behaviors then of course give the virus a chance to spread. So my advice to the businesses would be to make sure that the virus doesn’t spread too easily in your workspace. Set up your business in such a way that the virus cannot spread too easily. The preventative measures would be different from business to business but it is an important step to take. The same goes for restaurants, factories and public transport. All the preventative measures such as maintaining social distancing, wearing masks, washing hands properly is still as important as in the initial days. Again, business owners should be able to take individual responsibility when it comes to their own setup.

How close are we to finding a vaccine? What does it mean for a nation like Nepal?

When vaccines are developed, they have to go through various phases of testing in regards to its safety protocol and its effectiveness. And normally these phases are done one after the other and it takes time. However, because of the pandemic a lot of these different steps are being done at the same time. Normally you don’t do that. While producing a vaccine, we have to wait for one phase of development and move on to the next phases, and when you are sure the vaccine is working then you receive your license and then you start producing. So that process takes a couple of years. But currently by doing everything at the same time, the manufacturers are basically trying to develop the vaccine in a short timeframe.We already have information that some of the manufacturers are producing vaccines at a large scale although the vaccine is not yet approved. So these companies are taking a huge risk because they may end up with a stock of vaccine that may not work and thus have to throw away. There are at least 100 vaccines in the pipeline and a dozen or so are in the final phases of trial. As for the results, we will probably get more information in a couple of months and be better informed by the end of this year. The idea is that by the end of 2021, about two billion doses in total will be produced because the assumption is that each individual needs two doses of the vaccine. And these two billion doses would therefore be enough for about one billion people. So the idea is that they become available throughout 2021. All these are speculations, I mean nobody really knows the correct timeline or when the vaccine is coming out but when it does the idea is that first people to get immunised would be health workers and people with underlying health conditions and older people because we know if they get infected their chances of dying is higher. And the doses that are being produced in 2021 will probably be sufficient worldwide. And by 2022 the hope is that everybody else will start receiving the vaccination.

Will Nepal get a subsidised rate on the vaccine?

There is a traditional method which is also likely to happen here. For example, traditionally you have manufacturers who produce vaccine; they take it to the market and sell it to whoever wants to buy it for a given price. If that would happen, Nepal would be in a disadvantageous position because Nepal cannot compete with more developed countries on price. So, that would be the normal way of the market working and in case of the vaccine in a country like Nepal, it would not be something to look forward to because Nepal would probably not be among the first to get a vaccine. However, to avoid this predicament, at the global level WHO has set up a facility called COVAX. COVAX is one of the three pillars of the Access to Covid 19 Tools (ACT) Accelerator, which was launched in April by the World Health Organization, the European Commission and France in response to the pandemic. COVAX aims to bring together governments, global health organisations, manufacturers, scientists, private sector, civil society and philanthropy, with the aim of providing innovative and equitable access to Covid 19 diagnostics, treatments and vaccines. COVAX focuses on how to distribute the vaccine and how to make it affordable. To answer the question of how do we fund this, how can we make sure that people at risk in Nepal will get the vaccine once its available, actually the financing aspects bring together rich countries and comparatively less richer countries. The richer countries put in money in the pot and buy vaccine for themselves. The pot of money is being further topped up to pay for vaccines that are for less richer countries and these said countries can apply and will get the vaccine at a subsidized rate (not decided yet). The cost of the vaccine is still to be worked out. But the idea is to have a mechanism based on solidarity and not on market forces. We have to consider that we are all in the same boat here. Some of us as countries, we may have more money but because we are all in the same boat, if we have more money, we should be able to make sure that number one we don’t take everything and number two, we make it possible for the poor countries to also get the vaccine. So that is the solidarity mechanism which already exists for other vaccines. Additionally, there is Global Alliance for Vaccines and Immunisations (GAVI). They have a system which Nepal also benefits from for quite a number of vaccines, where the vaccine is bought, the government pays a small amount and GAVI pays the rest. And as countries become richer over time, their share becomes higher and they have to pay more as their subsidy decreases.