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May 25, 2015

Some thoughts on Dr. Sack's important question on OCV delivery - Part 4 of 6 part series

It is been complete 3 weeks. I came here soon after first big Earth quake hit Kathmandu valley and those Northern  as well Southern hill districts with huge loss of life and infrastructure damage. If we calculate these losses in terms of monetary value, then I think, never before in our history have we suffered so much like in 2015!! However, I found  that we Nepali people are sturdy on close observation. Also, one essence of goodness that we possess is acceptance of "what it is as it is". That means - we have a capacity to accept death and nature's brutality so comfortably. 

During this period of hardship, each of us have to contribute from our position at whatever capacity we possess at individual and professional level. We do understand, immediately aftermath of Earthquake - triage, safety, food, security, injury treatment and efficient management of relief task is always of highest priority, however once time moves forward and healing of acute trauma ensues then there is always our secondary priorities that relates to preparedness of possible infectious diseases outbreak. In this line - I have the same question as raised by Dr. Sher Bahadur Pun, "Are we prepared to respond to  possible outbreaks of infectious diseases?" I know this is such an important question that revolves and strikes different corners of the government mechanism and processes, while in this pertinent threat that Dr. Pun has timely raised also comes the important role of citizens, field of journalism, professionals, opinion leaders and of course - civil society to address and raise concern for preparedness and its action. In this preparatory effort - effective leadership is key so any action taken is timely, focused and evidence based rather than only political. In this light - a senior public health professional said in a casual talk - "You like it or not - public health politics is important and we have to learn to play the game judiciously so we know where we are going and where to act !!" I also think, this is important - key message would be "Politics for better or worse plays a crucial role in health affairs." This is relevant to the public health politics of cholera and its preventive measures. I know, this is a bit rash for some corners involved in this affair of public health policy of implementation and its administration. However, the ground truth is that we all linked up knowingly or unknowingly to web of interests that may be guided by true passion or just of the shake business. For me what count the most is passion of involvement. In this regard, I always stick and commit to the opinion that fruits of science like vaccine for cholera or typhoid fever that are purely developed for the benefit of humanity have to be available to the community. There should be fast track or expedited process for its use or even untangle the administrative web if its use is ethical based on comprehensive safety, efficacy and effectiveness data. 

Going back to the same question that Dr. Sack raised: "How to handle the mismatch between the actual needs and the use of tools available?" This is a challenge that I consider interesting since I foresee solution in near future and that will be based on efficient advocacy and concerted efforts that will bring local government, international partners and most important would be to bring local opinion leaders on board - this will include doctors, civil society and famous figures. Also, I have considered these challenges and mismatch as "a guru" for our learning to negotiate through the climate of uncertainties. Now in Nepal, we are working closely with government in preparedness to respond to possible outbreak should it occur in affected district post earthquake. We are of the same opinion like all learned personalities that Water Sanitation & Hygiene (WASH) strategy is the key approach to control and prevent possible outbreaks of diseases like cholera. However, should the threat outweighs and the risk of outbreak is extremely high in remote areas of the affected districts, then acting upon preemptive vaccination along with WASH measures should be highly considered. No one denies this universal fact and nobody has an intention to go against the prevailing wisdom.This consideration is aligned with the WHO cholera vaccine position paper (2010). Nonetheless, we strongly assert that there should not be any delay in the name of professional interest or I would call it in literal meaning "compartment syndrome" that we decide from here in the capital the fate of peoples living in extreme condition due to Earthquake and on top of that, people exposed to extremes of nature's cruelty - landslide, flooding, when monsoon is just a little more than a month away. Understanding the ground situation - myself who also survived cholera / viral hepatitis during younger days, I strongly urge all to think twice how we decide and act for common good at this hour of national distress. Most important point that we hear from everybody on close conversation is the "real" threat of acute diarrheal illness in the remote and high risk areas!! So the relevant question everybody is asking: "Will the outbreak be followed by cholera outbreak in Nepal given the situation that Vibrios cholerae are in circulation and reported in academic journals?" For details, we can read Dr. Lorenzo Von Seidlein, from the DOVE project ( in his PLOS blog post at

Anuj in Himalayas

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