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Focus on the impact of the conflict on rural health

[Nepal] A 70-year old man in Jajarkot, another poor remote district of Nepal, 400 kms west of Kathmandu. He is waiting impatiently for health workers to come for his aid. IRIN
A 70-year old man in Jajarkot, another poor remote district of Nepal, 400 km west of Kathmandu. He is waiting impatiently for health workers to come to his aid.
Min Bahadur Tamang is 16 years old, but doesn't know if he will see his next birthday. Living in remote Ichok village in Sindupalchok district, 80 km northwest of the Nepali capital, Kathmandu, it is hard to find a medical facility nearby. He has to walk for nearly eight hours down to Melamchi, the nearest urban centre in the district, to reach the government-run Primary Health Care Centre (PHCC). He had been bed-ridden for the last three months and it was only after he lost consciousness that his father and uncle decided to risk taking him on the long trek to Melamchi. He was diagnosed with acute typhoid. Severely malnourished and running a high fever, Min is so weak that he can barely swallow his food. "It's a desperate situation for so many villagers living up there," explained the health assistant while treating Min. "Many are at risk of losing their lives as they arrive here only after their condition becomes very serious," she added, explaining that threats from Maoist insurgents, the long distances and difficult terrain deter villagers from seeking timely treatment. Shanti Lama, an 18-year-old woman suffering from serious heart disease, died in the same village in late January when she was unable to visit her doctor for treatment following surgery in Kathmandu. After her operation, she was forced to return to the village as she could not afford to live in the capital. She died because there was insufficient food or medicine to support her in her vulnerable post-operative condition. RURAL HEALTHCARE SHRINKAGE Health facilities in rural Nepal have been contracting as the nine-year rebellion has left up to 80 percent of the country in the hands of the Maoists. Most government-employed health workers are afraid to make field visits to regions controlled by the rebels in case they are abducted and forced to work for the insurgents. If they do offer health care in Maoist regions, they are at risk of being targeted by security forces and accused of "helping the terrorists". The health sector has been affected along with education, road building and other development activities. "It would be dangerous to assume that things are all right in the health sector," a health expert from a foreign aid project, requesting anonymity, told IRIN. The climate of fear among rural health workers means that most don't want to be openly critical of the consequences of the rebellion for fear their projects and NGOs could come under attack. But the impact the conflict is having on rural health is difficult to gauge. Only a handful of organisations have managed to collect data on the subject. According to the local human rights organisation, INSEC, at least 40 rural health posts were destroyed between January 2002 and December 2004. Health workers said that their posts were usually attacked when they refused to give medical aid to the rebels. REBEL ATTACKS The poorly-resourced clinics are the only means of hope for healthcare in large areas of rural Nepal. According to the department of health, around 700 rural clinics and 84 hospitals still operate, serving a population of nearly 25 million, out of which more than 75 percent are rural. But most are short of medicines, expertise and equipment as the government struggles to keep them supplied. Because of the mountainous terrain in much of Nepal, medicines and supplies for the clinics have to be carried by porters. But without armed escorts they are often looted by insurgents. A safer alternative is airdropping them into the villages, but Kathmandu is afraid that supplies will still fall into the hands of the Maoists.
[Nepal] Primary Health Care Centre in Melamchi. The only heath centre for many villagers from remote areas, takes days to reach here for many.
The primary health care Centre in Melamchi. The only heath centre for many villagers from remote areas, takes days to reach here for many
In September 2004, rebels in the remote Okhaldhunga district, east of Nepal, took control of typhoid vaccines supplied for the immunisation of children. About 35 porters who were carrying the consignment were also captured by the rebels. In the same month, a half-year blockade in the remote district of Baitadi in the far west of the country led to the unavailability of basic medical supplies for typhoid, dehydration and other common illnesses. An estimated 48,000 female health care volunteers (FHCVs) play a key role in reaching out to people in the rural areas. But most of them are now reluctant to go to the villages for fear of the Maoists. "The Maoists force health workers to work for them and torture, abduct or physically harm them if they do not do what they say. The supply of medicines, which used to be distributed for free by the government, has now been stopped. Someone suffering from even a minor disease has to go to the capital city for treatment - totally unrealistic given the reality of Nepal," the INSEC Annual Report of 2004, said. RURAL DISEASE PROFILE A large number of rural Nepalese still die from preventable and curable diseases. Malaria is a major vector-borne disease prevalent in 65 districts, according to the 2002-2003 health ministry report. Diarrhoea, acute respiratory infections (ARI) and measles are some of the other major diseases. Infectious disease and nutritional deficiencies are some of the major causes of child morbidity, disability and mortality. More than 20,000 children die of diarrhoea-related disease every year. According to the ministry, ARI is one of the major health problems among children under five, and is responsible for many deaths. A 2004 report by the government revealed that ARIs were now affecting up to a million children. There are also concerns that many primary health initiatives in remote areas have closed as they are being forced to register with the Maoists before launching any programme. "In Nepal, chronic political instability has made it difficult for patients to receive care in a weakened health care system already hindered by poverty and insufficient medical personnel and supplies," said the 2003-2004 activity report of the medical NGO, Medicins Sans Frontieres (MSF), which was forced to curtail its activities last year in Jumla, one of Nepal's poorest districts in the midwest, because of the conflict. MSF SCALES BACK "The organisation had begun to rehabilitate health posts in Jumla as part of a general health project, but pressure from both sides of the conflict made the work impossible," MSF noted. In August 2003, the rebels abducted four MSF workers. They were dragged into the jungle and told they would be enslaved to the Maoists for five years. "In villages, health work is becoming extremely difficult. The villagers usually come to urban centres from their villages but now even the flow of patients has been cut a lot. Such is the direct impact of the conflict," explained Bharat Pradhan of Model Hospital, a popular private hospital in Kathmandu which also runs community-based health care programmes in several districts. "Villagers fear to travel to urban centres to receive treatment. There are insufficient outreach clinics and health centres. With the monsoons now approaching, water-borne diseases will claim a large number of lives," he added. Because health education programmes are on the decline, there is the danger of a rise in communicable diseases, health workers say. "All this is the reality today and if we don't take appropriate measures there could be serious outbreaks of disease in rural Nepal that we would be powerless to prevent," explained a foreign health expert working with the health ministry.

This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions

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