Malcolm Gladwell, in his 2008 bestseller Outliers, provides a case study of Korean Air in the 80s and 90s. Korean Air, South Korea’s largest airline, suffered a number of fatal crashes in those two decades, which Gladwell attributes not to technical issues or poor plane conditions but to the Korean culture of deference, where subordinates are afraid to question the decisions of their superiors. A hierarchical culture prevented crew members and copilots from questioning the faulty decisions of their captain, according to Gladwell.

Gladwell’s assessment of Korean Air in those days perfectly encapsulates the current culture of work inside the Health Ministry, said a former senior official who is intimately familiar with the goings-on in the ministry.

According to the official, a new hierarchy has been established within the Health Ministry ever since the Covid-19 pandemic arrived in Nepal and at the very top of the structure is not Health Minister Bhanubhakta Dhakal, but Dr Khem Karki, the minister’s chief adviser.

Ever since Karki was appointed adviser to the minister in March, the existing chain of command has been dismantled and Karki has involved himself in every decision made by the ministry, say multiple officials, both former and current, that the Post spoke to.

Almost all of the officials spoke to the Post on condition of anonymity as they were afraid of reprisal either from Karki or the ruling Nepal Communist Party (NCP).

As a political figure, Minister Dhakal is often unaware of the intricacies of dealing with a public health crisis like the pandemic and thus depends heavily on Karki. All other bureaucrats and experts have been shut out, unable to influence decisions or suggest solutions, say officials.

Karki is involved in everything, from awarding procurement tenders to transferring staff, which is well beyond his brief, said one current official.

“The minister only listens to his expert adviser, and the adviser interferes in every decision,” a senior official at the Health Ministry told the Post.

The parliamentary Public Accounts Committee has already implicated Karki in the botched procurement process involving Omni Business Corporate International. According to a preliminary report produced by the committee and obtained by the Post, Members of Parliament have raised questions regarding the involvement of Karki, an unelected official who is not a civil servant, in awarding the procurement tender for medical equipment from China to Omni in late March. The tender was annulled in early April after widespread criticism of the entire process and the cost and quality of the goods procured.

Karki, however, said that he had no real role in the tender process and only took part as the minister’s adviser.

“I took part in a meeting held at the Health Ministry’s auditorium that was called to finalise the tender,” Karki told the Post. “I was asked to write the final minutes of the meeting as a new person who did not know the supplier.”

According to Karki, the deal was important to contain the Covid-19 pandemic and he had no idea about Omni, the contracting company. The deal was awarded and cancelled by the Department of Health Services but it dragged him into a controversy, he said.

Karki entered the Health Ministry in March, appointed by the Cabinet on the recommendation of Minister Dhakal. Earlier, he had been working as the member-secretary at the Nepal Health Research Council, a political appointment by former health minister Khagaraj Adhikari in the aftermath of the 2015 earthquakes. Karki is also part of the faculty at the Institute of Medicine, Tribhuvan University.

As an MBBS doctor with a Master’s in public health, Karki might have seemed suited for the position of chief adviser to the health minister but, according to multiple officials, he has instead been responsible for most of the ministry’s failures in dealing with the Covid-19 pandemic.

From the very beginning, Karki underestimated the pandemic and was dangerously complacent, telling the Post that he did not believe that the number of Covid-19 cases would reach even a hundred.

“I think we will end Covid-19 cases in the double digits,” Karki had told the Post about two months ago when there were just under 50 cases of the coronavirus nationwide. “Our decision to enforce a timely lockdown and seal the border has helped us contain the disease. I think the curve will start to flatten after 60 cases.”

As of Saturday, Covid-19 infections have crossed 12,000 and caused 28 deaths and show no signs of slowing down. The virus has now been detected in all 77 districts. There is no sign yet of a plateau and the ministry has not been able to come up with a single disease pattern model.

According to officials, the Health Ministry currently lacks an epidemiologist and a risk communication expert.

Dr Radhika Thapaliya, the only risk communication expert at the Health Ministry, has not been given any responsibility at a time of crisis.

More recently, Dr Bikash Devkota was replaced by gynaecologist and obstetric surgeon Dr Jageshwor Gautam, former director of the Paropakar Maternity and Women’s Hospital, as chief of the Health Coordination Division and the ministry spokesperson. Mahendra Shrestha, director-general of the Department of Health Services, and Bhogendra Dotel, director of the Management Division, were also transferred out in the midst of the pandemic.

All of the transfers in and out of the ministry in the past three months have been conducted at the behest of Karki, say officials. Those with years of experience or public health backgrounds have been sidelined while medical doctors from unrelated fields have been given responsibility for most of the divisions.

“People having sound public health knowledge and who knew the gravity and seriousness of the problems in the Health Ministry were transferred out,” said an official from the Department of Health Services.

“I don’t understand why a gynaecologist is needed at the Health Ministry at this moment,” he said, referring to the induction of Gautam.

Karki himself admitted that he had lobbied for the transfers but said that they were done to bring in the right people into the right posts.

“Those with an MBBS or higher degrees could do better in the ongoing national crisis,” Karki told the Post. “We have corrected the flaws made knowingly or unknowingly in the past.”

Karki’s tenure at the Health Ministry has also resulted in a significant rise in opacity. Access to journalists in the Health Ministry has been severely restricted and the ministry premises remain occupied at all times by Nepal Communist Party cadres. Ministry officials have been warned not to speak to the media, as per Karki’s directions.

He said that access of people including journalists was restricted after Covid-19 cases rose, some journalists and doctors also tested positive to the virus.

On April 18, Dr Sher Bahadur Pun, a virologist at the country’s frontline Sukraraj Tropical and Infectious Disease Hospital, was summoned to the Health Ministry to furnish a clarification after speaking to the media about a lack of preparations to deal with Covid-19. After a severe backlash from the media and the public, the ministry refrained from taking action, with Karki saying that Pun was called to the ministry for his expert advice.

“No one from the Health Ministry has contacted me since then,” Pun told the Post.

A looming threat of censure from the minister, at the behest of Karki, hangs over the entire ministry, said officials.

“We have to obey people who do not hold any official position,” said a joint-secretary at the Health Ministry. “How can we fulfil our duties when we are constantly afraid that we might be punished for our actions?”

Dr Baburam Marasini, former director of the Epidemiology and Disease Control Division, said that the adviser's role should be limited to giving suggestions to the minister.

“Whether to take those suggestions or not is up to those who sought them,” said Marasini. “No employee in the Health Ministry should recognise the health minister's adviser as a superior as his role is only to give advice to the health minister.”

But ministry officials say that Karki behaves like a tsar, attending meetings and taking decisions that widely affect the ministry. No one dares to complain as Karki has the minister’s ear.

“All are following the adviser, who is behaving like an executive head,” said a Health Ministry official. “When you appoint party cadres from top to bottom instead of experienced officials, how can you expect better results?"

Public health experts from outside the ministry too are tired of providing opinions and advice to the ministry as their suggestions are most often ignored. When these experts point out the shortcomings of the ministry or the government, they are cut off and never contacted again.

Marasini said that he was invited to a meeting at the Health Ministry around three months ago and when he objected to the use of rapid diagnostic tests in case diagnosis, officials stopped contacting him.

Karki, for his part, says that he has done nothing wrong and is only helping the Health Ministry deal with the ongoing Covid-19 pandemic. He said he was dragged into a controversy over the decision to use rapid diagnostic tests, as he was against their use.

“I am still against the use of rapid diagnostic test kits for diagnostic purposes,” said Karki. “I have clearly said that the time has not come to use rapid kits and they should only be used after 14 days of quarantine.”

According to Karki, he had attempted to prevent corruption at the ministry and had made enemies in the process.

“I have prevented people from openly demanding commissions and doing illegal things. They are now dragging me into the controversy using various means,” he said.

But officials are not convinced by Karki’s arguments.

"All those who came to the Health Ministry through political appointments have weakened the system," said a senior ministry official. “Health Minister Dhakal and his chief adviser have been behaving like former US President George W Bush: ‘either you are with us or against us’.”