For the longest time, most <a href="https://nepalitimes.com/editorial/hunger-for-governance">Nepalis lacked adequate food</a> and were <a href="https://nepalitimes.com/opinion/guest-editorial/we-are-what-we-eat">undernourished</a>. Fast forward three decades, and the country is starting to grapple with obesity. At the pace with which the proportion of <a href="https://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018">overweight people</a> is growing, half of Nepal’s adult population will be obese by 2050, according to a forecast study published this week in the health journal The Lancet. This is much higher than next-door India where about one-third of its vast population is projected to be obese. Alarm bells should be ringing because the study shows a rise in obesity over the last 35 years. Nearly 12% of men were obese in 1990, and this had risen to about 30% by 2021, and is expected to rise to 52.5% by 2050. As for women, about 14% were obese in 1990, and this more than doubled to 28% in 2021, and will reach 48% in the next 25 years (graph).  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250314030340_5a381f60225e865970832c7e7dd3595be624cafe51f784183038a5f9a5d8f7e4.jpg" data-media-id="editor_3" data-image-id="20250314030340_5a381f60225e865970832c7e7dd3595be624cafe51f784183038a5f9a5d8f7e4" data-rendition-name="original" width="1221" height="494" loading="lazy" alt="Obesity graph"> <figcaption>Data: THE LANCET</figcaption> </figure>  As for obesity in children, the collective figure for South Asia in 1991 was 0.9% which is expected to increase to 8.3% by 2050. Similarly, the figure for overweight children in the region was 3.3% in 1991 and is projected to reach 9.3%. “Obesity is the mother of all diseases, it is the biggest <a href="https://nepalitimes.com/editorial/poor-health-makes-nepalis-poorer">public health concern </a>draining our already<a href="https://nepalitimes.com/news/local-governments-lack-resources-to-tackle-covid-19-rup2466w"> limited resources</a>,” says public health expert Aruna Uprety. “Changing eating habits including the<a href="https://nepalitimes.com/here-now/junk-food-is-making-nepali-children-shorter"> intake of junk food</a> and a sedentary lifestyle is making more and more Nepalis overweight.” Obesity has been associated with diabetes, high blood pressure, stroke, heart, kidney and liver diseases, visual impairment, dementia, infertility, and certain cancers. Increasing obesity means dietary plans and fitness have become big business, even though many people cannot lose weight fast enough. Read also: <a href="https://nepalitimes.com/here-now/a-deadly-sugar-rush">A deadly sugar rush</a>, Yugottam Koirala In 2017, in came a new drug that has become a game changer: the <a href="https://archive.nepalitimes.com/news.php?id=18656">anti-diabetic medication </a>Ozempic developed by the Danish pharmaceutical company Novo Nordisk. By chance, it was also found to be effective for weight loss, and Ozempic export and licenses gave the company a market value of $570 billion, making it larger than the Danish economy.&nbsp; “Ozempic is a classic case of a serendipitous discovery,” explains Buddha Basnyat of the Oxford University Clinical Research Unit. “It was supposed to be a drug for diabetes, and not intended for weight loss. But it was so effective, it threatened to put weight loss regimens in danger of going out of business.” An active ingredient in Ozempic is the compound semaglutide, which belongs to a class of molecules known as glucagon-like peptide-1 (GLP-1) that delays gastric emptying, causing a feeling of fullness. It also seems to influence areas of the brain that controls<a href="https://nepalitimes.com/here-now/growing-appetite-for-school-lunches"> appetite</a>, making people feel sated. It also reduces<a href="https://nepalitimes.com/banner/the-heat-is-killing-us"> cardiovascular disease</a> as well as the risk of dementia, and in stroke prevention and fighting alcoholism. Says Basnyat: “In many ways, Ozempic is that one <a href="about:blank">modern medicine</a> that can treat a lot of conditions. It is a blockbuster drug.” Ozempic is not available in Nepal yet but as a Least Developed Country (LDC), the country is exempt from patent protection for pharmaceuticals until 1 January 2033, and can manufacture generic medicines without compensating or informing the innovators. Novo Nordisk is set to enter the Indian market despite quickly approaching patent expiry in January 2026. Its patent in China is also set to expire in 2026. “<a href="https://nepalitimes.com/news/nepal-must-allow-foreign-investment-in-pharmaceuticals">Manufacturing a new drug</a> in Nepal isn’t simple as approval doesn’t come easy unlike in our neighbouring countries but we are trying,” says Shankar Ghimire of Asian Pharmaceuticals about Ozempic, adding that it did start working on semaglutide three years ago. “If we have approval, we can bring the molecule and formulate it here in three months.” Ozempic is usually given as an injection once a week but is also available in a pill form called Rybelsus which has to be taken daily. The drug can cost about Rs10,000 per month. Nausea, vomiting, diarrhoea, abdominal pain and bloating are some of the side effects to the drug. Because it can cause rapid muscle loss, users may experience sagging and develop a gaunt appearance. Stopping the medication could again lead to weight gain. Aruna Uprety also cautions against following certain weight loss trends too quickly, and to take into considerations specific health needs and conditions before taking new medication. She says: “We don’t yet know long term effects of these drugs for obesity, elsewhere people are also opting for bariatric stomach surgery but nothing quite beats a healthy diet and natural methods to keep fit.” &nbsp; Read also: <a href="https://nepalitimes.com/here-now/the-karnali-s-hunger-emergency">The Karnali’s hunger emergency</a>, Anita Bhetwal

Sonia Awale

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Undernourished to overweight

In a corner seat on the first floor of Bir Hospital, a middle-aged kidney patient winces in pain. Next door, a lady has nerve damage, and is unable to feel the growing wound on her sole. Two floors up, a crowd of desperate patients wait for an appointment with an endocrinologist. This week, the hospital in Kathmandu was filled with different medical complications. But many of them were related to a single disease: diabetes. “On any given day, we see up to 200 patients in our department, and more than half have to do with diabetes mellitus,” says consultant endocrinologist Manil Bajracharya at Bir. Diabetes mellitus is a condition where the body either does not produce enough insulin, or does not use it effectively, resulting in dangerously high blood sugar levels. Untreated, it can lead to life-threatening complications, including disorders of the cardiovascular system, eyes, kidneys, and nerves. In Nepal, the incidence of diabetes is on the rise, with an estimated 8.7% of adults between 20-79 living with the condition in 2021. This number was 3.6% in 2011, and is expected to reach 9.4% by 2045. “This rise most likely has to do with rapid changes in lifestyle and diet,” explains Bajracharya. “We have seen a shift from traditional cereal and vegetable-based diets to ones rich in animal products and processed foods high in fat and sugar content. This nutritional transition, combined with reduced physical activity, has significantly increased the risk of diabetes.” Bagmati Province has a five times higher prevalence of diabetes than the Karnali. Other provinces with urban centres like Gandaki and Lumbini also have a high burden of the disease. Read also: <a href="https://nepalitimes.com/opinion/comment/saving-kidneys-to-save-nepal">Saving kidneys to save Nepal,</a> Rishi Kumar Kafle  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240607150624_2deb3cabd4a1367ea0656a84e817aa0c8bcc920bb4b33bda30037272931024b0.jpg" data-media-id="editor_1" data-image-id="20240607150624_2deb3cabd4a1367ea0656a84e817aa0c8bcc920bb4b33bda30037272931024b0" data-rendition-name="original" width="3952" height="3021" loading="lazy" alt="Diabetes in Nepalis NT"> </figure>  “Nepalis who migrate to cities often have reduced physical activity and transition to high-calorie diets, which contribute to obesity and elevate the risk of diabetes,” says Bajracharya. City dwellers are twice as likely to develop diabetes compared to rural Nepalis. Diabetes mellitus has no cure, but it can be managed through careful monitoring, lifestyle changes, and improving medications. Many people diagnosed with diabetes live for years without experiencing serious symptoms. But Nepal has a huge gap: 43.5% of adults living with diabetes do not know that they have the disease. This means two out of every five cases go undiagnosed, and therefore untreated.&nbsp; “If diabetes isn’t detected on time, it can become life-altering, and may even be fatal,” adds Bajracharya. Raman Tamang did not know he had diabetes until a wound started growing on his foot. “I first thought it was just a normal cut. But it grew and started stinking. It got so bad that my family started avoiding me,” says Tamang. When he was brought to Helping Hands Community Hospital in Chabahil, his wound had turned chronic. A patient with long term diabetes suffers nerve damage. This results in the loss of sensation in the feet. Elevation in blood glucose also reduces the body’s ability to heal wounds. “Minor cuts, scrapes, or wounds often go unnoticed until the body can no longer heal them on its own,” explains orthopaedic surgeon Hem Limbu at Helping Hands.&nbsp; Read also: <a href="https://nepalitimes.com/here-now/junk-food-is-making-nepali-children-shorter">Junk food is making Nepali children shorter</a>, Marty Logan  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240607150624_4e61c5cb980f287da4393eaf277d0c7418dbe95ffb717bb761ffa6f25d8418de.jpg" data-media-id="editor_3" data-image-id="20240607150624_4e61c5cb980f287da4393eaf277d0c7418dbe95ffb717bb761ffa6f25d8418de" data-rendition-name="original" width="1281" height="841" loading="lazy" alt="Diabetes in Nepalis NT"> </figure>  Called diabetic foot ulcers, such wounds often persist and in the worst cases may get infected and have to be amputated. Across the globe, 85% of all amputations happen due to diabetic foot ulcers. “We have to amputate almost half of all cases of diabetic foot because many patients come too late,” adds Limbu. Not amputating the leg can lead to infections spreading to the bloodstream. Studies have shown that 19-47% of diabetic patients in Nepal also have diabetic retinopathy, where high-glucose blood damages blood vessels in the retina of the eye, impairing vision. However, less than 30% of Nepalis who have diabetes know about this risk of blindness. And an additional 50% never get their eyes checked despite living with diabetes. Diabetes also elevates the risk of kidney failure, heart disease, and stroke.&nbsp; An estimated 9,000 Nepalis under 60 died due to some form of complication attributable to diabetes in 2021. Then there are 9.2% of Nepali adults who are prediabetic with elevated blood glucose levels that could reach diabetic levels if their lifestyle does not change. “But because most don’t know they have the condition, proper screening and awareness are essential,” says Hem Limbu. Read also: <a href="https://nepalitimes.com/here-now/myopia">MYOPIA</a>, Yugeshwor Koirala  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240607150624_fcdcf19b68a2f40d6b17f9753cc6d6fa13d511dae2a4b649a665db07c9c23a72.jpg" data-media-id="editor_5" data-image-id="20240607150624_fcdcf19b68a2f40d6b17f9753cc6d6fa13d511dae2a4b649a665db07c9c23a72" data-rendition-name="original" width="1262" height="849" loading="lazy" alt="Diabetes in Nepalis NT"> </figure>  Screening involves a blood test, and to manage high blood sugar, patients require insulin replacement therapy through injections or an insulin pump. But insulin resistance can often be managed with dietary modifications and exercise. “Prediabetes is gaining increasing recognition as a significant health concern, and a growing number of adults are seeking assistance even for mild symptoms,” notes Bajracharya. While this trend reflects improved awareness, it is equally vital to identify prediabetes in younger adults. Developing diabetes at a young age prolongs the duration of the condition and escalates the risk of complications. Timely diagnosis and effective management can mitigate complications: reducing the risk of diabetic retinopathy by up to 95%, foot ulcers and amputations by 85%, kidney disease by 70%, and both cardiovascular disease and stroke by 50%. “Prevention is better than cure for most diseases, but for diabetes, prevention and early detection are the only cures. Once the disease advances, reversing its effects becomes exceedingly challenging, necessitating lifelong symptom management,” adds Bajracharya. “So Nepal’s challenge isn’t just about forming an action plan for diabetes awareness, screening and treatment, but about implementing it in areas where essential drugs and equipment are out of reach.” In urban cities, the challenge is different. Drugs, diagnostic services and self-monitoring equipment are accessible, but so are processed foods and sugary drinks. “After essential healthcare services are in place, preventing and managing diabetes comes down to personal choices and attitudes. Whether or not diabetes continues to surge in Nepal, therefore, depends on each individual more than anything else,” says Bajracharya. &nbsp; Read also:<a href="https://archive.nepalitimes.com/news.php?id=18379"> Diabetic dilemma</a>, Buddha Basnyat

A deadly sugar rush

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110151112/636d06f59c7e80680e0a5f92jpeg.jpg" alt="" width="1500" height="1000"/><figcaption>Photo: MONIKA DEUPALA</figcaption></figure>The past year-and-half since the Covid-19 outbreak, Nepal’s limited health resources all had a singular focus. But now that the second wave is waning and the lockdown has been eased, hospitals are once again flooded with patients with <a href="https://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018" target="_blank" rel="noopener noreferrer">diabetes</a>, cardiovascular diseases and kidney ailments.Many of these patients had left these conditions untreated, and doctors say nursing them back to health will be more complicated. One of the most common disorders is hypertension or high blood pressure, which has become an epidemic.Hypertension is a silent killer and one of the most common causes of chronic conditions like <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/A-mysterious-rash-of-kidney-failures,3639" target="_blank" rel="noopener noreferrer">kidney damage</a> that are often too costly to treat for the majority of Nepalis. Now, mental stress due to Covid has also added to the problem.“Hypertension makes up for the majority of patients in hospitals these days now that the lockdown has been relaxed,” says cardiologist Prakash Regmi. “Also worrying is that many of these are new patients coming in due to Covid-related stress, a large number of people who had their blood pressure under control previously after treatment are also relapsing.”To be sure, Nepal has been seeing a dramatic rise in hypertension patients even before the pandemic – some of them in their teens and 20s. <a href="https://www.hindawi.com/journals/ijhy/2021/6610649/" target="_blank" rel="noopener noreferrer">A paper published in March</a> in the International Journal of Hypertension, shows that since 2000, the hypertension rate in Nepal has been increasing at 3.5% per decade, and 44.7% of Nepali men will be suffering from hypertension by 2025.The study also found that high blood pressure is disproportionately affecting men, the elderly, those without formal education, and those who reside in urban areas, and seems to be most common in Gandaki Province.Worldwide, an estimated 1.13 billion people have hypertension, and it is responsible for 9.4 million deaths globally every year. In 2015, 1 in 4 men and 1 in 5 women had elevated blood pressure.In Nepal, close to one-third of the adult population has some form of hypertension, but in urban centres the figure is as high as 40%, with 25% in rural areas suffering from it.There is no specific cause of hypertension, but its biggest risk factor is high sodium intake. A survey in 2020 revealed that on average, the mean dietary <a href="https://onlinelibrary.wiley.com/doi/epdf/10.1111/jch.13813#:~:text=Overall%2C%20estimated%20mean%20salt%20intake,d%20(SD%20%C2%B1%204.7)." target="_blank" rel="noopener noreferrer">salt intake of a Nepali</a> per day is 13.3 mg. Most of the world consumes double the WHO recommended 5g of daily salt intake, increasing the risk of heart disease and strokes, which kills some 3 million people annually worldwide.“Traditionally Nepalis have a preference for salty food, but now with higher consumption of processed and <a href="https://www.nepalitimes.com/banner/nepalis-binge-on-junk-foods-the-west-rejected/" target="_blank" rel="noopener noreferrer">junk food</a>, our salt intake has grown,” says public health expert Aruna Uprety, adding that the sodium content in packaged foods is often much higher than what companies claim.In May WHO (World Health Organisation) released a new set of <a href="https://www.who.int/news-room/events/detail/2021/05/05/default-calendar/launch-event-who-global-sodium-benchmarks-for-different-food-categories" target="_blank" rel="noopener noreferrer">global benchmarks for sodium levels</a> that will act as a guide for countries and industry to reduce sodium content in more than 60 categories of processed foods, in line with the global target of reducing salt intake by 30% and hypertension by 25%, both by 2025.Another prominent risk factor is mental stress and lack of physical exercise, both of which have been exacerbated with people staying at home for months and under the uncertainty of the pandemic. Family history of hypertension also plays a significant role in an individual developing high blood pressure, as does smoking and drinking alcohol.Undetected hypertension, and non-medication to control it, can lead to other disorders like stroke, heart disease, kidney failure, etc.Despite the huge burden of the disease on public health and the economy, treatment of hypertension is ill-managed. Patients are never diagnosed because often times there are no prior symptoms.And of the 50% who are diagnosed with high blood pressure, half ignore their condition and get no treatment. Of the remaining, 25% do get some kind of treatment but half of them again do not follow-up or take the correct dose of medication.“All in all only about 10% of hypertension patients get proper treatment in Nepal. Lack of proper health monitoring system, as well as misconceptions about life-long medications, hasn’t helped,” says cardiologist Prakash Regmi. “This often leads to a point where treatment is either too expensive, or even unmanageable.”Hypertension is first and foremost a lifestyle disease with strong ties to a possible failure of crucial organs in the human body. Its prevention and control are heavily dependent on an <a href="https://www.nepalitimes.com/banner/junk-food-is-making-nepali-children-shorter/" target="_blank" rel="noopener noreferrer">individual’s choice of diet</a>.A state-sponsored robust awareness campaign to focus on preventive measures and a strong healthcare system are urgently needed to reduce the epidemic of hypertension.Says public health expert Aruna Uprety: “Mandatory blood pressure check-ups for certain age groups at fixed intervals is a good place to start. It goes a long way in reducing the cost of the disease and human lives.”Stages of hypertension<ul style="font-weight: 400;"><li>Normal: Less than 120/80 mm Hg</li> 	<li>Prehypertension (Elevated): Systolic between 120-129 and diastolic less than 80</li> 	<li>Stage 1 (Moderate): Systolic between 130-139 or diastolic between 80-89</li> 	<li>Stage 2 (Severe): Systolic at least 140 or diastolic at least 90 mm Hg</li> 	<li>Hypertensive crisis: Systolic over 180 and/or diastolic over 120</li></ul>Types of hypertension<ul style="font-weight: 400;"><li>Primary or essential: Most common high blood pressure among adults. No specific cause but risk factors include diet, age, physical activity and genetics.</li> 	<li>Secondary: Up to 10% of hypertension is secondary. Most often caused by another medical condition or the use of certain medicines.</li></ul>Risk factors<ul style="font-weight: 400;"><li>High salt/sodium intake</li></ul>WHO recommendation: 5gm/day<ul style="font-weight: 400;"><li>Mental stress</li> 	<li>Lack of physical exercise</li></ul>WHO recommendation: at least 150–300 minutes of moderate-intensity aerobic physical activity<ul style="font-weight: 400;"><li>Family history of high blood pressure</li></ul>

Why do so many Nepalis have high blood pressure?

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a66739c7e80680e059980jpeg.jpg" alt="" width="1500" height="1000"/><figcaption>Photo : BIKRAM RAI</figcaption></figure>There used to be a time when the main public health threat in Nepal was from infectious diseases like <a href="https://www.nepalitimes.com/here-now/the-mosquito-that-changed-nepals-history/" target="_blank" rel="noopener">malaria</a>, encephalitis, <a href="https://www.nepalitimes.com/banner/tb/" target="_blank" rel="noopener">TB</a> and typhoid. Whether vector-borne or transmitted through contaminated air or water, the most cost-effective way to address them was through prevention. Communication was the first line of defence against communicable diseases.Things have changed. Awareness has grown because literacy rates are up. Most Nepalis now suffer from non-communicable ailments like cardiovascular diseases, <a href="https://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018">diabetes</a>, <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/A-mysterious-rash-of-kidney-failures,3639" target="_blank" rel="noopener">renal failure</a> and malignancies. These need treatment in medical facilities at a time when the over-commercialisation of hospitals has made healthcare unaffordable for a majority of the population. In fact, <a href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">poor health</a> is making Nepalis poorer.Read also:<a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">Is free health care possible in Nepal?</a>, S P Kalaunee<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/?p=37821&amp;preview_nonce=9ce6a7c55d&amp;preview=true" target="_blank" rel="noopener">Federalism leaves Nepal’s medical sector ailing,</a> Sewa BhattaraiAlso, communicable diseases have not been completely overcome. Diarrhoeal dehydration and other water-carried infections are still major killers. One of the reasons Nepal’s progress in reducing child mortality has stalled is because of the state’s failure to ensure adequate and safe drinking water in remote regions. In this paper we have also reported on <a href="https://www.nepalitimes.com/banner/nearly-half-of-nepali-children-still-malnourished/" target="_blank" rel="noopener">stunting and wasting among children</a> due to malnutrition.In addition, <a href="https://www.nepalitimes.com/here-now/air-pollution-is-more-dangerous-than-smoking/" target="_blank" rel="noopener">worsening air pollution</a> has caused an epidemic of chronic obstructive pulmonary disease (COPD), which has led to lung infections in all age brackets and causing terminal pneumonia and other complications in the elderly. At current levels of PM2.5 concentration in the air, studies show, the average lifespan of city dwellers in Nepal could be reduced by up to four years.Read also:<a href="https://www.nepalitimes.com/here-now/nepal-is-a-microcosm-of-all-of-the-changes-in-world-health/" target="_blank" rel="noopener">"Nepal is a microcosm of all of the change in world health"</a><a href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">Poor health</a>, EditorialNepal’s burden of non-communicable diseases and injuries has doubled in the last 25 years, with nearly 15% caused by <a href="https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/" target="_blank" rel="noopener">road traffic accidents</a> or natural disasters. Traffic accidents are now the second biggest killer of young Nepalis. Just in the past three weeks, 90 people have been killed on highways due to poor road condition or carelessness.A vivid indication of the threat of non-communicable diseases is today’s prevalence of diabetes. South Asians are genetically more susceptible to cardiovascular diseases and diabetes, but there are now new risk factors caused by increasing rural to urban migration. While the world prevalence average for both types of diabetes is 8%, research has shown that 14% of people in Dharan suffer from the disease. Taplejung, from where many have migrated to Dharan, has a rate of only 1%. The reason is clear: increased intake of carbohydrates and a more sedentary lifestyle when people move to cities.To meet these challenges, Nepal desperately needs <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">affordable and accessible medical care</a>. At the moment, hospital treatment is neither. The poor in remote, underserved areas of the country are disproportionately vulnerable. As our report from Bajura shows, the problem is further complicated because confusion over federalism, budget and jurisdiction has left most rural government hospitals underfunded and underserved. It is imperative that the government act quickly to resolve the retention crisis caused by medical staff getting themselves transferred out of their jobs in remote areas.Read also: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">A national health insurance is not as easy as it looks</a>, Sonia Awale<a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" target="_blank" rel="noopener">This is how to upgrade Nepal's rural health</a>, Sewa BhattaraiA survey last year showed that half of all <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">medical expenditure of Nepalis families</a> is out-of-pocket, and 60% of that is for treatment of non-communicable diseases and injuries. The federal government allocates only about 10% of its budget to health care, and the focus is still on communicable diseases. Donor priority is also not on non-communicable diseases and injuries. A study of government hospitals by the Nick Simons Institute shows a huge unmet need in remote areas for basic surgery like caesarean sections and orthopaedics.One bright spot ahead is the success of pilot insurance schemes being tried out in various parts of the country. In a <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/" target="_blank" rel="noopener">commentary this week</a>, S P Kalaunee of Nyaya Health, an NGO that helps the government manage hospitals in Achham and Dolakha, presents a proven 60:25:15 formula of health insurance. In this arrangement, non-profits, the private sector and all three levels of government can make medical care affordable to all Nepalis, if upscaled. Under the scheme, 60% of the cost of care comes from insurance, provincial governments pay 25% and municipalities take care of the remaining 15%.Parts of the scheme are being tried out in <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" target="_blank" rel="noopener">Bayalpata Hospital in Achham</a> (which last week <a href="https://www.nepalitimes.com/banner/bayalpata-hospital-in-nepal-wins-global-design-award/" target="_blank" rel="noopener">won the Global Architecture Festival award</a> in Amsterdam for its design). Insurance reimbursement covers the cost of insurance-covered care, the local government allocates funds required for basic and emergency healthcare, and the provincial government pays for managing the cost of referrals beyond insurance coverage. Internationally, this has become an issue with 12 December marked as Universal Health Coverage Day.Nepal’s constitution now guarantees basic and emergency healthcare as fundamental rights of citizens, and puts the responsibility on to the state. The government  can no longer keep passing the buck on providing universal insurance for its citizens.<h2>10 years ago this week</h2>Nepali Times <a href="http://archive.nepalitimes.com/issue/480" target="_blank" rel="noopener">issue #480 of 11-17 December 2009</a> carried an <a href="http://archive.nepalitimes.com/news.php?id=16572#.XfId7ZMzaUk" target="_blank" rel="noopener">interview on page 1 with Baburam Bhattarai</a>, who was then vice-chair of the Maoist party.  Excerpts:‘From the very beginning, we have said that the basis of the federal system should be nationality. In Marxist terms, nationality means a common language, geography, economy and psychological make-up. A group of people that shares these qualities is called a nationality.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a66769c7e80680e059981jpeg.jpg" alt="" width="392" height="600">On this basis we have proposed to constitute federal autonomous units in Nepal and we also practised this during the People’s War. Since the very beginning we have been consistent that federalism should be along the lines of nationality.’

POOR HEALTH MAKES NEPALIS POORER

https://www.youtube.com/watch?v=kJLBI7sim0M&amp;feature=youtu.beA revolutionary treatment for open wounds has dramatically reduced the healing period of <a href="http://archive.nepalitimes.com/news.php?id=711#.XSckw-szaUk" target="_blank" rel="noopener">leprosy patients in Nepal</a>, saving them money and prolonged pain. The new procedure has huge implications internationally, as it reduces the medical cost for treating patients with chronic open wounds.The technique, called Leukocyte Platelet Rich Fibrin (LPRF), was <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6089057/" target="_blank" rel="noopener">devised for dental surgery</a> by Nelson Pinto of Chile and has proven to accelerate the healing of tissue. Now, it is also being used to treat hard-to-heal skin lesions of <a href="https://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018" target="_blank" rel="noopener">diabetes</a> and leprosy patients.“LPRF has shown miraculous results in the treatment of chronic wounds in Nepal,” says dental surgeon Sushil Koirala who is pushing the new treatment in government hospitals. “It does not need special equipment, is cheap and, so simple even paramedics and nurses can perform it.”<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131140/636a4f009c7e80680e04fce5jpeg.jpg" alt="" width="1400" height="1050"/><figcaption>SECOND CHANCE: Surgeon Indra Bahadur Napit guides a paramedic during a session of LPRF on a patient with leprosy at Anandaban Hospital. Pic: KUNDA DIXIT</figcaption></figure>There are three specialised leprosy hospitals in Nepal: Ananadaban in Lele, Green Pastures in Pokhara, and Lalgadh in Dhanusa. Anandaban Leprosy Hospital 16 km south of Kathmandu has been trying out LPRF on patients with excellent results.Leprosy is a biblical disease in which bacteria called Mycobacterium leprae damages the patient’s nerves and causes the fingers, toes and limbs to go numb, leading to further injuries. Leprosy is treated with antibiotics, but some patients suffer antigen reaction and need long-term rehabilitation.One of the patients at Anandaban is Phelit Sahi, who was ostracised by her community in Jumla because she had leprosy and had been living in a cave for 25 years. Reporters who had gone to cover a local event in a helicopter found out about her, and flew her to Kathmandu for treatment.Every week, doctors draw 80cc of blood from her and place it in a special centrifuge for 12 minutes. The clear plasma separates from the red corpuscles and is compressed to form a high-density fibrin clot which is applied to her wound.“She is among more than 100 patients that we have treated with LPRF, and we have gained enough experience in this technique to lead the way for the world,” says surgeon Indra Bahadur Napit at Anandaban, who presented his results at WHO in Geneva.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131140/636a4f039c7e80680e04fce6jpeg.jpg" alt="" width="1400" height="933"><figcaption> </figcaption></figure>Raju Lama was 27 when he was diagnosed with leprosy, but because of late diagnosis, his fingers and toes were deformed, and he had to abandon his job. Doctors recommended amputating his right leg, but became the first patient to get LPRF treatment. He is happy with his “ragat upachar” (blood treatment) and says after several LPRF procedures his wounds are healing much faster.Ram Kumari Sah and her husband from Janakpur have been living with leprosy for decades. She does not feel pain in her hands and legs and often hurts herself. Her lesions become infected and never healed. This week, she was waiting for her turn at the LPRF ward in Anandaban.The hospital’s LPRF pilot study has shown that 97% of the cases healed completely within seven weeks. The results are so encouraging that news of this revolutionary treatment has spread through word of mouth. A dozen patients, currently at Anandaban were referred by hospitals in India. A team of Nepali doctors is also training doctors in Burma, Bangladesh and Nigeria.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131140/636a4f069c7e80680e04fce7jpeg.jpg" alt="" width="1400" height="1003"><figcaption> </figcaption></figure>The new treatment is expected to add to Nepal’s success in reducing the prevalence of leprosy from 21 cases per 10,000 in the 1980s to less than 1 today. Nepal was officially declared leprosy-free in 2010 when the prevalence rate came down to 0.79%.However, in recent years, the prevalence rate is creeping up again, and was 0.94% in 2018. More than 3,000 new patients are diagnosed with leprosy every year, with most of the cases found in Province 2. Experts say this could be a result of active case finding and may not mean that the prevalence is increasing.Leprosy is curable with multidrug therapy but many do not get treatment on time. The incubation period is five years on average and symptoms may occur within a year, but can also take as long as 30 years to become visible, making the disease difficult to diagnose, and the delay leads to nerve damage and deformities. Leprosy is transmitted through the air during close and frequent contact with untreated cases.“Leprosy can afflict anyone but there is a correlation between the disease and poverty,” explains dermatologist Mahesh Shah. “If one’s immune system is strong, the bugs do not do any damage. But poor hygiene and nutrition increases susceptibiltity. Neglected people from neglected countries suffer from leprosy the most.”<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131140/636a4f0a9c7e80680e04fce8jpeg.jpg" alt="" width="1400" height="1169"><figcaption> </figcaption></figure>Up to 40% of patients undergoing multidrug treatment develop a reaction, and need long-term hospitalisation. Since the patients are poor, most private hospitals are not interested in treating them. At Anandaban, treatment is free as it is supported by government grants and charities.Since 1% of cases suffer from relapse in Nepal, active door-to-door case finding is important to meet the WHO target of zero leprosy transmission by 2030.Even more daunting is to counter societal stigma and ostracisation of leprosy patients. Family members regard the disease as punishment from the gods, and even some medical interns and nurses refuse to touch patients despite patients being on antibiotics and unable to spread the disease. Nepal’s laws still allow husbands to divorce their wives if they have leprosy.“It is a complicated disease made even more so by stigma and ignorance,” says Napit, “but with LPRF, we now have a powerful weapon in our arsenal. A vaccine would be the final solution, but no one cares about leprosy. All the funding goes for diseases like HIV.”   <h2>Miraculous healing</h2>When Nelson Pinto’s favourite horse broke its leg, he had two options: either put it down or amputate its leg. The Chilean dentist decided on a third option.He drew some blood from the horse, spun it in a centrifuge to separate the autologous fibrin matrix which is rich in platelets, and applied the plasma to the horse’s wound. After a few weeks, the horse was cantering again.Pinto knew about the technique because Leukocyte Platelet Rich Fibrin (LPRF) was developed for dental implant treatment. The surgeon was so convinced that the new process would be useful in treating chronic open wounds that he embarked on a global crusade to spread its use.Pinto convinced fellow-dentist from Nepal, Sushil Koirala, whom he met at an international conference, to adopt the technique. Since then, Koirala has been trying to convince the government and private hospitals to adopt the procedure, but without much success. However, Anandaban Leprosy Hospital in Lalitpur has seen phenomenal improvements in the healing time of lesions among its patients. (See adjoining report above)LPRF is now used to treat diabetic wounds, lesions caused by leprosy, localised <a href="http://archive.nepalitimes.com/article/nation/burning-in-the-aftermath,3757" target="_blank" rel="noopener">burns</a> and surgical wounds, and with this, healing time is often cut in half. It is also being used in cosmetic surgery to remove wrinkles and rejuvenate the skin. The reason why it is so effective, Pinto explained during a trip to Nepal last month, is because it is completely natural and autologous, which means a patient is not receiving any foreign tissues or chemicals.And the treatment is cheap. A similar treatment used in Europe, which involves a kit manufactured by a multinational pharmaceutical company, costs $3,000 per patient. LPRF costs only $30. But it seems as though private hospitals are not interested in this treatment as patients heal so quickly. Many doctors are also not enthusiastic because LPRF can be administered by a paramedic or a nurse.Says Sushil Koirala: “The reason they don’t like it is because there is no money in it. LPRF only uses the patient’s blood and there are no chemicals or equipment involved for multinational companies to make money out of.”Koirala’s Punyaarjan Foundation has donated centrifuge machines to a few hospitals in Nepal including the Sushma Koirala Memorial in Sankhu, Anandaban Leprosy Hospital, Bir Hospital in Kathmandu and to three hospitals in Burma with varying degrees of acceptance.The Bible relates how Jesus Christ miraculously and instantaneously cured ten lepers at the gates of Jerusalem. LPRF may not cure leprosy lesions as quickly, but the procedure is nearly as miraculous.<h2>Life after leprosy</h2><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131140/636a4f0d9c7e80680e04fce9jpeg.jpg" alt="" width="1400" height="1050"><figcaption> </figcaption></figure>Kumar Tamang, 47, is putting the final touches on his painting of an elephant with a bejewelled crown and a howdah. He dips his paintbrush on a palate and paints the border bright red. His fingers are numb and deformed by leprosy, yet he has been painting for 25 years. His love for Mithila art is on full display on the walls, pillars and ceiling of Shanti Sewa Griha, a leprosy clinic set up by the German charity, Leprahilfe, in 1992.Nearby, in a dark corner, is 50-year-old Nathuni Barai from Nawalparasi, who also has deformed fingers which he uses deftly to draw intricate patterns on a letter pad. Both Tamang and Barai are former patients at <a href="http://archive.nepalitimes.com/news.php?id=15213#.XSckyeszaUk" target="_blank" rel="noopener">Shanti Sewa Griha,</a> making a livelihood from products that Leprahilfe buys from fundraising. Their families live nearby, and their children attend a school set up by the charity.Now, nearly three decades after the clinic was set up, Shanti Sewa Griha runs a school and orphanage in Budhanilkantha, an organic farm in Sundarijal and a rehabilitation centre near Pashupati.As the number of patients grew, they were trained in painting, tailoring, quilt making, carpentry and jewellery making as a form of livelihood. Bags, uniforms, paintings, stationery and decorative items are sold as souvenirs to raise money for the upkeep of the shelters and to pay former patients.“This is a form of operational therapy which tries to break the vicious circle this disease has formed,” said Marianne Grosspietsch, one of the founders of Leprahilfe. “Our goal is to create hope in Nepal.”In 1974, Grosspietsch adopted a young boy named Puskar Limbu who had leprosy like the rest of his family. She took the boy to her home in Germany, treated his leprosy and sent him to school. Limbu went on to pursue a successful career in graphic design in Germany and is a grandfather himself today.Children of former leprosy patients have also gone on to become nurses and doctors.Kalpana Pariyar (pictured above) was 14 when she was diagnosed with leprosy before there was serious nerve damage to her fingers. She grew up in the shelter and married fellow-patient Krishna Majhi, whom she took care of until he died eight years ago. She now has a college going daughter and an eight-year-old son.“I have spent my entire life here. This is my home, this is where I made my life and found peace,” says Pariyar, looking up from her sewing machine on which she was weaving dhaka fabric.Sonia Awale

New treatment offers hope for Nepal’s leprosy patients

For many decades it was an accepted truth that Nepal’s main public health threat was from infectious diseases, and the most cost-effective way to address that was through prevention. In other words, the first line of defence against communicable diseases was communication.Whether it was gastric infections caused by contaminated water, respiratory ailments due to cold and pollution, or diseases spread by insect vectors like malaria – the goal was to spread public awareness about prevention. Radio jingles about oral rehydration salts or acute respiratory infections in children indirectly helped save millions of lives over the years.Many of these challenges remain. Despite dramatic progress, many Nepalis still lack safe drinking water – not just in the roadless hinterland but right here in the heart of the capital. There are frequent <a href="http://archive.nepalitimes.com/article/nation/%20jajarkot-open-defecation-free,2023">cholera</a> epidemics. Children’s lungs are still affected by indoor smoke from wood fires. Malaria is on the comeback due to resistance and there is an annual epidemic of dengue and encephalitis.Yet, compounding these endemic infections, there is now an <a href="http://archive.nepalitimes.com/article/nation/Communicati-about-non-communicable-diseases,1153">increasing burden of non-communicable diseases and injuries</a> (NCDI). New lifestyle-related cardio-vascular afflictions, chronic obstructive pulmonary disease (COPD) caused by <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/every-breath-we-take-air%20pollution,3536">pollution</a>, or <a href="http://archive.nepalitimes.com/article/nation/stigma-and-silence-mental-health-nepal,3486">mental health disorders</a> have added to the burden of disease and disability. <a href="http://archive.nepalitimes.com/article/nation/diabetes-in-south-asia,3018">South Asians are already genetically susceptible to diabetes</a>, and now there are new risk factors due to migration to urban centres. While the world average for prevalence of both types of diabetes is 8%, more than 14% of people in urban centres like Dharan have diabetes – even though the prevalence for rural Taplejung, for instance, is only 1%.A study by The Nepal NCDI Poverty Commission released this week shows that the burden of NCDIs has doubled in the last 25 years. More than half of all death and disability today are caused by NCDIs, with nearly 15% caused by injuries in conflict, natural disasters or highway accidents. <img width="900" height="802" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/636517699c7e80680e02c275jpeg.jpg" alt=""/>Being afflicted with an NCDI (or chronic disease) is more fatal in Nepal than in developed countries because of affordability and restricted accessibility to adequate medical treatment. The poor are disproportionately vulnerable. The NCDI burden in Nepal is also different than in other parts of the world – there is a higher incidence of ischemic cardiac conditions, asthma, neurological disorders, cancers caused by untreated infections and injuries, for instance.For us, the report’s main finding, and most damning inference, is about how <a href="http://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">treatment of NCDIs is driving Nepalis into indebetedness and penury</a>. The survey shows that half of all medical expenditure of families is out-of-pocket, and 60% of that is for treatment of NCDIs. This is because the government spends only 11% of its budget on health care, and only 6.4% of that is for treatment of non-communicable diseases.Despite the proven link between chronic ailments and poverty, donors still allocate only 1% of their development assistance for NCDIs.Treatment of injuries, gastro-intestinal infections, heart diseases, cancers, kidney and liver diseases are the most impoverishing NCDs for households. The report’s main conclusions are corroborated by our <a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/">field report</a> from Achham and Kavre this week  about how the lack of even basic surgical facilities in district hospitals and health posts is forcing Nepalis to undertake expensive and extended trips to private hospitals in the cities.Another recent study of 39 government hospitals commissioned by the Nick Simons Institute (NSI) showed a huge unmet need in remote areas for basic surgery like caesarians, orthopaedics, and abdominal operations. Nepal’s surgery rate is well below the Lancet Commission’s target of 5,000 operations per 100,000 population. Only one-third of patients currently can reach an orthopedic surgeon within two hours of travel. <img width="640" height="456" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/6365176b9c7e80680e02c276jpeg.jpg" alt="">The public-private partnership models that NSI and Possible are carrying out in remote government hospitals are ways to plug this gap: ensuring minimum staffing of a MDGP physician, anaesthesia assistant, staff nurse and biomedical technician in each hospital can offer basic treatment and surgery in remote areas, reduce the need for referrals, and save household income. At present Nepal’s density of hospitals with such staffing and equipment is at 0.4 per 100,000 population, as against the Lancet Commission’s recommendation of 20/100,000.The Nepal NCDI Poverty Commission report suggests additional measures: national health care delivery should respond to the increasing burden of NCDIs by decentralising.Impoverishment of households due to the high cost of treatment should be addressed through disease-specific policies for high-cost conditions and expansion of insurance coverage.It is often said that health is wealth, but in Nepal wealth is health. That can only be changed by making treatment of chronic conditions and injuries accessible, affordable, inclusive and equitable.Read also:<a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/">State of the art rural hospital</a>, Marty logan <a href="http://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">A national health insurance scheme is not as easy as it looks</a>,  Sonia Awale<a href="http://archive.nepalitimes.com/article/nation/Communicati-about-non-communicable-diseases,1153">Communicating about non-communicable diseases</a>,  Elina Pradhan and Bigyan R Bista

Poor  health

Fenerbahçe Beko won the Turkish Airlines EuroLeague finals in Abu Dhabi, held 23-25 May, defeating Monaco 81-70 in the final. Olympiacos, who defeated Panathinaikos 97-93, finished the series in third place. The Most Valuable Player (MVP) of the final match, Nigel Hayes-Davis from Fenerbahçe Beko, received a prize of 1,000,000 Miles&amp;Smiles from Turkish Airlines’ Chief Commercial Officer Ahmet Olmuştur. The carrier has been the title sponsor of the Turkish Airlines EuroLeague, a top tier tournament, since 2010.

Turkish Basketball

Thousands of Nepali students dreaming of an American education have been forced to look elsewhere as the Trump administration’s visa restrictions make their future uncertain.
The US was long considered a top destination for higher studies, making Nepal the 10th biggest country of origin for international students in America.&nbsp;
However, that number has seen a significant decline with the total for Nepali students now at 16,482. Some 8,000 Nepali students obtained no-objection certificates to study in the US from the Ministry of Education in the past year.&nbsp;
India, Australia, Canada, South Korea, United Kingdom and Japan are the other popular destinations for Nepali students. There are no clear numbers for Nepalis going to India, but a slight decline was noted this year after the deaths of two female students.
The US State Department has issued a circular to its embassies not to issue new visas to applicants until further notice. US Secretary of State Marco Rubio in the directive stated that the department planned to expand the screening of applicants' social media.&nbsp;
While new applicants are barred including those applying for visitor visas, students with scheduled interviews are allowed to proceed.
“Many of our students are affected by the new restrictions, but those who had applied for student visas earlier have got interview dates,” one Kathmandu-based college counsellor told us.
Meanwhile, even foreign students with spotless records already in the US have not been spared, as visa scrutiny intensifies under the new policy. In a move that underscores the growing sense of insecurity, many US colleges advised international students to carry their passports and documents at all times, even when traveling locally.
“Me and my friends did not go home this summer because we were not sure we would be allowed back, so we just went to Niagara Falls,” said a Nepali undergrad in Ohio, who like many interviewed for this report did not want her name used for fear of repercussion.
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Nepali students have adopted a cautious stance, with many choosing not to return home during summer vacation due to fear of visa revocations as well as travel bans. Meanwhile, over 7,000 Nepalis with Temporary Protected Status (TPS) will have to come back to Nepal by 5 August or face deportation. Thirty-seven were flown back to Kathmandu on Omni Air last week.
“The US is one of the most sought-after destinations for higher education, and the ban will definitely impact bright students,” says Narottam Aryal of the King’s College in Kathmandu.
Indeed, Nepali undergraduates admitted into Ivy League colleges for the 2025 academic year have been asked to look for alternatives. The entire Fulbright Foreign Scholarships Board resigned on Wednesday citing interference from the Trump administration on the selection of this year’s cohort. Some Nepali students already on Fulbright scholarships have noted disruptions, delays and even cancellation of stipends.&nbsp;
The student visa restrictions were initially just for foreign students admitted to Harvard University, but it was later extended to all Chinese students and now to all students. Universities like Columbia which actively recruit foreign students, face sharp enrolment declines, threatening their financial stability and diversity.
An Indian female PhD candidate at Columbia University had her visa revoked by the US State Department, and said she was targeted on the basis of her social media posts on Israeli military attacks in Gaza. Social media vetting of political activism has raised concerns about privacy and freedom of expression in a country where such rights were a given.
Many students have been informed via email that their visas have been revoked for getting speeding or parking tickets, but even others with no criminal record have been affected. The fear of deportation looms large amongst international students, including those from Nepal.&nbsp;
For most Nepalis who migrate to the US for education, the journey is a high-stakes investment. They come largely from middle-class families, often rely on a patchwork of scholarships, work-study programs, loans, or even the sale of family assets to afford fees.
Most Nepali students pursue STEM subjects which offer extended Optional Practical Training (OPT) periods that help fund their education. But with the US backsliding on education and humanitarian matters, countries like the UK and Canada are becoming more attractive despite their own recent stricter controls on student visas.&nbsp;
The UK universities saw a 63% rise in Nepali students’ admissions in 2024. Japan is another popular destination with 64,816 Nepali students enrolled as of 2024.
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Already, China, Hong Kong and Malaysia are poised to benefit from the increased scrutiny of US student visas. Several Hong Kong universities are offering unconditional admission to affected students, while Malaysian institutions are targeting previously US-bound Asian students. China and India have 330,000 and 280,000 students respectively in America, but the numbers for China have seen a sharp drop in the past year.
Elsewhere, branch campuses of American institutions such as NYU in Abu Dhabi, Georgetown in Dubai and Northwestern in Doha are getting more admission applications, and universities in the Gulf region are expanding infrastructure to accommodate those who would otherwise have gone to the US.&nbsp;
Even educational institutions in Nepal are hopeful that the US visa restrictions can be an opportunity to at least keep Nepali undergrads in Nepal, and also attract foreign students from the region.&nbsp;
“Many students might choose to complete their undergraduate degree here in Nepal and then move abroad for their Master’s degree later,” says Aryal of King’s College. “There was a need for quality higher education in Nepal anyway in terms of innovation and opportunities, so this could be the time to reduce our dependence on other countries.”
Nepal’s strategic position between India and China makes it sensitive to US policy shifts. India, a key ally, is also under US scrutiny for potential student travel restrictions. Chinese universities are already offering more scholarships to Nepali talent to capitalise on the US retreat.
American universities have challenged student visa restrictions in the courts. A federal court in Boston revoked the blanket ban on Harvard, and the State Department has ordered the resumption of processing student and exchange visitor visas.&nbsp;
Some are still hoping that President Trump will backtrack on the student visa restrictions, just like he has done with many of his more drastic executive orders.
Even so, the visa see-saw and longer-term uncertainties about living in the United States and its education system means students across the world are making alternative plans.
Says Aryal: “Policies of foreign countries change according to their needs, so excessive dependence was never a good idea. We should work to create different opportunities and choices of higher education within Nepal, so students are retained.” &nbsp;

America no longer prime destination for Nepali students

That winter day in January 1664 marked an exceptional event in the reign of King Pratap Malla of Kathmandu. It was 15 Paush 784 of the Nepal Sambat and for the first time, a historical event was being immortalised on canvas for generations to come.&nbsp; The occasion was the grand Tuladaan ceremony of the King’s youngest son Chakrabartendra Malla from his wife Anantapriya, an Indian princess from Cooch Behar in present-day Assam.&nbsp; During the ritual, the prince was weighed against gold, silver, pearls, and other precious stones, which were then offered to Goddess Taleju Bhavani, the guardian deity of the Malla dynasty.&nbsp; The 170 x120cm painting captures the time of King Pratap Malla in all its splendour and is more than a personal tribute to his son: it is a significant visual historical document. It was evidently completed five years later in 1669, and could be considered a photographic record, with retrospective recreation of the event by the unknown artist. A Tuladaan ceremony is performed to purify one’s karma, quell impending bad luck, or as an act of charity and devotion. Chakrabartendra Malla was not well, and the ritual was performed in hopes of restoring his health. King Pratap Malla had arranged for each of his sons to take turns ruling Kathmandu so they got administrative experience. But Chakrabartendra died just two days after assuming power in 1670 (790 NS). This painting is considered the earliest known example in which the composition is dominated by an architectural landscape: the Taleju Temple. Given the stylistic features such as side-profile facial depictions and the rendering of human forms, it is believed that the Nepali artist was trained by a Rajput master.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250615040624_ddad3bc27a327e3f9926c8473287e4f14b53081296c295049009f327a4d97051.jpg" data-media-id="editor_0" data-image-id="20250615040624_ddad3bc27a327e3f9926c8473287e4f14b53081296c295049009f327a4d97051" data-rendition-name="original" width="3248" height="4395" loading="lazy" alt="Tuladaan NT"> </figure>  During that era, there were regular exchanges of artists between Northern India and Kathmandu Valley. The painting is also a melding of Nepali, Tibetan, Mughal, and Rajput art styles of the time. Pratap Malla could have been inspired by a painting of Mughal Emperor Jahangir’s Tuladaan ceremony for his son Khurram in 1607. The Mallas and Mughals shared cordial relations, which is reflected in the cultural influences seen in the art and attire of the period.&nbsp; The clothing of the Malla ruling class, in particular, features colourful tunics, turbans, and jewelry that display strong Rajput and Mughal stylistic elements. The musicians in the upper tier are also dressed in Indian-style clothing, while the ensemble on the lower steps wear local attire, notably without turbans. Their hairstyles also differ, with the lower group wearing their hair tied in a bun at the front. This national treasure is currently in storage at the Collège de France in Paris, and has never been publicly displayed. Nepal’s art scholars like Gautam Vajracharya, Pratap Aditya Pal and Anne Vergati have written about this iconic paubha in the past, but the only detailed study is from the perspective of music history by researcher Richard Widdess who had access to high resolution copies of the original.&nbsp; Widdess from the Department of Music at the School of Oriental and African Studies (SOAS) in London describes the paubha as the most significant and richly detailed documentation of music in Nepali art. He identifies distinct musical ensembles on the terraces of the temple, and remarkably most of them are actively used today. One of them reflects the Mughal naqqārakhāna model — a loud outdoor ensemble typically composed of kettledrums, trumpets, and cymbals, traditionally performed from the gateway of the emperor’s palace to announce his entrances and exits. The depiction of such an ensemble in the tulādāna painting is likely the earliest known representation of a complete naqqārakhāna in Nepal — considered the forerunner of the panche baja, the traditional Nepali ensemble. On the stepped pyramid base of the temple are two groups of musicians playing local instruments: dhimey, bhushya, and dha. They are unmistakably Newar musicians, wearing short skirts and short-sleeved tops, with bare heads and legs—clearly distinguished as local performers.&nbsp; Higher still on the temple pyramid are musicians of apparently higher status, positioned close to the king, and his courtiers, possibly professional court musicians from India, well-versed in rāga and tāla. A dāphā group is also clearly depicted, identifiable by their characteristic instruments.&nbsp; Dāphā bhajan is likely the oldest surviving tradition of Newar devotional singing, and this paubha is the oldest visual record of it. Pratap Malla himself is believed to have composed songs that continue to be performed by dāphā groups throughout Kathmandu till today.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025061211064_d67636730cdc0ec778c02494817aca0b99654f2950d0fae4b95499a61faf7ef3.jpg" data-media-id="editor_1" data-image-id="2025061211064_d67636730cdc0ec778c02494817aca0b99654f2950d0fae4b95499a61faf7ef3" data-rendition-name="original" width="596" height="768" loading="lazy" alt="Priceless paubha in Paris NT"> </figure>  The artist’s thorough attention to musical detail may be attributed to King Pratap Malla’s own deep interest in music. His inscriptions on this painting and elsewhere proclaim his mastery of all branches of knowledge, including music. He is also known as the author of dance dramas and poems, penning his name as Kavindra (king of poets). Some noteworthy elements of new art techniques stand out: for example, the roof of the temple is filled with realistically rendered white doves, pigeons, and crows. This is a rare feature in paubha, where animals and birds are stylised, mythological forms. This remarkably talented unknown artist has managed to also render an orthographic projection: the front and side view of Nepal’s first architectural paubha. The Taleju Temple, with its staggering multi-tiered structure and numerous steps and platforms, is masterfully translated into layers within the painting. This represents a significant artistic achievement of the time, especially considering that dimensional perspectives had not started in deity-based paubha.&nbsp; The artist has also made a meticulous effort to capture architectural details such as the toran (ornamental arch) and temple struts with impressive precision. There are flickering lamps along the steps and some people carrying what appear to be oil pots.&nbsp; It is a full moon night and the dark sky is adorned with all the gods and goddesses, who are depicted as blessing the ceremony while seated on stylised thangka clouds. There is a lot happening in this painting, with people engaged in various activities. The artist has also rendered a forest backdrop behind the temple, complete with deer, trees, and flowers. Could there have once been a royal garden behind the Taleju Temple?&nbsp; More details and clarity can only be achieved if we are able to view the original or a high-resolution scanned version of the artwork. Many countries proudly display art depicting historical events in their national museums with great reverence. France, for example, has The Coronation of Emperor Napoleon and Empress Joséphine by Jacques-Louis David (1808–1822), along with numerous paintings of the Napoleonic Wars. Many were commissioned by Napoleon himself for future generations to remember.&nbsp; For Nepal, the equivalent is the Tuladaan paubha which is a visual record capturing a historic moment involving one of Kathmandu’s greatest kings, on the very day the event took place. Sadly, we await the day when this masterpiece is displayed, shared in high resolution for detailed study, or more rightfully — repatriated to its homeland, where it truly belongs. &nbsp; Shaguni Singh Sakya is the Director of the Museum of Nepali Arts (MoNA) at Kathmandu Guest House in Thamel. <h2>Gods homeward bound</h2> The Nepal Heritage Recovery Campaign and Nepal’s Department of Archaeology are convening the first international conference on the Recovery of Cultural Heritage from 16-18 June in Patan. The conference will address urgent issues of theft, illicit trafficking, the campaign to repatriate looted cultural artifacts, and explore how the return of sacred antiquities contributes to justice, healing, and reconciliation for communities and nations affected by cultural loss. American art crime professor Erin L Thompson and Saubhagya Pradhananga of the Department of Archaeology will deliver the keynote. Meanwhile, author and Nepali Times publisher Kunda Dixit will lead a conversation on Illicit Trafficking: Public Opinion and Role of Media with Erin Thompson, Amr Al Azm, associate professor of Middle East History and Anthropology at Shawnee State University in Ohio, as well as Bradley J Gordon, a lawyer based in Phnom Penh. There will be sessions looking at repatriation perspectives from Cambodia, India, Vietnam, China and Poland, international frameworks for repatriation, emerging digital technologies in the repatriation of cultural heritage, cultural property agreements, museums as well as trends in the art market, and heritage diplomacy and the role of media.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025061211068_59cfccfa8f5d73bfe8b4c5811a7f53abc09ea04e8cb7c638933d62e5283efdf6.jpg" data-media-id="editor_2" data-image-id="2025061211068_59cfccfa8f5d73bfe8b4c5811a7f53abc09ea04e8cb7c638933d62e5283efdf6" data-rendition-name="original" width="1080" height="1350" loading="lazy" alt="Heritage recovery NT"> </figure>  <h2> </h2> Some of the other highlights include James K. Reap, a professor in the Master of Historic Preservation Program at the University of Georgia who has a session on the US response to illicit trafficking. Art historian Lea Saint-Raymond is taking on “Gods at Auction: The Market for Himalayan Artefacts”, while lecturer of criminology at the University of Glasgow Emiline Smith is delving into transformative approaches to heritage ownership and repatriation. Helena Arose of Antiquities Coalition and Melina Antoniadis of NOSTOS Strategies that specialise on the return home of cultural heritage as well as Hao Liu of International Cultural Heritage Law at the School of Law at Shandong University are some of the others attending. The Nepal Heritage Recovery Campaign was set up in 2020 to develop a coordinated movement to reclaim Nepal’s stolen gods and goddesses, with an aim to ensure that recovered items are returned to their original shrines, niches or sanctums. Ahead of the conference opening organisers have arranged for a film screening of Loot &amp; Return: 4 Documentaries at YalaMaya Kendra in Patan Dhoka between 14-15 June. Following the conference is a multimedia exhibition titled Absent Gods: Nepal’s Lost Heritage from 31 July to 4 August at Patan Museum.

Priceless paubha in Paris

While Nepal was hosting the Sagarmatha Sambaad international climate conference in Kathmandu this month, on Mt Everest it was pretty much business as usual.&nbsp; The signs of climate breakdown are all there: a river now runs through Base Camp in summer, the Khumbu Icefall is more unstable, and there are more &nbsp;frequent avalanches. When expeditions arrived in March, the mountains were bare: it had not snowed since September, but then blizzards dumped unseasonal snow in May. And despite climate worries, such is the pull of Himalayan mountaineering that the Everest Industry showed no signs of slowdown. More than 600 international climbers and their Nepali guides had made it to the summit of the world’s highest mountain. At one point there were an estimated 2,000 people in the tent city on the Khumbu Glacier. All the ropes and ladders on the Icefall came down on Thursday, marking the official end of the spring climbing season, and just in time to avoid a monsoon cyclone approaching from the Bay of Bengal. It has been an action-packed season. One factor could be that Everest fees will go up from September: each foreign climber needs to pay a $15,000 royalty, up from the present $11,000. The cost for a Nepali climber on the South Col route will also go up: from Rs75,000 to Rs150,000.&nbsp; The fee to climb Everest in autumn is $7,500 (up from $5,500), but most climbers still prefer spring. Winter permit fee (December-February) is only $3,750 per person and the mountain is now also open for monsoon (June-August) climbs, when the fee is ever lower at $2,750. The revised rule also makes it mandatory for every two climbers on an 8,000m peak to hire one Nepali mountain guide.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025053004050_67f856fe52714e4bdcf21ae7d45c6f18c82117b9d0a5f73ed1efa04c96de1046.jpg" data-media-id="editor_0" data-image-id="2025053004050_67f856fe52714e4bdcf21ae7d45c6f18c82117b9d0a5f73ed1efa04c96de1046" data-rendition-name="original" width="931" height="732" loading="lazy" alt="The Everest Industry graph 1"> </figure>  In addition, climbers also have to pay for porters and guides, equipment, Base Camp costs, Ice Fall and fixed rope team fees, so climbing Everest does not come cheap. But such is the draw of climbing the world’s highest peak that some say the increased fees will not diminish the crowds next year. The government has tried to spread expeditions out to other seasons and other 8,000ers, but with not much success. Earlier this year, Nepal unilaterally increased the number of 8,000m peaks to 14 by adding six more sub-summits to broaden the choice for climbers. Added were: Yalung Kang (8,505m), Yalung Kang West (8,077m) &nbsp;Kangchenjunga Central (8,473m), Kangchenjunga South (8,476m), Lhotse Middle (8,410m) and Lhotse Shar (8,400m).&nbsp; The announcement could go against the accepted topographic criteria that a stand alone peak has to be at least 300m higher than an adjoining prominence, and at more than 3km isolation from it. The UIAA (Union Internationale des Associations d'Alpinisme) still recognises only 14 mountains as eight-thousanders, and only eight of those are in Nepal, or on the border with China. Nepal’s revised mountaineering regulations also increased the insurance coverage of high-altitude workers to protect porters and high altitude guides who usually take more risks on the mountains. Rescue teams and clean-up campaigners to collect trash and remove bodies of dead climbers up to Camp IV of Mt Everest do not need permits.&nbsp; The Sagarmatha Pollution Control Committee is now using drones to fly down trash in 20kg sacks. Each climber is also required to bring down at least 6kg of waste and not just their own, but this rule is erratically enforced. With five fatalities on Everest and Lhotse, Spring 2025 had a historically low death toll. Another five climbers died on Annapurna, Kangchenjunga and Makalu.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025053004050_38681de22f0fefb6faa12b01755566d09c5064d0ff84e12ccc7b5d68ea9ba38a.jpg" data-media-id="editor_1" data-image-id="2025053004050_38681de22f0fefb6faa12b01755566d09c5064d0ff84e12ccc7b5d68ea9ba38a" data-rendition-name="original" width="665" height="740" loading="lazy" alt="The Everest industry graph 2"> </figure>  Journalist Ben Ayers who ran the Everest Live social media channel from Everest Base Camp with daily updates credited the low death rate to dramatic rescues of climbers from the ‘Death Zone’ by their Nepali guides and longline helievacs — the visuals all uploaded on YouTube.&nbsp; “Ironically, this perception of safety is bringing more and more inexperienced climbers to the mountain, and they need more rescues,” Ayers said in one of his dispatches.&nbsp; American expedition chronicler and summiteer Alan Arnette suspects there is a lot of under-reporting given that the jet stream and storms were lashing Everest even till late in the season. He told us: “I heard a lot about frostbite and rescues that were not made public. It’s become practically impossible to cover the details on Everest. All the teams report nice news, and they don’t talk about bad stuff to avoid hurting businesses.” Although trash on Nepal’s mountains makes headlines, what does not receive as much attention is the climate impact of so many expeditions. The Sagarmatha Sambaad conference sidestepped this issue, which is ironic given that the impact of climate breakdown is most evident on Himalayan peaks and their glaciers.&nbsp; <h2>Need for Speed</h2> The big stories this year have been about speed-running from their home cities to the top of Everest. Ukrainian entrepreneur Andrew Ushakov flew out of JFK on 15 May at 10:15AM Nepal time, and was on the summit 3 days, 23 hours, and 7 minutes later on 19 May at 9:22AM.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250601080640_1c5cc6fc991307861768f07037ed9d30930fb20f35dbb57dc31c9a92a9e1a885.jpg" data-media-id="editor_2" data-image-id="20250601080640_1c5cc6fc991307861768f07037ed9d30930fb20f35dbb57dc31c9a92a9e1a885" data-rendition-name="original" width="1440" height="1800" loading="lazy" alt="The Everest Industry"> <figcaption>Andrew Ushakov at the summt. Photo: ELITE EXPED</figcaption> </figure>  “I could never find the time for the traditional 40-50 days of acclimatisation,” Ushakov explained matter-of-factly. His ‘Everest Sea-to-Summit’ climb was possible because he spent 400 hours in hypoxic sleep tents over the past four years in New York. However, Ushakov did use ropes already fixed, hired four Nepali guides, helicoptered to Base Camp, and used much more oxygen than an average climber. And after the climb, Ushakov was arrested at Kathmandu airport for being in possession of $20,000 of undeclared cash and spent a night in jail and fined $60,000.&nbsp; The other speedsters were Garth Miller, Alastair Cairns, Anthony Stazicker, and Kev Godlington, all former British Army commandos. They left London and summited five days later on 21 May, and flew right back. They also used hypoxic tents to simulate the thin air high on Everest.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250601080644_90c8dd5cc07b4b43f2989b1dc0c0650ab80f10ebb06680c25a6909c519957bd8.jpg" data-media-id="editor_3" data-image-id="20250601080644_90c8dd5cc07b4b43f2989b1dc0c0650ab80f10ebb06680c25a6909c519957bd8" data-rendition-name="original" width="810" height="668" loading="lazy" alt="The Everest Industry "> <figcaption>All four members of the Furtenbach team at the summit. Photo: Sandro Gromen-Hayes</figcaption> </figure>  But more controversial was their use of xenon gas therapy in a German hospital to ramp up the production of oxygen-carrying haemoglobins in their blood. Xenon is banned by the World Anti-Doping Agency for being performance enhancing in sports. Expedition leader Lukas Furtenbach said this rule does not apply to mountaineering, as it is not a regulated sport like swimming. Nepal has no rules about xenon, but the Department of Tourism said it was launching an ‘investigation’ to decide on future policy since it is difficult to ban xenon, but allow oxygen. The controversy has also divided the mountaineering community, with some climbers saying they just want to maximise their chances of survival. Spending less time on the mountain could make climbing safer by reducing avalanche risk. It would also mean less trash on the mountains, but it would reduce the income of Nepal’s expedition industry. It is also unclear how much of the success was due to xenon therapy and whether the ex-special forces were already in good physical shape.&nbsp; The need for speed hides the fact that climbing in the Himalaya is dangerous business, and climbers cannot sprint to the top just by huffing xenon. But ultra-fast climbs could be charged more, and the revenue generated can be used to establish state-of-the-art rescue operations, and increase pay and insurance for guides. Two other speed chasers this season were Swiss-Ecuadorian Karl Egloff and American Tyler Andrews, both on Everest without oxygen. Andrews choppered to Base Camp to catch a weather window, but turned back from 8,500m due to high winds. Heavy snow and wind also forced Egloff to descend from 7,000m. Slow and steady climbers like Anja Blacha from Germany did make it to the summit without oxygen, while Kami Rita Sherpa broke his own record with his 31st Everest summit as he led a 26-strong Indian Army group. There were 468 permits issued for foreign climbers from 48 expeditions to Everest this spring. Nepal’s other eight-thousanders together had only 17 expeditions. Nepal has more than 1,000 peaks above 6,000m, and has opened only 476 of them for climbing.&nbsp;