key: cord-0895070-rshlenku authors: Sah, Ranjit; Sigdel, Shailendra; Ozaki, Akihiko; Kotera, Yasuhiro; Bhandari, Divya; Regmi, Priyanka; Rabaan, Ali A; Mehta, Rachana; Adhikari, Mahesh; Roy, Namrata; Dhama, Kuldeep; Tanimoto, Tetsuya; Rodríguez-Morales, Alfonso J; Dhakal, Rachana title: Impact of COVID-19 on tourism in Nepal date: 2020-07-07 journal: J Travel Med DOI: 10.1093/jtm/taaa105 sha: 57049ded73e23daddd127c0f4c200740f2e079f5 doc_id: 895070 cord_uid: rshlenku nan *To whom correspondence should be addressed. Tel: +9779851123474. Email: sailendra.sigdel@mmc.tu.edu.np † Ranjit Sah and Shailendra Sigdel equally contributed to this work. ‡ Namrata Roy: https://orcid.org/0000-0001-7389-9246 Submitted 16 May 2020; Revised 15 June 2020; Accepted 16 June 2020 We read the recent article by Shrestha et al., 1 about Nepal's first case of COVID-19 and public health response with great interest. Despite recent progress and the government's commitment to reduce the absolute poverty rate to 16.7% from 18.7% last year, 2 the World Bank forecasts that 31.2% of Nepalis are at risk of falling into extreme poverty, primarily because of reduced remittances from overseas workers, foregone earnings of potential migrants, collapse of the tourist industry, job losses in the informal sector and increased cost of essential commodities, all as a result of COVID-19. 3 COVID-19 related deaths worldwide were approaching 400 000 as of 1 June. The effects of COVID-19 on the global economy have been and will be, catastrophic. However, the full global impact, in both economic and health terms, remains unknown. The consequences in low-and middle-income countries, such as Nepal, where national economies rely on a small number of services and industries, are deeply worrying. Tourism is one of Nepal's largest industries. Tourism revenue in 2018 accounted for 7.9% of the country's Gross Domestic Product (GDP) and supported >1.05 million jobs, with the expectation of providing >1.35 million jobs by 2029. 4 Nepal hosted 1.19 million foreign tourists in 2019, and the 'Visit Nepal 2020' campaign, officially introduced on 1 January, aimed to attract 2 million tourists, generate $2 billion and create thousands of new jobs. However, on 23 January, the first case of imported COVID-19 was detected in Nepal. In response to cases worldwide increasing exponentially and amid growing public concern, the government suspended the 'Visit Nepal 2020' initiative on 3 March. Shortly after the World Health Organization (WHO) declared COVID-19 a pandemic on 13 March, the government suspended all permissions for mountaineering expeditions and suspended all visas. After confirmation of the second imported case on 23 March, the government locked the country down and suspended all national and international flights. Massive cancellations of hotel and tourist bookings followed, resulting in widespread unemployment, loss of income and threatened livelihoods for thousands. The collapse of international and domestic tourism followed a 2% drop in tourist arrivals in January 2020 compared to 2019. 5 Over 10 000 tourists who had entered Nepal before the lockdown was also left stranded, although many of them were eventually repatriated. Remittances from 3.5 million Nepalese living and working abroad account for almost a quarter of the country's GDP. Since 2009, Nepal's Department of Foreign Employment issued over 4 million permissions to migrant Nepalis working in 110 countries. 6 When the 2015 earthquake hit Nepal, foreign remittances jumped 20%, cushioning families against the financial shock of the disaster. COVID-19 is set to have a much worse economic impact than the earthquake and the migrant worker saviours have themselves become a problem. International flights are banned, keeping job-seekers at home and stranding migrant workers abroad. On 24 March, the government's High-Level Coordination Committee for Prevention and Control of COVID-19 informed Nepalis abroad to remain where they were and appealed to host countries to offer them protection. Many have been laid off and are unable to return home. In some countries, migrant workers are still employed but the safety and health of all are jeopardized by the pandemic. 6 The government is currently investigating the repatriation of workers stranded in COVID-19 affected countries, even though this may place extra strain on the nation's health system. Healthcare systems of any country depend on the economy and Nepal's lost remittances and tourism revenues have crippled the nation's finances. Loss of income has concomitant adverse impacts on the health of all citizens. Funding from donor countries to help Nepal's health system, which constitutes around 50% of the health budget, 7 will probably decrease, as donors are also suffering from the pandemic, although billions of dollars have already been pledged to help Nepal's COVID-19 response. Unfortunately, the move to federalism, work to overcome regional health disparities, and attempts to accomplish the Sustainable Development Goals and improve the nation's poverty rate have all been set back by the pandemic. Fortunately, Nepal has so far evaded the full impact of COVID-19. As of 31 May, there were around 1500 confirmed cases, most of which were asymptomatic, with only eight deaths. Yet Nepal has insufficient resources and manpower for the massive testing and treatment of people that may be needed. Currently, Nepal has 18 000 doctors and 35 000 nurses working in 500 public and private sector hospitals, but there are only around 1100 critical care beds and 600 ventilators for a population of 28 million. 8 Because of the high prevalence of the respiratory disease in Nepal, due to air pollution, large numbers of cigarette smokers, and widespread indoor combustion of biomass fuels, coupled with weak health care facilities, the country will likely experience a high death toll if community transmission of COVID-19 does occur. Furthermore, the country's public health and social support systems will be put under great strain to cope with a flood of returnees from abroad, especially via the border with India. All returnees will need to be tested, quarantined, fed and sheltered. At present, concerted efforts are being made to resolve the lack of testing kits, PPE and medical supplies. 9 Diagnostic and treatment protocols have been established. As of 30 May, the government has established RT-PCR labs in each province and testing is now available in 20 centers in Nepal and 127 hospitals have been designated as COVID-19-ready. 10 So far >60 000 RT-PCR tests have been carried out. Emergency medical deployment teams has been established in the hub hospitals and medical colleges and is planning to mobilize them as per the need of the provincial and other hospitals. All points of entries at international airport and ground crossings are strengthened with a dedicated standard health desk equipped with adequate human resources and necessary commodities. The pandemic has already challenged Nepal's economy and the healthcare system. The resurgence of tourism may take longer than witnessed after the 2015 earthquake and remittances may not normalize soon. The government is taking steps to invest significantly in Nepal's agricultural sector and is planning to incentivize migrant workers to stay and work in Nepal, as a means to boost the country's economy in the long-term. The COVID-19 pandemic has sensitized the entire population as well as central and local authorities to the need for quality in healthcare. The government has increased the health sector budget to over 6% for the coming fiscal year, although this is still well below the recommendation of WHO (10%). The pandemic necessitates long-term extreme measures to prevent healthcare facilities from being overwhelmed. The extent of the impact will depend on COVID-19 progression and the country's ability to cope. Thus, there is a profound need for all stakeholders to take a far-sighted view and plan how best Nepal can, in the future, offer an appropriate and affordable healthcare service to its citizens. Nepal's first case of COVID-19 and public health response COVID-19 Batters hopes of sound economic growth The world Bank In Nepal Nepal tourism generated Rs240b and supported 1m jobs last year: reportt Visit Nepal 2020 Tourist Arrivals: 2% Drop in January Nepali labor migrants, Covid-19, and the state Foreign aid, and development in Nepal Coronavirus in Nepal: laborers returning home allege bias in hospitals. Anadolu Agency Covid-19 pandemic: public health implications in Nepal Situation update-coronavirus disease (COVID-19). WHO Country Office for Nepal None. AO and TT receive personal fees from MNES Inc., outside the submitted work. None.