Guerillas in the midst

Peace has long been elusive to Nepal. More than 11'000 lives have been lost during nine years of Maoist insurgency. Since the king seized power in first of February this year, the freedom of people has been severely restricted, including the right to health, say Khagendra Dahal and Kaushal Raj Pandey

Twenty nine year old Ranu from western Nepal started to knit a sweater for her baby when she found out she was pregnant seven months ago. When her labour pains started at the beginning of April, she was rushed to a nearby health centre. The health centre then referred her to a larger centre in Kathmandu, the capital. Travelling to the hospital, the ambulance carrying her was stranded in a traffic jam for more than 36 hours. Sadly, Ranu died in distress and pain. The doctors in the hospital said the cause of her death was obstructed labour.¹

On 2 April 2005, the Maoists declared an 11 day nationwide transport strike to block routes to Kathmandu and other major cities. This disrupted health services, food supplies, as well as education in different parts of the country.²

This is only the latest of the conflicts in Nepal. In 1990, a multiparty democracy was re-established ending the 30 years of the king's autocratic rule—the "Panchyat system." Since then the political environment in Nepal has been unstable; there have been 10 different governments in 12 years.

In 1996, the Communist Party of Nepal—Maoists—declared a people's war to overthrow the existing monarchic state and establish a communist republic. The war initially started from five hilly and remote districts in western Nepal, but then spread to all of the 75 districts, although the severity differs throughout the country.

DEVENDRA M SINGH/AFP/GHETTY

King Gyanedra in a state of emergency

On 1 February this year, King Gyanendra sacked the government and declared a state of emergency. He suspended fundamental civilian rights because he claimed not enough was being done to defeat Maoist rebels. The king's move, however, only boosted the Maoists by confirming their view of the monarch as an opponent of democracy.

Effect on health care

As the war has progressed, violations of human rights by both sides have escalated. People are raped, tortured, and executed, and they disappear. Although, there have not been any studies on how the conflict has affected people's health, the common perception is that it has been badly jeopardised. This is bad news for Nepal, which is one of the poorest countries in the world, with the per capita income of $236 (£130; €195) a year, and has one of the worst health indicators.³

The conflict has affected rural health care in particular. People staffing rural health posts and centres have deserted the clinics in fear of being targeted by both the Maoists and the state.⁴ "The Maoists come and take anything they want and the next day the security personnel come and threaten you for helping the rebels. We are in a difficult situation," said a health worker from a health centre in eastern part of Nepal.

Also, Maoists have attacked the health posts and ambushed the ambulances carrying patients, thinking they have security personnel in them.^4-5 A study by the Informal Sector Service Centre, a human rights organisation, suggests that at least 40 rural health posts were destroyed between January 2002 and December 2004.⁶

The government has also adopted a policy of not sending medicines and basic supplies to the conflict zones because they might be looted by the rebels. The government has also issued a directive forbidding health professionals to treat anyone unless they are notified to the ministry of internal affairs. If doctors fail to do this, they are liable to prosecution. This has added to the problems facing health institutions in Nepal that are already poorly funded and inadequately staffed.^7-8

The operating rural healthcare centres are inundated with patients. In one 15 bed health centre in Rukum, a district badly hit by conflict, an average of 75 patients come everyday for check ups. Some of the patients are direct victims of conflict, wounded by explosives or bullets, but thousands of others are affected indirectly because of undernourishment, a lack of vaccines, and unsafe drinking water.⁹

Although urban health care has not been affected as adversely, there have been some serious changes. "For the last few years, we have been seeing more patients who have sustained physical trauma due to conflict," says an orthopedic surgeon in Tribhuvan University Teaching Hospital, a tertiary care centre in Kathmandu.

Women and children

Women's and children's wellbeing has been badly affected. Up to 12000 children may die every year in Nepal because of the lack of essential medicines and nutritional support.¹⁰ Children are also made to serve the rebels as porters, messengers, helpers, and even soldiers. Children as young as 13, are reported to have been arrested, tortured, and gunned down by security personnel.¹¹ Growing up amid fear and insecurity has affected their behaviour and put them at increased risk of psychological problems.¹²

Also, the number of children coming to the cities in search of jobs has increased, with some girls ending up in the sex trade. A survey by General Welfare Pratisthan, a non-governmental organisation working on HIV/AIDS prevention, shows that the "flesh trade" around urban areas and along the highway is on the rise.¹³ Conflicts have also affected maternity care. In Nepal the maternal mortality rate is as high as 540 per 100'000 and the infant mortality rate is 66 per thousand.³

Detainees

In the months after the king seized the power there has also been great concern from international bodies, including the United Nations and Amnesty International about the wellbeing of Nepalese activists. As many as 3000 political activists, human right defenders, trade unionists, and journalists were detained with the aim of preventing protest against the king's takeover.

FREDRIK NAUMANN/PANOS

Maoist guerillas on a long march

A report from Amnesty said that political detainees had been tortured. Detainees were also kept in poor conditions in temporary detention centres, leading to a deterioration in health. However, international pressure has meant that many of those who have been detained illegally have been released.^14-15

Internally displaced people

The conflict has had a profound effect on development projects, education, and communication. The number of internally displaced people has also increased. Out of fear of being abducted by the Maoists and tortured and detained by the security personnel, an estimated 150'000 people from different parts of Nepal have flocked to the city areas and neighbouring India in search of shelter, jobs, and security.¹⁶ One news report estimated that as many as 500 people from the western hills are moving to India through a border in western Nepal every day.¹⁷ Children, old people, and women are often left behind in the villages. Neglect by both the governmental and non-governmental agencies has forced these people to live in the dirty and crowded camps or in the jungle, where there is a lack of food and safety. Infectious diseases are reported to be rife, and displaced children have no access to ­education.¹⁶

Medical students

Although conflicts have had a destructive effect on health care, medical students themselves have not been directly affected. The conflicting parties have not touched the teaching hospitals or medical schools. "But as citizens of the country we have suffered if not directly then indirectly," said Chandra Prakash Sharma, a medical student.

The future for Nepal's health care does not seem optimistic. Though the best way to resolve present health crisis is to hold dialogues between the conflicting parties, there needs to be temporary measures to halt the decline of the health sector. Both parties should vow to regard the health sector as a peace zone and should not interfere with healthcare delivery. And the non-governmental organisations and international organisations that have pulled out of rural areas should review their decisions. Last June, at least half a dozen international non-government organisations decided to stop their projects in rural areas; many of them were ­working on health, education, and ­development.¹⁸

The recent establishment of United Nations High Commission for Human Rights monitoring system in Nepal has brought some hope. On 11April 2005, the government of Nepal and the commission signed a memorandum that would provide for deployment of international human rights monitors to Nepal. This move has been welcomed by human rights organisations and civil society. "The establishment of a freestanding office of the High Commissioner for Human Rights in Nepal is an important step towards protecting human rights in Nepal," said Brad Adams, Asia director of Human Rights Watch.¹⁹ This is supposed to monitor and investigate the violations of human rights of the Nepalese people and in some ways try to pressurise the warring parties to comply with their commitments towards respect of health and other human rights.

Khagendra Dahal, medical student
Email: khagenvikram@hotmail.com

Kaushal Raj Pandey, medical student, Institute of Medicine, Kathmandu, Nepal
Email: Krpandey702@emailaccount.com


studentBMJ 2005;13:265-308 July ISSN 0966-6494

1. Woman dies off obstructed labor due to blockade. Kantipur 2005 Apr 5.
2. IRIN. Maoist blockade hits vulnerable rural communities. (accessed 20 Apr 2005).
3. United Nations Development Programme. Human development indicators 2003, Nepal. New York: UNDP, 2003. (accessed 3 May 2005).
4. Integrated Regional Information Networks. NEPAL: Focus on the impact of the conflict on rural health. (accessed 3 May 2005).
5. Maoists attack ambulance. Kathmandu Post 2004 Apr 9.
6. Informal Sector Service Centre. Human rights yearbook, 2004. Kathmandu: INSEC, 2004..
7. RNA blocks supplies in Achham. Kathmandu Post 2004 Apr 18.
8. Sick Rolpa. Samaya 2005 May 13.
9. War is bad for health. Nepali Times 2004 Aug 6-12.
10. Unicef. Thousands more could die due to transport shutdown in Nepal, UNICEF warns. (accessed 1 May 2005).
11. Human Rights Watch. Child soldier use: a briefing for the 4th UN security council. New York: Human Rights Watch, 2003. (accessed 25 Apr 2005).
12. Poudel K. Dangers of changing behaviours. Spotlight 2002 Nov 29-Dec 6.
13. Flesh trade on the rise due to increase in violence. Kathmandu Post 2004 May 18.
14. Amnesty International. Nepal human rights abuse escalates under emergency. (accessed 16 June 2005).
15. 75 detainees released, Pokharel re-arrested. Kathmandu Post 2005 May 28.
16. Prakash. Internally displaced persons in Nepal. 2005. (accessed May 1, 2005)
17. The war in the west. The Himal South Asian 2003 Jan.
18. Development deadlock. The Nepali Times 2004 Jun 4-10.
19. Human Rights Watch. Nepal: UN human rights field operation a step forward. New York: Human Rights Watch, 2005. (accessed April 25, 2005)

       

           

	Responses published this month

Articles	Responses
LIFE Guerillas in the midst       Khagendra Dahal (Jul 2005)	Matiram Pun (August 30th, 2005) Read this response

	LIFE Guerillas in the midst       Khagendra Dahal (Jul 2005))
	Matiram Pun (August 30th, 2005)       Fourth Year Medical Student, Institute of Medicine, Kathmandu, Nepal mati@iom.edu.np
	Dear Editor, Student BMJ The article "Guerillas in the midst" (1) vividly picturizes the situation going Nepal. Thanks for the authors who have chronologically described the changes and the impact on the health in Nepal that are happening sometime back. The situation was really worse when King Gynendra took over and ceased all sorts of communications including hospitals, ambulances and doctors. That has innumerable loss in the people's life that has not been documented. Next point that has been really a matter for the health care system in Nepal is of course insurgency. The Maoists had adopted to eradicate the central government from all the sectors of the peripheries. According to that they have demolished all the government administration infrastructures mainly Village Development Committee's (VDC) Buildings. These are the buildings where our Sub Health Posts (SHP) is in. Nepalese government's policy is that each VDC must have one SHP. During demolishing and firing on the VDC buildings, the SHPs have also been burnt to ashes. In most of the districts all the VDC offices have been shifted to the District Headquarters and what about SHPs? They virtually nonexistent.