Intended for healthcare professionals


Twin crises in Nepal: covid-19 and climate change

BMJ 2022; 377 doi: (Published 09 June 2022) Cite this as: BMJ 2022;377:o1434
  1. Basu Dev Pandey, doctor and professor12,
  2. Kouichi Morita, professor3,
  3. Anthony Costello, professor of global health and sustainable development4
  1. 1Everest International Clinic and Research Center, Kathmandu, Nepal,
  2. 2Department of Molecular Epidemiology, Institute of Tropical Medicine, Nagasaki University, Japan
  3. 3Department of Virology, Institute of Tropical Medicine, Nagasaki University, Japan
  4. 4University College London, UK

Nepal has been on the frontline of both the covid-19 pandemic and climate change, and in both crises the response by the international community and Nepal’s government has been marked by a failure to prepare or to invest proactively in strong prevention measures.

The first case of covid-19 in Nepal was reported in January 2020 and the country’s modest first wave peaked in late October 2020 with a case fatality rate of less than 1%.12 As cases fell steadily in January 2021, the government relaxed—a response that would turn out to be premature.

Throughout spring 2021, hundreds of thousands of people assembled on the streets in party political activities to prepare for the May election, adding to the number of people already joining gatherings for seasonal weddings and religious festivals. Meanwhile, in March 2021 the new delta variant, considered more infectious and virulent by the World Health Organization (WHO), was contributing to surging case numbers in India.3 In April, at a time when cases in India were steadily rising, an estimated 50 000 Nepali pilgrims went to northern India for Kumbh Mela, a Hindu festival participated in by millions of people.4 While there, many of the pilgrims caught covid-19.

Thousands of migrant workers also crossed over into Nepal from India, bringing the Delta strain with them, where it spread rapidly through the populous Kathmandu valley.5 In Kathmandu, the hallways and courtyards of hospitals became crowded with patients competing to get a bed linked to an oxygen supply. Many patients were turned away due to lack of oxygen, ICU beds, and ventilators. Nepal’s president called a state of health emergency and 75 out of 77 districts had imposed a lockdown by 23 May. Nepal’s Ministry of Health and Population (MoHP) reported the country’s highest number of daily deaths (246) so far on 19 May 2021.6

Restrictions were lifted as cases fell in July 2021 but the number of deaths surged again in August with a test positivity rate of 24% and more than 2500 cases recorded per day.7 Many people in Nepal’s scattered rural population lack access to tests and deaths go unrecorded—a situation that is little different from India, where estimates suggest there were as many as 3.4-4.9 million excess deaths from the pandemic’s start to June 2021, numbers that are around 10-fold higher than official reports.8 Hospitals and ICUs were full again during this period, including many severe cases in children. This wave hit the country so hard because communities were unprepared, the government had a false sense of security, residents relaxed social distancing, and authorities allowed religious festivals and political gatherings to go ahead as normal. The country still faces shortages of oxygen, ventilators, and other intensive care equipment.

Vaccines could have helped to relieve this pressure on Nepal’s hospitals, but the country has been beset by difficulties in obtaining them. At the end of March 2021, at a crucial point in the pandemic, India banned exports of AstraZeneca jabs until 2022.9 This included one million doses already purchased by Nepal. By 11 December 2021, just 30% of the population had received two doses of the vaccine.10 Nepal was not in a strong position then as the new omicron variant emerged and began to spread globally. First reported in Nepal by its MoHP in late December 2021, the omicron variant peaked with more than 10 000 daily cases on 18 January 2022.1112 More than 600 healthcare workers at the five biggest public hospitals in Kathmandu were infected and their absence added to the strain on the health system.12 The number of daily deaths was much lower in the third wave (32 at its peak compared with 246 in the second wave) and cases dropped quickly to 2.9 per 100 000 population at the national level by the first week of March.131415 As before, the India-Nepal border was without strict screening, social distancing restrictions were relaxed, and compliance with public health protocols was often poor, all contributing to this third wave. But the introduction of covid-19 vaccination undoubtedly helped to reduce hospitalisations and mortality.

Against the backdrop of the covid-19 pandemic, another crisis unfolded. The annual monsoon season beginning in June 2021 brought flooding and landslides like never before across many of Nepal’s districts. Major rivers and streams swelled dangerously, and people lost their lives. After 200 mm of rain fell in six days up to 14 June, floods from the Melamchi river alone swept away 13 suspension bridges, seven motor bridges, and numerous stretches of road, destroying 337 houses, 259 enterprises, and thousands of acres of rice paddies.16 The risk of flooding grows as glaciers in the Himalayas melt as a result of both rising temperatures and the proliferation of black carbon deposits from industry, vehicles, and cooking.17

The government was overwhelmed, lacking as they do comprehensive plans for monsoon flooding. They mobilised the army and the Red Cross to assist communities, and arranged safe areas, drinking water, and food supplies. But they have no early warning systems, no anticipatory plans in place, and poor communication with many officials in local municipalities. A flood warning via Twitter was only sent out on 16 June—two days after dangerous flooding was first reported.18 The country’s disaster budgets are tiny and procurement law does not allow relief materials and equipment to be bought in advance—only after disaster strikes subject to government approval.19 Policies that build resilience against climate related disasters should be a top priority for the government because, while the pandemic may recede, the impacts of climate change will only worsen.

The latest reports from the Intergovernmental Panel on Climate Change have been red alerts for the world, describing climate change as widespread, rapid, and intensifying.20 The mountain ranges of South Asia contain almost 55 000 glaciers that store more freshwater than anywhere but the North and South Poles. A World Bank report estimates that global black carbon emissions could be cut in half with policies that are currently economically and technically feasible, allied with the cuts in carbon emissions set out in the Paris Agreement.21 Without urgent action, glacier melt will threaten hundreds of millions of people in Nepal, Afghanistan, India, Pakistan, China, and beyond.

As a low income country, Nepal deserves much greater international support through the Covax scheme to provide vaccines, diagnostics, and treatments, and for climate resilience through the “loss and damage” funds agreed at the COP26 summit in Glasgow. At the same time, Nepal’s government could have done far more to mobilise preventive and responsive measures for these twin crises; making sure the country is better prepared for the next one must be a priority.


  • Competing interests: None declared.

  • Provenance and peer review: Not commissioned; not peer reviewed.