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People smoking, chewing tobacco, and more recently vaping in public are some of the common scenes in Kathmandu. Although the city authority has banned the consumption of tobacco products in public places, the veto has not been effectively enforced. All forms of tobacco are harmful, and there is no safe level of exposure to tobacco. Cigarette smoking is the most common form of tobacco use worldwide, the World Health Organization (WHO) says. Other tobacco products include various smokeless tobacco products, cigars and e-cigarettes. The Kathmandu Metropolitan City reintroduced the ban on the consumption of all forms of tobacco products in public places on 17 Sept 2022, following a decision by the eleventh municipal executive meeting. “The ban on tobacco consumption in public spaces has been imposed to protect public health,” the KMC notice says. If the authorities are really concerned about public health, the ban should be properly implemented. Also, the government must raise the tax on tobacco products, experts say. Earlier too, in March 2019, the KMC had announced a ban on smoking and tobacco use during Bidya Sundar Shakya’s tenure as the mayor. Before that in 2016, the Metropolitan Police Range Kathmandu had stepped up action against smoking in public places. The KMC has even imposed a fine of Rs 100 against those violating the rule of consuming cigarettes in public spaces. Still, the ban has not worked. “The bans announced by the city and police have only been on paper,” says Dr Jaya Kumar Gurung, senior research specialist at Nepal Development Research Institute, calling for an effective implementation. Law governing tobacco control Nepal signed the WHO Framework Convention on Tobacco Control (WHO FCTC) on 3 Dec 2003. After its ratification on 7 Nov 2006, the country became a party to it on 5 Feb 2007. Based on the WHO FCTC, the government has enacted laws and procedural documents aiming at tobacco control. The Tobacco Product (Control and Regulatory) Act 2011 is the primary law governing tobacco control in Nepal under which public places where smoking has been banned are—hospitals, health institutes, public offices, public transport, court buildings, educational institutions, libraries, and auditoriums. The ban also applies to hotels, motels, resorts, restaurants, bars, dining halls, canteens, lodges, hostels, guest houses, stadiums and sports facilities. The Act also states that the sale of cigarettes and other tobacco products is illegal within a 100-meter radius of educational institutions, healthcare facilities, childcare centers, and old-age homes. But the rules on tobacco use are almost never followed. Steps survey According to the Steps Survey 2019, conducted by the Nepal Health Research Council, 3.8m people in the 15–60 years age group use tobacco in some form—smoked or smokeless. At 48.3 percent, male have over four times higher prevalence than 11.7 percent of women. The prevalence rate is increasing for smokeless tobacco. According to the survey, 17.1 percent of adults, which equates to 2.8m people, smoke tobacco products in the country. Around 3m people—18.3 percent of adults (33.3 percent of men and 4.9 percent of women)—use smokeless tobacco. Health impacts Tobacco use leads to more than 8m deaths worldwide each year, according to the WHO. More than 7m of those deaths are the result of direct tobacco use, most of them from low- and middle-income countries such as Nepal. Smoked tobacco products contain over 7,000 chemicals, including at least 250 chemicals known to be toxic or to cause cancer. Use of smokeless tobacco products can result in serious—sometimes fatal—health problems. Tobacco smoke damages the arteries of the heart, causing the build-up of plaque and development of blood clots, thereby restricting blood flow and eventually leading to heart attacks and strokes. Tobacco use (both smoked and smokeless) is responsible for a significant burden of oral disease. Both forms are known to cause mouth cancer, increase the risk of head and neck cancers, Women who smoke or are exposed to second-hand smoke during pregnancy are at an increased risk of miscarriage. The UN health body says that around 1.2m deaths result from non-smokers exposed to second-hand smoke. In Nepal, 3.7m adults (22.5 percent) are exposed to second-hand smoke at the workplace and 5.5m (33.5 percent) at home, the Steps Survey found. E-cigarettes These days, traditional cigarettes are being replaced by e-cigarettes. The use of e-cigarettes is particularly high among the young population—even schoolgoing children—because they come with various flavors like candies and do not leave behind the smell of traditional cigarettes. According to the WHO, e-cigarettes emit nicotine, the addictive component of tobacco products, which can have adverse effects on the development of the fetus during pregnancy and may contribute to cardiovascular diseases. In Nepal, e-cigarettes do not fall within the scope of existing national legislation on tobacco production, distribution, and use. Public health experts warn they pose significant health risks similar to conventional cigarettes. “The government must not ignore e-cigarettes and hookahs available in the market. They are equally harmful for public health,” warns Dr Gurung. “Laws should be enacted to regulate them.” The Tobacco Products (Control and Regulatory) Act 2011 has divided major forms of tobacco use in Nepal into two categories: smoking and smokeless tobacco products. Smoking includes cigarette smoking along with hand rolled cigarettes (Bidis). Smokeless tobacco products include Gutkha, which contains areca nut, tobacco, catechu and sweet flavor; Zarda-Paan or betel quid, rolled betel leaf with lime, betel nut and tobacco; Khaini, flavored tobacco mixed with lime; and Sokha, non-flavored raw leaf of tobacco crushed manually, mixed with lime and rolled in hands before use. Importance of tax on tobacco Experts say taxation plays a vital role in effective tobacco control measures. The current tax rates imposed on tobacco products in Nepal is considerably low. Despite increases in tobacco tax rates during the past two fiscal years 2021/2022 and 2022/2023, the percentage of tax relative to the retail price in Nepal remains at a mere 41 percent. The WHO has recommended a minimum taxation rate of 75 percent to effectively discourage tobacco consumption, but Nepal’s low tobacco tax policy has made tobacco products easily accessible to all. The government has implemented a three percent increase in the excise duty on tobacco for this fiscal year; there has been no increase in the Health Hazard Tax. “When accounting for the estimated inflation rate for the upcoming fiscal year, the overall percentage of tax will decline overall to 39 percent from the 41 percent, further hampering efforts to reach the WHO recommended 75 percent and to effectively control tobacco use,” says Anjana Lamichhane, research associate, Nepal Development Research Institute. Experts believe increased tobacco tax can drastically discourage tobacco consumption and reduce the prevalence of tobacco-related diseases, leading to sustained high morbidity and mortality rates. “If we are aware about the health of the public, the government must fix the minimum taxation rate of 65 percent to reduce its consumption,” suggests Lamichhane. “The government should increase the tax on tobacco products to raise the income of the country. If the government raises the tax on tobacco products then the income generated from there will be given to the Ministry of Health and Population. If the income of the health ministry increases it will use it in enhancing the health services in the country,” says Dr Sushil Nath Pyakurel, former acting health secretary.

Mahesh Bikram Shah is a Nepali writer and a retired policeman who has authored several short story collections. Some of his notable works are ‘Sataha’, ‘Kathmandu ma Camrade’, ‘African Amigo’, ‘Bhuinkhat’ and ‘Sipahiki Swasni’. Among them, his short stories collection called ‘Chhapamar ko Chhoro’ was awarded the ‘Madan Puraskar’ in 2007. Anushka Nepal from ApEx talked to Shah about his dedication to continuing writing despite having a full-time job. From being a police officer to an award-winning author, what was the journey like? I worked as a police officer for 30 years and I carried my career in writing. I have been interested in literature since I was a child, and have previously published a few of my works in Nepali newspapers too. I stopped writing while I was in high school since studying science didn’t give me a lot of time to focus on it. But deep down I knew I would definitely become a writer someday. I think it’s that dream that made me get back to writing again. I loved writing so much that I didn’t mind doing two things at the same time. My attachment to writing and literature never waned. How did you manage to juggle writing with a full-time job? I was lucky enough to get posted at Bharatpur Police Training Center in Chitwan where I was surrounded by an academic environment. And the job wasn’t as hectic as it would be if I were posted somewhere else, like in a department where I would have to be on site a lot. That gave me some leisure time to start writing again. I wrote stories and poems that reflected on the lives of the people from Tikapur, Kailali, my hometown in the western part of Nepal. That’s how it started. And I never discontinued writing after that. How did you feel when your writing first got published?  It was a poem I wrote that got published in one of the newspapers. I was quite young at that time. The amount of joy I had cannot be described in words. I was proud of myself and every time I saw my name in print, I would have a smile on my face. When I published my first book, I realized that I had finally achieved the dream of becoming a published author. Not just that, I knew I could do so much more and write many other books with the recognition I had received. It was a surreal experience. What’s the inspiration behind the books you write? It’s the things I have seen, experienced, read, and heard about that inspire me to continue my work. I also like to listen to other’s experiences and understand their pain, and suffering, as well as their happiness, which can be incorporated into my writings. So, in short, it’s the small things that happen in our society that inspire me. I’m someone who can never come up with a storyline if I sit down and start thinking. It’s the things that I see, hear, or experience that gives me the idea of what I can write about next. How do you come up with the plots and characters? Whenever I get an idea for a story, I already have an outline in my head of how I can start and conclude my story. I’m also aware of the behavior and personality traits I would like my characters to have. So basically, I just write down whatever I have on my mind. Yes, there will be some changes in between and I might come up with some new ideas. But the framework remains the same. I think the most important thing about planning your story is to know exactly what the moral of your writing is going to be. A writer must be clear on what he wants to say through his stories. Only then can you frame it well. Any authors/books that have inspired you? I grew up reading the works of BP Koirala, Parijat, Govinda Bahadur Malla, Ramesh Bikal, Laxmi Prasad Devkota, Rabindranath Tagore. and Premchand. So I would have to say these are the writers who have inspired me to become a writer myself, especially when it comes to writing stories and poems. Shah’s picks Madhabi by Madan Mani Dixit ‘Madhabi’ by Madan Mani Dixit is a Nepali mythological novel published in 1983 by Sajha Prakashan. The book won the Madan Puraskar in the same year. Sumnima by BP Koirala ‘Sumnima’ is a novel written by BP Koirala. The book was published in 1969 by Sajha Prakashan and it tells the story of a Kirat woman and a Brahmin boy. Koirala wrote the book in eight days during his imprisonment at the Sundarijal jail. Shakuntala by Laxmi Prasad Devkota This is one of the greatest works of Laxmi Prasad Devkota, published in 1945.

On 23 July 2022, the World Health Organization (WHO) declared monkeypox (mpox) outbreak a Public Health Emergency of International Concern. It’s a virus that belongs to the same family as smallpox and chickenpox. The outbreak was seen in 112 countries, with a total of 87,972 laboratory-confirmed cases and 1,097 probable cases, including 147 deaths, as of 19 June 2023. And the first case in Nepal was seen recently, on June 16. This has raised several concerns among the public about the possible outbreak of mpox in Nepal. “While mpox isn’t as contagious as Covid-19 since the virus isn’t airborne, there’s still a chance that this one case might lead to an outbreak if we aren’t careful,” says Dr Prajwal Pudasaini, a dermatologist at the Civil Service Hospital, Minbhawan, Kathmandu. According to a WHO report, an infected person can transmit the virus one to four days before showing any symptoms, and until the symptoms/rashes heal. The incubation period (the number of days between the start of infection and showing of symptoms) for the mpox is around three to 17 days. The common symptoms might last two-four weeks, which include high fever, swollen lymph nodes, and rashes. It transmits sexually, through skin-to-skin contact, saliva, mucus, and pus from rashes and droplets. The symptom starts with fever and rashes appear two-three days post-fever. “It can easily be confused with common viral fever, during which people might not maintain the needed distance,” says Dr Pudasaini. Also, since many people aren’t aware of mpox, they might not opt for medical tests. He adds that some might also confuse mpox with chickenpox, not knowing the difference between the rashes. “In the case of mpox, rashes first appear on palms, feet, and genitalia, whereas chickenpox appears all over the body,” he says. The rashes in mpox are filled with mucus/pus, unlike in chickenpox. “Also, people might not stay in isolation thinking they are already immune to chickenpox,” he adds. Despite that, the possibility of an outbreak is quite minimal, especially in Nepal because virus transmission is not possible without close physical contact, says Dr Janak Koirala, professor of infection disease/internal medicine at Patan Academy of Health Sciences (PAHS). “Since the first case was quickly identified, it might not have spread in a group,” he says, “But it’s necessary to follow the infected’s travel history, as well as trace and monitor her contacts.” Dr Rudra Marasini, director, Epidemiology and Disease Control Division (EDCD) under the Ministry of Health and Population (MoHP), says that the 60-year-old infected individual’s contacts have been traced and they are under close observation. “She had a travel history, and we have managed to contact everyone who came into contact with her within the 21 days prior to when her symptoms appeared,” he says. So far, only one of the contacts has shown signs of mpox, but the test result came out negative. Dr Hemanta Chandra Ojha, section chief, Zoonotic and Other Communicable Disease Control Section, EDCD, says other contacts haven’t shown any symptoms of mpox thus far. They will be under observation until the incubation period is over. “Since the illness didn’t originate in Nepal, it’s highly unlikely that this will turn into an outbreak,” he says. But to remain prepared, Dr Marasini mentions that medical professionals in Nepal have received training on dealing with cases of mpox. “We have 14 sites all over Nepal where professionals trained in handling mpox have been stationed,” he says. Dr Dharmendra Karn, a dermatologist, says most healthcare professionals began keeping themselves updated with the mpox virus after an outbreak in 2022. “We didn’t know when it would enter Nepal, so we have always stayed prepared,” he says. Also, for most individuals, the symptoms are only limited to fever and skin rashes, unless they are immuno-compromised. “It might prove to be fatal for infants, elderly and pregnant individuals, as well as people with chronic illnesses like diabetes, existing heart and liver issues, and HIV/AIDS,” says Dr Karn. In these cases, mpox might lead to other complications like meningitis, encephalitis, pneumonia, and organ failure. However, the mortality rate, so far, is less than one percent globally. “Much depends on the type of mpox variant,” says Dr Pudasaini. There are two variants of mpox prevalent globally—Central African (Clade I) and West African (Clade II). Among them, Clade II doesn’t cause much severity, whereas, according to Pudasaini, Clade I is thrice as lethal as the omicron virus. “Not knowing what variant we are dealing with, we can’t be sure on what the outcome might be,” he says. Nevertheless, the 2022 outbreak was caused by the subtype of Clade II called Clade IIb, which isn’t as severe as Clade I. Unfortunately, Nepal doesn’t have the mechanism to identify mpox variants. The best thing to do at the moment, Dr Karn believes, is to go back to the preventive measures everyone took during the Covid-19 pandemic. “We need to start maintaining distance, wearing masks, and using sanitizers,” he says. He adds that it’s necessary to inform people on the possible symptoms of mpox and precautions to take when one shows signs of infection. “Many people don’t even know what mpox is,” he says. Dr Koirala says it’s important to prevent the virus from reaching places like hostels, schools, and workplaces, where there is close contact. “It’s also transmissible from towels, clothes, utensils, and items used by the infected,” he says. If found in places where people remain together in a cluster for long hours, an outbreak cannot be prevented. But if there is an outbreak, doctors and medical professionals ApEx spoke to believe that Nepal’s healthcare system is well-equipped to handle it. “Many hospitals now have good isolation wards, ICUs, and have a good knowledge on dealing with medical crises,” says Dr Santa Kumar Das, deputy director, Tribhuvan University Teaching Hospital at Maharajgunj, Kathmandu. But there are a few improvements needed, like increasing the number of labs that conduct Polymerase Chain Reaction (PCR) tests for mpox. Currently, the test is only available at the National Public Health Laboratory (NPHL) in Teku. To prevent the virus from making inroads into the country, a proper screening system must be put in place to know whether a person is suffering from mpox, experts say. “The best way is to prepare a screening questionnaire, and send individuals showing symptoms for a PCR test,” says Dr Koirala. For now, the MoHP has stationed trained individuals at airports to perform proper screening. “We are doing everything we can to prevent the virus from entering the country,” says Dr Marasini. Data: Countries with maximum mpox cases since the 2022 outbreak, as of 6 June 2023

Source: Centers for Disease Control and Prevention (CDC) Symptoms Fever Rashes first appear on the palm, feet and genitalia two-three days post fever. Pus/mucus filled rashes appear all over the body Swollen lymph nodes Control measures Maintain physical distance Wear mask Use sanitizer Raise public awareness on the disease

Deputy Prime Minister and Home Minister Narayan Kaji Shrestha is traveling to China today. He will be leading a seven-member delegation to attend a trade fair in Chengdu. Bilateral engagements and visit exchanges between Nepal and China have increased in recent days. Only last week, Minister for Industry, Commerce and Supplies Ramesh Rijal attended the 13th Xinjiang-Kashi-Central Asia and South Asia Commodity Fair organized by the Kashi Prefecture Administration of China. Rijal delivered a statement at the opening ceremony of the event on 21 June, where he said that fairs and expos offered a good platform for exhibitors, entrepreneurs, and businessmen from South Asia and Central Asia to showcase their products, as well as to strengthen economic and people-to-people relations. He also appreciated the trade facilities provided by China to Nepali products while stressing the need for bolstering Nepali exports to China. In the second week of June, Chairman of the National Assembly, Ganesh Prasad Timalsena, also visited China. He met the Chairman of China’s People's Congress, Zhao Leji, and the two agreed to advance cooperation between the legislative bodies of the two countries. Leji said that leaders of the two countries have elevated the China-Nepal relationship to a strategic partnership of cooperation featuring ever-lasting friendship for development and prosperity. Beijing has also stepped up efforts to strengthen people-to-people relations with Nepal. For instance,  Himalayan Airlines resumed its direct flight between Kathmandu and Beijing this week following a three-year interval caused by the Covid-19 pandemic. According to the Nepali Embassy in China, direct flight between Kathmandu and Beijing, which takes place every Saturday, will play a significant role in promoting tourism, and socio-economic and cultural relations between the two countries. Also this week, a Sichuan Airlines charter flight arrived at the Pokhara International Airport this week, making it the first international flight to land at Nepal’s third international airport since its inauguration in January.  This week Nepal-China Friendship Dragon Boat Race Festival was organized in Pokhara where Chinese Ambassador to Nepal Chen Song said that it is an implementation of China’s Global Civilization Initiative (GCI). WeChat Pay, a mobile payment service run by China’s tech giant Tencent, was launched in Pokhara, while Tencent is joining hands with Nepal’s NMB Bank to launch the service. All these developments within a short period of time indicate China’s softer approach toward the Pushpa Kamal Dahal-led government.  Prime Minister Dahal himself is likely to visit China later this year to further cement the Nepal-China ties. Dahal visited India from May 31-June 3 this year. Key visits 

• Deputy Prime Minister and Home Minister Narayan Kaji Shrestha’s China visit
• Minister for Commerce and Industry Ramesh Rijal’s China visit
• Chairman of National Assembly Ganesh Timalsina’s China visit
• Former speaker Agni Prasad Sapkota’s China visit
• A four-member delegation of CPC visited Kathmandu
• Wang Xiaohui, CPC Secretary of the Sichuan province, visited Kathmandu