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. 

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, Medecins 
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.