<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101132/636b73eb9c7e80680e062365jpeg.jpg" alt="" width="1500" height="911"/><figcaption>Photo: NATIONAL TRAUMA CENTRE</figcaption></figure>Speeding along a narrow winding mountain road in Dhading, a heavily intoxicated truck driver lost control of the <a href="https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/" target="_blank" rel="noopener">vehicle</a> and it overturned, killing seven and severely injuring 34 passengers hitching a ride.This was a mass trauma incident that required immediate attention, but <a href="http://nationaltraumacenter.gov.np/" target="_blank" rel="noopener">Nepal’s only trauma care centre</a> was located in Kathmandu, 90km away via bumpy roads jammed with traffic.Read also: <a href="https://www.nepalitimes.com/?p=40249&amp;preview_nonce=aefd82ecbe&amp;preview=true" target="_blank" rel="noopener">injured use Internet to reach physiotherapists in Nepal</a>, Sonia AwaleMost passengers from the truck accident were taken to nearby hospitals in Dhading, but the 21 most critical patients were airlifted or driven in ambulances to the National Trauma Centre in Kathmandu.“It had already taken a while to bring the patients to the Trauma Centre, so we had to act quickly once they were here,’’ recalls Pramod Yadav, acting medical superintendent at the facility.The standard protocol for trauma care is the triage system -- determining the priority of treatment based on the severity of injury. Doctors at the National Trauma Centre quickly designated yellow, green and red codes to patients to ensure that those in critical condition were taken care of first, and fast.Read also: <a href="https://archive.nepalitimes.com/article/nation/accident-prone-Mugling-Narayangadi-highway,3828" target="_blank" rel="noopener">Unblocking an artery</a>, Sanjeev SharmaOn-call doctors were contacted and began assessing the patient’s injuries. But without a functioning MRI and a faulty CT machine, some had to be sent to private clinics and later returned to the hospital.This is a recurring event for patients seeking immediate care at the government-run Trauma Centre where patients in critical condition have to be moved about from one facility to another for tests.“We cannot afford an MRI machine, it is very expensive to repair our CT machines, we have limited trolley beds and only 11 ICU beds when we need more than 50,” says Yadav. “We are requesting the government for Rs420 million to become a real trauma centre, especially since we are the only one in the country.”There were 60,000 severe trauma injuries in Nepal in the last year, a 3,000 increase from the previous year, and a whopping 27,000 over the year before that. Like with all government-run medical centres, the Trauma Centre lacks resources, is under-staffed, and is incapable of handling this exponential increase.“In the last two, three years, falls, physical assault, <a href="https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/" target="_blank" rel="noopener">road traffic accidents</a>, sports injuries and <a href="https://archive.nepalitimes.com/article/nation/burning-in-the-aftermath,3757" target="_blank" rel="noopener">burns</a> have been the leading causes of trauma,” lists  Siddhartha Dhungana, the Medical Record Officer at the National Trauma Centre. “Head injuries and multi-organ failures have been the highest causes of death in these cases.”Most hospitals in Nepal, like the National Trauma Centre, follow the World Health Organisation’s trauma protocol. During a trauma case, medical personnel are contacted as soon as possible, patients are screened, their needs are identified and necessary care is given.Although the government has not developed a standard care protocol for trauma like it has for cancer patients, private hospitals have implemented and refined their own systems based on WHO guidelines.<a href="http://archive.nepalitimes.com/article/nation/politics-behind-epidemic-of-hospital-vandalism,3578" target="_blank" rel="noopener">Om Hospital</a>’s Continuing Medical Education Program is at the forefront of teaching trauma care to new doctors and providing courses on improved techniques to existing doctors.“We make sure that the ABCs of trauma care are followed strictly and that blood is readily available be it from our blood bank or staff-chain blood donors,” says Binod Adhikari of Om, which handles dozens of cases every day and has systems in place to coordinate between doctors, nurses and critical care anesthesiologists to provide emergency care to patients.<h2>Ambulance chasers</h2><figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101132/636b73ee9c7e80680e062366jpeg.jpg" alt="" width="1500" height="1125"><figcaption> </figcaption></figure>Most of Nepal's ambulances are just jeeps with stretchers, with no life-support systems or medical attendants. It was only in 2011 that Nepal’s first emergency medical service was established. Supported by the Patan Academy of Health Sciences and the Stanford University School of Medicine, Nepal Ambulance Service (NAS) has since trained more than 100 emergency medical technicians (EMTs) and ambulance drivers and operates the <a href="http://archive.nepalitimes.com/news.php?id=18888#.XjvhpTIzaUk" target="_blank" rel="noopener">'Dial 102' service</a>. NAS operates mainly in Kathmandu Valley, Pokhara, Chitwan, Butwal and Bhairawa.“Before this, only few private hospitals had ambulances and they were used mainly for patient transfer rather than pre-hospital care,” says Hari Khadka, a paramedic at <a href="https://www.grandehospital.com/" target="_blank" rel="noopener">Grande International Hospital</a> and a member of the first EMT batch of NAS. “Ten years ago, there was simply no concept of pre-hospital care or paramedics in Nepal.”Now, many hospitals have their own EMS systems with mostly Type 3 ambulances that have first aid kits and basic medical supplies. <a href="https://www.nrcs.org/" target="_blank" rel="noopener">Nepal Red Cross Society</a> (NRCS) operates 283 ambulances nationwide. Although not every ambulance carries a paramedic, every driver has received first aid training.“We have five Type 2 ambulances and a paramedic in each vehicle,” says Bipul Neupane of NRCS. “We send these ambulances to patients who need basic life support systems.”But for patients needing critical care in remote areas, there is no recourse but expensive helicopter medical evacuation.Like Type 1 ambulances, some of these helicopters can have doctors, ventilators, advanced life support, and EMTs.“EMS has helped save many lives in Nepal but it isn’t always the best option considering the geography of Nepal and the condition of the roads,” says Sanjaya Karki, Head of the Emergency Department at <a href="https://www.nepalmediciti.com/" target="_blank" rel="noopener">Nepal Mediciti Hospital</a>. “Helicopter Emergency Medical Services ensure that we can get to critical patients as quickly as possible and provide the best pre-hospital care.”

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It’s an emergency: Nepal needs to improve trauma care

<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108151120/636a664f9c7e80680e059974jpeg.jpg" alt="" width="1200" height="793"/>Around the world, in rich countries and poor, financing healthcare is one of the biggest challenges. In poor countries, it becomes a life-or-death issue.Over 40% of global healthcare expenses are still covered by patients and their families, and more than half the world’s population lacks access to essential health services. Medical bills push 100 million people into extreme poverty every year.Nepal has taken remarkable strides in healthcare in past decades despite internal conflict and instability, but <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028" target="_blank" rel="noopener">medical care is still unaffordable</a> or inaccessible to most. More than half the healthcare expenditure of Nepalis is still covered out of pocket. Nearly a third of families spend over 10% of their annual income on medical care.Read also: <a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" 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 Bhattarai <a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/" target="_blank" rel="noopener">State of the art rural hospital</a>, Marty LoganThursday, 12 December, is Universal Health Coverage Day, an important date to remind ourselves of the next steps we need to take to achieve healthcare for all. The 2015 constitution of Nepal declares basic and emergency healthcare as fundamental rights of citizens, putting the responsibility of financing such care on the state. Following federalism, municipal governments have got the responsibility to manage basic and essential care. A national health insurance bill has been passed and is being implemented.The state guarantees quality healthcare without financial burden on citizens, for which the insurees pay Rs3,500 per year for a family of five, and receive care worth Rs100,000. This is expected to reduce the burden of out of pocket and catastrophic expenses, while the government covers the premium for citizens under the poverty line.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 scheme is not as easy as it looks</a>, Sonia Awale<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/editorial/poor-health/" target="_blank" rel="noopener">Poor health</a>, EditorialThere is also a provision for free essential drugs and free treatment for patients with cardiovascular disease, cancer, spinal injuries, renal ailments and sickle cell anaemia, through the Disadvantaged Citizens Medical Treatment Fund.None of these initiatives is being implemented fully yet, but with federalism Nepal has a chance to build an accountable and sustainable healthcare system. The country therefore needs to focus on the following areas to manage health financing to meet the targets of the Sustainable Development Goals:<ul><li>Increase public sector healthcare investment to at least 7% of annual national budget. This should also be targeted towards reducing external aid.</li> 	<li>Empower people for self-care and make treatment more strategic and efficient as the burden shifts from communicable to non-communicable diseases.</li> 	<li>Focus on primary health care and improve services at the first point of care with comprehensive, accessible and community based care.</li> 	<li>Coordinate multisectoral policy action involving education, agriculture and social behaviour.</li> 	<li>Launch a priority national campaign to spread insurance coverage. Enrollment can be top-down starting with all government officials and then the public at large.</li></ul>A mixed financing model using tax-based funds through the treasury, and premium-based funds through health insurance can work for public, private, community, and other hospitals that run under the state-non-state partnership. An example of state- non-partnership is Bayalpata Hospital in Achham district, managed through a public-private partnership between the ministry of health and population and the non-profit Nyaya Health Nepal, where insurance reimbursement covered over 60% of the hospital’s operating costs.The hospital provides healthcare with no user fees. The care is extended from hospital to communities using a network of community health workers. How can care delivery with no user fee sustain? Can Nepal afford to provide such care to its entire population?It is possible. The country should effectively implement the national health insurance program, and strategically invest tax based funding. In the mixed financing model, for a ‘district level hospital, insurance can cover 60% of healthcare operating costs, and tax-based funding can take care of the rest. But to ensure effectiveness, the tax-based investment will need to be unrestricted and tied to audited performance indicators. The cost of care should also incorporate the extension of hospital-based services into communities in the catchment area.Bayalpata Hospital serves both as a primary care facility and also as a referral hospital. In this case, the tax-based contribution can be split into the three government tiers, with the federal government providing support for infrastructure, and provincial and local governments covering the cost of basic healthcare, and referral care not covered by the insurance.Insurance reimbursement then 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.<a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://archive.nepalitimes.com/article/nation/Nation-Crowdfund-globally-act-locally,490" target="_blank" rel="noopener">Bayalpata Hospital</a> provides basic and referral care, and its tax-based contribution can be split into the three government tiers, with the federal government providing support for basic infrastructure and provincial and local governments covering the cost of basic and referral care not covered by the insurance.Insurance reimbursement then 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.The proposed model has a 60:25:15 ratio to pay for health care, with 60% from insurance and provincial and local governments paying 25% and 15% of the cost. When the benefit package increases to cover the cost of healthcare without capitation, the share of health insurance coverage percentage will increase significantly, thereby reducing the tax-based direct public sector investment.S P Kalaunee is Executive Director of Nyaya Health Nepal, which manages Bayalpata and other public hospitals in partnership with the ministry of health and population.

Is free health care possible in Nepal?

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110714118/636903869c7e80680e037cc9jpeg.jpg" alt="" width="1000" height="616"/><figcaption>Photo: SHRADDHA SABURI HEALTH SERVICE</figcaption></figure>As a married, working woman with a child, it was impossible for Jasmine Bajracharya to take days off to care for her ailing parents. T<a name="_GoBack"></a>hey needed physiotherapy, but her father refused to visit a hospital. So they had to get the physiotherapist at home. Both are recovering thanks to home treatment.<a href="https://doctorsonkall.com/">Doctors on Call Nepal</a>, which provided the service to Bajracharya’s parents, is one of many new home care services that have come up in Nepal as the population ages, and their offspring are either abroad or busy at work.“My father is very talkative, so I was worried that he might offend the doctor on call,” Bajracharya says, “but the whole experience turned out to be very useful both for my parents and me, because of good communication and coordination. Now I know I have someone to turn to if my parents need care again.”Home health care has also helped provide jobs in Nepal for staff nurses and caregivers who may have otherwise have <a href="https://www.nepalitimes.com/here-now/migrating-males-and-population-decline/">migrated abroad</a>. In turn, as more and more young Nepalis go abroad to study or work, there is a growing demand for care givers who can take care of elderly parents at home, or take them to hospital for treatment.Another service provider is <a href="http://healthathome.com.np/">Health at Home</a> (see box) which was established in 2009 and has now grown into a nationwide network with units in Pokhara, Chitwan and Biratnagar besides Kathmandu.“In the West, every hospital has a home care unit. Its prospects in Nepal indicate that it is the future of medical care, which needs continuous innovation,” says founder Bishal Dhakal.Health at Home and others provide a range of services from nurses, doctors, physiotherapists and lab technicians on call to caretakers, travel support and appointment management. Many provide full doctoral supervision, while a few outsource nurses and caregivers only.The demand for care-givers is new in Nepal, and has grown exponentially to meet growing demand. Their work includes non-professional assistance which nurses do not perform, and some families prefer male health assistants.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110714118/636903889c7e80680e037ccajpeg.jpg" alt="" width="640" height="808"><figcaption> </figcaption></figure><a href="http://healhomecare.com/">Heal Home Care</a> and <a href="http://www.sshealthservices.com/">Shraddha Saburi Health Service</a> outsource female nurses and caregivers, employing more than a hundred trained personnel each, and one-third of them have been hired by Nepalis living abroad who want their parents cared for.Along with an improvements in physical health, many doctors and clients have also felt that such a service has positive effects on the mindset of elderly people, who prefer not go to a hospital. A simple follow up call or a quick visit brightens up the mood of elderly people who are often lonely, anxious or depressed because of health issues and separation from children.While the increasing demand has led to the mushrooming of home care in Kathmandu, health experts are worried that the quality of care may go down and put the health of the elderly at risk.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110714118/6369038b9c7e80680e037ccbjpeg.jpg" alt="" width="640" height="860"><figcaption> </figcaption></figure>Ramesh Kadel, Nepal’s first Geriatric Specialist, expresses concern over nurses trained in specialized care of the elderly. He says, “Service providers should keep hospitals and doctors in the loop. Our society is not fully geriatric friendly yet, and negligence of elderly people’s health is still prevalent, we need to be more aware and careful.”For the first time in world history, <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/need-to-prepare-for-ageing-society,3624">the population of people above 60 has exceeded that of children below 5</a>, and in 30 years more proper and holistic health care will be needed for the aging population.“There has been a lot of research and experiment on child health care, but proper research is lacking in the field of geriatrics. What will the future look like for today’s active population when they grow older?” asks <a href="https://www.google.com/url?q=http://archive.nepalitimes.com/news.php%3Fid%3D6370&amp;sa=U&amp;ved=0ahUKEwiKmsT_-u7cAhXRfCsKHY9xDzsQFggHMAE&amp;client=internal-uds-cse&amp;cx=011870630917993763279:opm7uqsat-4&amp;usg=AOvVaw3bqUqf9aY11y1eBubOwlMC">Krishna Murari Gautam</a> of <a href="http://ageingnepal.org/">Aging Nepal</a>, which has started a week-long specialised training for care givers of elderly patients.Doctors on Call Nepal and Health at Home also have a guided selection procedure and orientation program for nurses and caregivers, and a systematic recording of their patients to maintain quality.<h2>Health care at more homes</h2><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110714118/6369038d9c7e80680e037cccjpeg.jpg" alt="" width="1000" height="662">Home care for the elderly is one of their social enterprises that run as a business, while providing a public service. The company <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/Doctor,344">Health at Home won the Surya Nepal Award in 2012</a> for the concept of a socially responsible business. It hasn’t looked back.Nine years later, Health at Home has grown into a nationwide network of home care service company with centres in Pokhara, Kathmandu, Patan, Chitwan and Biratnagar providing much-needed home care for Nepal’s rapidly-aging population. With young men and women migrating abroad for work and studies and a growing demand from their elderly parents for health care, Health at Home is planning to open four more centres.“When we started, it was a small idea. With innovation, the idea turned into an industry and today we look forward to be an influencer that provides global standard health facility in the comfort of patient’s own home,” explains founder Bishal Dhakal.As it grew, the company has corporatised its structure with four partners, and CEO Amit Shrestha. The idea is to serve people in their community by building care capacity through an accountable, transparent and predictable process.“The concept of home care ten years ago was just to send nurses home to take care of the elderly. We are trying to constantly innovate and meet demands from patients for specialised care,” says Dhakal.Shrestha says Health at Home is poised to be a global player in virtual health care. The company is partnering with Samsung to invent a virtual platform for data management of home care parameters. This means doctors and the health management team do not need to visit homes, and can monitor patients remotely, making visits only if intervention is required.“We want to redefine health care for the new generation with new technology,” says Shrestha.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110714118/636903909c7e80680e037ccdjpeg.jpg" alt="" width="640" height="960"><figcaption> </figcaption></figure>Health at Home customers have requirements from postnatal to elderly care, patients with chronic diseases, the terminally ill, and dependent patients. The company ties up with hospitals like Mediciti, Nidan, Nepal Cancer Hospital, Sumeru and Green City, and insurance companies like MetLife, Reliance and Citizen Life and various diagnostic labs and pathologist.And there are additional services like Japanese massage therapy and nurse placements with home care specialization. So far, Health at Home has built up a reputation for reliable and personalised care that is responsive to the needs to patients.With Nepal’s population expected to reach 33 million by 2030 with nearly 15% of them above  65, there will be an ever-greater need for elderly care. Combined with out-migration of the young, this means the field is wide open for innovation and expansion in home care services.Read also: <a href="https://www.nepalitimes.com/banner/lets-talk-about-it/">Let’s talk about it</a>, Duksangh Sherpa<a href="https://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/malnutrition-stunting-wasting,3603">Thought for food</a>, Marty Logan

Caring for those who cared

Nepal’s fertility rate is going down even though contraceptive use has not increased<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141140/636517189c7e80680e02c252jpeg.jpg" alt="" width="1400" height="933"/><figcaption>THE RIGHT SHOT: Health worker Januka Dhakal injects Depo-Provera on a woman at Rayale Health Post of Kavre district on Tuesday. With their husbands away, fewer women now want to use contraceptives. Sonia Awale</figcaption></figure>Sita Yonjan, 21, has a two-year-old daughter, and recently stopped using <a href="http://archive.nepalitimes.com/article/from-nepali-press/Ftnp-the-curse-of-the-contraceptive,493">contraceptives</a> even though she is not planning to have another child. She says she doesn’t need her birth control implant anymore because her husband went away to work in Qatar two months ago.Yonjan visited a health post in Rayale village of Kavre to remove the birth control implant that she had inserted last year. The tiny device prevents births for five years, and does not need to be removed even when users abstain from intercourse. But many Nepali men want their wives to stop using contraceptives when they leave for overseas work."My husband thinks I could sleep with anyone if I use contraceptives in his absence," Yonjan frankly admits.An estimated four million Nepali men of reproductive age <a href="http://archive.nepalitimes.com/article/nation/The-cycle-of-migration,3230">work abroad</a>, and their wives back home generally see no need for contraceptive implants, preferring to use short-term methods like condoms, pills and injectables when their husbands come home on leave. Like Yonjan, those using IUDs and implants remove them as soon as their husbands go away again.https://www.youtube.com/watch?v=8lXkqrDtUOUDemographers say this explains the riddle about why Nepal's fertility rate has been going down despite contraceptive prevalence rate remaining low.When Nepal conducted its first-ever nationwide health survey in 1996, only 26% women were using modern contraceptives. Within ten years, it had nearly doubled to 44%, but has leveled off since. The contraceptive prevalence rate actually declined to 43% in 2016, when the last National Demographic Health Survey (NDHS) was conducted. Even so, the fertility rate that measures the average number of children per couple has been going down -- from 4.6 in 1996 to 3.1 in 2006 and 2.3 in 2016 (see graphs, overleaf).Demographers were initially puzzled by the drop in the fertility rate despite contraceptive use rate flatlining. But an analysis in 2013 suggested a correlation between male outmigration and contraceptive use. Another analysis is now underway, which will probably confirm the impact out-migration of men may be having on contraceptive use and fertility rate."If we consider only women who are married and living with husbands, we find a high contraceptive prevalence rate," explains Sharad Pathak, a demographer at the government’s Family Health Division. "This rate is low only because lots of women generally do not need contraceptives when their husbands are away."<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141140/6365171c9c7e80680e02c253jpeg.jpg" alt="" width="900" height="826">However, experts warn that Nepal’s declining fertility rate may not mean that population growth will reach replacement level -- one in every four married women still have an unmet need for family planning. A third of young married women aged 15-19 do not use contraceptives, making them more vulnerable to unintended pregnancies and unsafe abortion.Kristine Blokhus at the UN Population Fund (UNFPA) says Nepali women are aware of the benefits of having fewer babies, but face barriers in accessing contraceptives: "Health facilities often run out of contraceptive stocks, and there are not enough trained health workers to provide long-term contraceptives like implants and IUD."A 2016 UNFPA assessment showed most health posts provide only condoms, pills and injectables because of the lack of trained staff. Only one third of the facilities provide all five types of modern contraceptives including implants and IUDS. In most villages, women have to choose between oral pills or Depo-Provera, which they cannot use if there are side effects. Male or female sterilisation is available occasionally, and most women complain their husbands do not want to use condoms.With rising female literacy, the number of women opting for traditional family planning like withdrawal and the rhythm method instead of modern contraceptives is also going up. In 1996, only 3% of married women used such natural methods, now it is 10%. However, the NDHS 2016 showed that 62% women using the rhythm method to avoid pregnancy did not have an accurate knowledge about the ovulation cycle.Nepal’s target is to increase its contraceptive prevalence rate to 52% by 2020, but it may not meet that goal because of male migration, the preference for natural methods, and family planning programs being scaled back due to a drop in U.S. funding after the <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/globe-rallies-to-aid-nepals-women,3841">gag rule under President Trump</a>. The United States has traditionally been the main supporter of family planning projects in Nepal, through organisations like Marie Stopes International that provide abortion services.Beth Schlachter, Director of Family Planning 2020, who recently visited Kathmandu to take stock of Nepal's progress, says: "The US gag rule might affect Nepal's family planning programs if organisations delivering safe abortion services here do not find other resources to supply contraceptives."Since Nepal is poised to become an 'aging' <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/need-to-prepare-for-ageing-society,3624">society by 2030 and an 'aged one' by 2050</a>, there is an even greater need to scale up family planning. For the country to reduce its dependency ratio and <a href="http://archive.nepalitimes.com/article/editorial/editorial-reaping-demographic-dividend,3621">reap the demographic dividend</a>, many more women must have easier access to a much wider range of contraceptives.The mix mattersWhen Nepal launched its first population control campaign in the late 1960s, its population was only 13 million, it was growing at 3% per year because the fertility rate was nearly 6 children per couple. The only contraceptive choice women had then was to get their partners to use condoms. Most men did not like using them, and women did not have any control over reproductive health. The pill could have given women freedom to limit or space births, but they were scared of its side effects.Later, injectables like Depo-Provera and IUDs were introduced and today the government provides five types of contraceptives for free, and conducts health camps offering permanent family planning methods like male as well female sterilisation. But many other contraceptives like emergency pills and female condoms are available only in private clinics, and most rural women cannot use them even if they want to.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141140/6365171e9c7e80680e02c254jpeg.jpg" alt="" width="900" height="609">Beth Schlachter, Director of Family Planning 2020, says Nepal needs to provide a much wider mix of contraceptives in order to protect women from unintended pregnancies, unsafe abortions and maternal deaths: "What a 15-year-old girl needs might be different from what a 24-year-old mother of two children needs," she says. "If we try to address all of them with just one or two methods, we will not be very successful."Marie Stopes International is preparing a pilot program to test the acceptability of a new type of Depo-Provera called Sayana Press which can be injected at home and would suit women who do not like to visit health posts every three months for their Depo-Provera.Read also:<a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/globe-rallies-to-aid-nepals-women,3841">Cutting the lifeline</a>,  Kate Ryan<a href="http://archive.nepalitimes.com/article/editorial/editorial-reaping-demographic-dividend,3621">Reaping the demographic dividend</a>, Editorial

Migrating males and population decline

This week at the National Population Policy launch Prime Minister K P Oli exhorted Nepalis to get married by age 20 and have three babies by the time they are 30. This was the first indication that the highest office in the land has understood the need to address Nepal’s dramatically <a href="https://nepalitimes.com/news/nepals-demographic-window-is-closing">falling birth rate</a>, but Oli’s statement was greeted with ridicule on<a href="https://nepalitimes.com/banner/avoiding-the-quicksand-of-social-media"> social media</a> — especially by women. Most urban young are already grappling with economic pressures and shifting life priorities. Even with a university degree,<a href="https://nepalitimes.com/here-now/workers-return-to-jobless-nepal?%2F"> many cannot find jobs</a>, and are taking the first flight out for overseas employment. Having a child is now a fraught decision shaped by income, individual autonomy, and family pressure. The <a href="https://www.unfpa.org/swp2025">UNFPA’s State of the World Population report </a>released last month, highlighted a significant <a href="https://nepalitimes.com/here-now/migrating-males-and-population-decline">decline in fertility rates </a>around the world. The global average fertility rate is 2.25 children per woman, and 18% of the reproductive adults said they will not be able to have the number of children they desire. The total fertility rate in Nepal has plummeted to 2.1 births per woman — down from 5 just 30 years ago. This is considered replacement level, meaning the newborns will replace their parents.&nbsp; However, birth rates are not declining as rapidly everywhere. The Tarai in has a total fertility rate of 2.20, and northwestern mountains is still 2.24.&nbsp; There are multiple factors in play, and the report broadly divides them into four categories: health issues, economic concerns, fears about the future, and lack of a supportive partner or their absence. More than half of the respondents said finance, which includes unemployment and increased cost of housing, as well as parenthood, was a barrier to having children. “More and more people prefer one or two children at maximum. Many women also decide to have children at a much later age,” says Kamala Devi Lamichhane of Tribhuvan University. “The opportunity cost is far higher for women.” But there is also a cost for the country, as the National Population Policy notes. At the rate the total fertility rate is falling it will soon be below replacement level — meaning that in the next three decades Nepal will be confronted with an <a href="https://nepalitimes.com/opinion/the-future-is-older">ageing population</a>.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250714140740_bac3e5a284b69a77d97b3b99daf2e7fd3019bc48f1a399fb2771381c751d8291.png" data-media-id="editor_6" data-image-id="20250714140740_bac3e5a284b69a77d97b3b99daf2e7fd3019bc48f1a399fb2771381c751d8291" data-rendition-name="original" width="1302" height="501" loading="lazy" alt="Nepalis having fewer babies. Why?"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250714140740_251115b0a88d4e82be70245c43cb74477f3be18042ef1aa3b904c597d815f13b.png" data-media-id="editor_7" data-image-id="20250714140740_251115b0a88d4e82be70245c43cb74477f3be18042ef1aa3b904c597d815f13b" data-rendition-name="original" width="1125" height="500" loading="lazy" alt="Nepalis having fewer babies. Why?"> </figure>  Besides income, there are also cultural factors at play in women having fewer babies — they are expected to do all the childcare duties, even putting their careers on hold. In general, there is little help from spouses, and with more nuclear families there is less support from relatives. “Women today are well educated, career-oriented, and economically independent, allowing them to delay marriage as well as being conscious about their body and <a href="https://nepalitimes.com/multimedia/nepal-far-from-hitting-contraceptive-target?%2F">reproductive rights</a>,” says Laxmi Tamang of the International Confederation of Midwives (ICM). Also present at the policy launch was demographer Yagya Bahadur Karki, who said that women are more educated and hence, empowered to take their own informed decisions regarding having children.&nbsp; He adds, “But the fertility rates have reached replacement rate, and that stands as a warning for the future.”&nbsp; Fertility rates have fallen in inverse proportion to the rise in female literacy. The regions of Nepal where couples have more babies is where women are less educated. Couples in Madhes and Sudur Paschim provinces, where child marriage, gender-based discrimination, menstrual huts and dowry are still widespread are where the fertility rate is still high.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250717120740_ababfd31ed5ff79ded427e1f1adfff02e6af2384bd541e51dfe05e52fbbccb39.jpg" data-media-id="editor_9" data-image-id="20250717120740_ababfd31ed5ff79ded427e1f1adfff02e6af2384bd541e51dfe05e52fbbccb39" data-rendition-name="original" width="994" height="682" loading="lazy" alt="TFR Map"> </figure>  And because female literacy also has a direct correlation with <a href="https://nepalitimes.com/news/fatal-discrimination">infant and child mortality</a>, couples in those regions tend to have more babies so some of them survive.&nbsp; But it is Nepal’s urban centres among the educated where the increased choices in reproductive health, including alternative methods of conception like IVF and treatment for infertility, as well as <a href="https://nepalitimes.com/banner/implant-service-providers-take-contraception-to-nepals-poor">contraceptives</a> offer more options for family planning. “There are more choices regarding reproductive health, and there is more awareness as well, which is why people decide carefully on whether or not to bear a child,” says population expert Yogendra Gurung. <a href="https://nepalitimes.com/here-now/migrants-returning-from-the-gulf-with-infertility">Migration is another factor</a> adding to the decline in fertility rates. Many young Nepalis of reproductive age leave every day in pursuit of better jobs overseas. Spousal separation means fewer children.&nbsp; “Once away, even if not educated, they realise that child-rearing costs are high, and try to have fewer and even no children in some cases,” Gurung adds. Recent studies have also shown that men returning after their stint in the Gulf and Malaysia, where they are <a href="https://nepalitimes.com/news/gulf-workers-need-protection-from-heat">exposed to extreme heat </a>for extended periods as well as various chemicals and toxins in their work environment &nbsp;have a range of health problems, including infertility. To increase the birth rate, Nepal will have to reverse its family planning strategy of the past 40 years. Complicating this is that some regions of Nepal will need measures to control the birth rate, while urban areas will need a strategy to help parents have more babies. One way to help families have more children is to develop more <a href="https://nepalitimes.com/here-now/future-proofing-nepal-s-population-strategy?s=04&amp;fbclid=IwY2xjawFQf-NleHRuA2FlbQIxMQABHRxSwwGPfm7_2cBhDVAowPxEmFXP0Os-KRs1DXqIW_84wDhciExtZuNi1g_aem_jzRqN2cEVAppfwr5qedxRg">family-friendly policies</a> that favour women and youth as the Nordic countries, which also have falling birth rates, have done. They have introduced flexible parental leaves for both parents, including financial and health incentives. China, also concerned about its declining birth rate and an ageing population, now has a three-child policy as well as tax deductions, expanded childcare services, and leave policies to encourage couples to have more children. “We must work towards childbirth and childcare policies and plans that are suitable for Nepal, so that couples planning for children do not have to think twice about it because of finances or other reasons,” adds Gurung. Tamang of the International Confederation of Midwives says a gender transformative approach is needed to address the issues of the gender gap which is adding to the decline in childbirth. Husbands need to play a more important role in child-rearing. Instead of increasing fertility for the sake of it, the objective should be to assist young people to start the families they desire, at a point and time of their choice. Respect for everyone’s rights and dignity lays a foundation for a more balanced demographic trend. Lamichhane sums it up: “If fertility rates are to be sustained, it requires changes in the gender roles and behaviour, keeping the youth’s aspirations in mind.”

Nepalis are having fewer babies. Why?

Does anyone know that 2023-33 was declared the <a href="https://nepalitimes.com/banner/visit-nepal-again">Visit Nepal</a> Decade? Or that Pokhara announced that 2025 is a Special Tourism Year? The fuselage of Nepal Airlines jets still carry the Visit Nepal Year 2020 logos. Such ad hoc and unnoticed promotion is emblematic of the way Nepal has tried to increase visitor arrivals <a href="https://nepalitimes.com/news/nepal-hopes-for-tourism-rebound-in-2021-rk4dlo9t">post-Covid</a> — and of the country’s wider political disarray. Deepak Raj Joshi of the Nepal Tourism Board (NTB) has his work cut out to coordinate various agencies of the government to boost arrivals.&nbsp; He says, “We have been working on marketing strategies to revive the tourism sector, and are hopeful that this year will mark a 8-10% increase in arrivals compared to the pre-pandemic times.” On paper, tourist numbers have rebounded to pre-Covid numbers with over 1 million last year, but official figures do not give a true picture of duration of stay, average spending, and the fact every visitor is counted as a ‘tourist’, even repeat visitors who come on business. The few bright spots are largely a result of private sector promotion of niche tourism products, individual social media posts of <a href="https://archive.nepalitimes.com/page/top-10-treks">adventurous treks in Nepal</a>, or the fact that Indians are allowed to enter China again to visit Lake Mansarovar and Mt Kailash via Nepal. Indeed, Simkot airport has up to 15 flights a day from Nepalganj bringing in <a href="https://nepalitimes.com/opinion/borderlines/nepal-india-trans-boundary-bonds">Indian pilgrims</a> who are then ferried by helicopter to the border in Hilsa, or Lapcha Pass from where the holy sites in Tibet are visible. The rudimentary hotels and rest houses along the route in Humla have been bursting at the seams for the past month, to the point that some establishments are no longer able to provide patrons basic amenities.&nbsp; Last year, 1.14 million tourists visited Nepal, and the government has projected up to 10% increase in tourist arrivals this year. International tourist arrivals to Nepal have been steadily increasing, especially from the US, Europe, and India. Domestic and regional travel has also increased after the <a href="https://nepalitimes.com/news/lockdown-5-utlzqtvs">Covid lockdowns</a>.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250717120756_e1c8f08e7e26496d2b2394e0be776e147fb46c415347b781ed9e5c64d9c9e505.jpg" data-media-id="editor_5" data-image-id="20250717120756_e1c8f08e7e26496d2b2394e0be776e147fb46c415347b781ed9e5c64d9c9e505" data-rendition-name="original" width="1145" height="668" loading="lazy" alt="Tourist numbers"> </figure>  The tourism industry employs at least 1 million people, trekking injects money directly into the <a href="https://nepalitimes.com/editorial/not-rising-nepal">rural economy </a>and sustains ancillary sectors like handicrafts and domestic aviation. In the last fiscal year, tourism brought in Rs82.33 billion, according to Nepal Rastra Bank. But the industry has been affected by negative publicity about poor infrastructure, air pollution in Kathmandu, travel safety and news of disasters like the <a href="https://nepalitimes.com/news/rasuwa-flood-likely-a-glof">China-Nepal flood last week</a> that made international headlines. Growing worries about the climate crisis is also affecting youth travel, especially from Europe. Read also: <a href="https://nepalitimes.com/news/missing-out-on-nepal-s-tourism-potential">Missing out on Nepal’s tourism potential</a> “The limitations of airport and road infrastructure has hindered the development of the tourism sector,” admits Joshi. “And many are put off by the appalling state of our road network, especially during <a href="https://nepalitimes.com/opinion/managing-the-monsoon">the monsoon season</a>.” Nepal is home to 20 protected areas, 10 heritage sites, and eight out of the world’s 10 highest mountains, and despite all the obstacles it is still the perfect destination for the modern social media savvy traveller, who are experience-driven and inclined to look for itineraries that emphasise wellness and cultural immersion.&nbsp; Some hotels around Kathmandu, Pokhara, Jomsom and the Khumbu have strived to adapt to this new tourism landscape, expanding facilities with significant international investment. <a href="https://nepalitimes.com/business/a-thamel-within-thamel">Luxury hotels like Aloft Kathmandu</a> in Thamel were inaugurated just before the pandemic lockdowns, survived the crisis and thrived as it. Says General Manager Vikram Singh (pictured, below): “Our prime location in Thamel enhances the guest experience, especially for those seeking convenience and immersion in the local scene and travellers who want to be in the centre of it all.”  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025071805070_8d29803e8b52bcd4439422e7b7a0bc25aa68ef3d227b9130bd0e079af626677d.jpg" data-media-id="editor_11" data-image-id="2025071805070_8d29803e8b52bcd4439422e7b7a0bc25aa68ef3d227b9130bd0e079af626677d" data-rendition-name="original" width="1066" height="1600" loading="lazy" alt="Aloft GM"> </figure>  <a href="https://nepalitimes.com/here-now/what-sustainable-tourism-means-in-practice">Sustainability </a>and environmental consciousness has also become an integral part of the hospitality industry. ISO certifications as well as sustainability initiatives like the Travelife sustainability certification for eco-friendly resorts validate credibility of hotels. Aloft is the first five-star hotel in Nepal to have earned the Waste Smart Certificate, and it has also been awarded the ISO 14001:2015 certification, which is the internationally recognised standard for environmental management systems (EMS). But such investments will not amount to much unless Nepal makes serious efforts to promote itself as a<a href="https://nepalitimes.com/here-now/peak-tourism-in-2023-9ukoi8iz?utm="> tourism destination</a>, especially to its two giant neighbours. More importantly, the country needs to increase activities in which tourists can spend the money they want to. “While <a href="https://nepalitimes.com/here-now/nepal-pushes-mountain-bike-tourism?fbclid=IwAR1MNH0iFGv1vRz5G9uZ4AzUlKxB6nY7JKq0qT6je_FV4_SuxPZqviwKGn0">mountaineering and adventure tourism</a> are extensively promoted, we have fallen short of marketing other elements such as wildlife, pilgrimage and cultural heritage,” says Joshi. “There is a need to diversify promotion to increase income from the tourism sector.” Meanwhile, making Nepal more accessible to international and domestic visitors, must also be a priority. Kathmandu remains the sole aerial gateway despite new airports in Pokhara and Bhairawa. “International airlines have shown interest, and if access and flights are increased these airports can be fully functional,” says Joshi. But Sichuan Airlines has stopped flying to Pokhara, and there does not seem to be much interest from Thai, Vietnamese and Cambodian carriers to fly directly to Lumbini. Says Singh: “There’s tremendous opportunity to strengthen Nepal’s destination marketing by telling richer, more compelling stories that <a href="https://nepalitimes.com/opinion/comment/culture-cannot-be-an-afterthought">connect travellers with our culture</a>, nature, and people.”

Tourism needs a new push

Many of us former Nepal Peace Corps volunteers (PCVs) would agree that our time in Nepal changed in significant but very different ways our perspectives on life if not the future paths we chose to follow. Of no one was this truer than Dorothy Mierow. Dorothy was born in 1920, in Colorado Springs. Her father Charles C Mierow was a classics scholar and Latin professor, who served for ten years as president of Colorado College.&nbsp; Dorothy developed an interest in animals as a child, graduated with a BA degree in natural history from Carlton College in 1942, a Master’s in biology from the University of Pittsburgh, and another Master’s in geography from the University of Minnesota.&nbsp; As a young woman, Dorothy traveled with her father throughout Europe, including a visit to ancient Greek ruins, and took a Magellan Tour by cruise ship around the world in 1958.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025071901074_0bad133ab22aada319e74bbad95d563e191371db291c08f373839fbd15440262.jpg" data-media-id="editor_0" data-image-id="2025071901074_0bad133ab22aada319e74bbad95d563e191371db291c08f373839fbd15440262" data-rendition-name="original" width="903" height="1178" loading="lazy" alt="How the Peace Corps changed a volunteer's life"> <figcaption>HOME AWAY FROM HOME: Dorothy Mierow as a college student in her native Colorado.</figcaption> </figure>  She was a college teacher during much of the 1940s, also teaching at a girls’ school in Hawaii. Then back to her native Colorado in 1953, where she became a curator and later director of the Colorado College Natural History Museum. She taught geography classes, and in her free time, Dorothy climbed 22 of Colorado’s 14,000-foot peaks. Traveling in India in 1960, Dorothy decided to spend two weeks in Nepal. In late 1961, she filled out an application to join the Peace Corps and specified that she wanted to go to Nepal, ‘because I admired the people so much when my father and I were there on our trip’.&nbsp; Dorothy reached Kathmandu in September 1962 as the first group of American Peace Corps volunteers in Nepal. She stood out from the others: one of the few women in that group, surely the oldest at age 41, a world traveler, and a woman who already had established a professional career.&nbsp; One doubts if Dorothy had had a husband and children whether she would ever have gone to work and spend much of the rest of her life in Nepal.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025071901078_68e84ade1ffb0f6c83c7f8fa5c1e7315b5f6c543217f96cde012e4d86f171515.jpg" data-media-id="editor_1" data-image-id="2025071901078_68e84ade1ffb0f6c83c7f8fa5c1e7315b5f6c543217f96cde012e4d86f171515" data-rendition-name="original" width="1259" height="910" loading="lazy" alt="How th Peace Corps changed a volunteer's life NT"> <figcaption>Pokhara Bazar in 1962.</figcaption> </figure>  The Peace Corps assigned Dorothy to teach geography at Tri-Chandra College. After the school closed in the winter due to lack of heating, USAID and the College of Education asked Dorothy to help train general science teachers.&nbsp; She taught for two months and became involved in a textbook-writing project, commenting: ‘I would like the children to know something about public health, conservation (the trees are going fast and so is the soil), and learn the names of some of their common birds, trees, and flowers. They are more impressed with electricity, airplanes, and cell structure.’ When a new college opened in Pokhara in 1963, Dorothy was transferred there and lived with a Nepali family. The college boasted 30 students and no permanent buildings.&nbsp; In October 1963, Dorothy wrote: ‘Pokhara is a town of almost 5,000 people … We are in a fertile valley surrounded by foothills … There is a small Mission Hospital … a Leper Hospital and Tibetan Refugee Camp started by the Red Cross and now run by the Swiss. With winter approaching, more Tibetans are appearing in town, often with pack horses or donkeys. Some have been carrying large boxes of powdered milk,donated (by USAID) to the camp from the airport … There is no electricity, and the transportation problems make many items scarce and expensive. I am really a sort of a museum. The landlord brings all kinds of people in to see how I live and count my shoes and dresses. They express amazement at my books, pictures, tin oven, Nepali dolls from Kathmandu, screened food shelves and curtained closet.’ The standard term for Peace Corps volunteers was two years, but Dorothy extended her term and was still at Prithvi Narayan College at the end of 1965, when she wrote that she had 20 Geography students in the first-year class and 6 in the second year preparing for the IA Examination. The college enrollment was 125 students, and the foundation for a new science building was being excavated.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025071901074_c6a80e5e0db0c705b2f8733c6d30dc0386fe3abbd2238ea9d947b7d746f94a29.jpg" data-media-id="editor_2" data-image-id="2025071901074_c6a80e5e0db0c705b2f8733c6d30dc0386fe3abbd2238ea9d947b7d746f94a29" data-rendition-name="original" width="902" height="605" loading="lazy" alt="How the Peace Corps changed a volunteer's life"> <figcaption>Mierow and friends at Phewa Lake.</figcaption> </figure>  Dorothy noted that she ate one meal a day at the (Shining Mission) Hospital but otherwise lived on dal-bhat, momo, and potato curry at local shops. However, she had developed a new passion: to build what she initially called the Pokhara Museum of the Himalaya. In commendable Peace Corps fashion, Dorothy always worked with Nepalis and respected the culture. ‘The greatest joy and satisfaction I have had has been from the building of a Museum-Library in memory of my parents … It has been possible to feel like a wealthy benefactor with the money saved by father for the family’s education and now available for the education of others… (Father) would have loved to be in on the founding of a new college and be able to plan a library. Several hundred of the books to be in the museum-library came from his collection and were carefully selected to be of use for students in Nepal…’&nbsp; ‘The museum part is to satisfy my own inclinations and was thought of when I found how little diversion there was for the people of Pokhara… It is part of the University requirements for the college that it should have a geography and biology museum. The museum building is small but adequate.&nbsp; I have tried to design it in harmony with Nepalese architecture and decorate it with some of the art of the best artists or woodcarvers… Posts holding up the porch roof are carved by Cottage Industries to represent different peoples of Nepal in typical costumes. The door was carved by a local wood carver and has typical birds of Nepal around it. Inside are 10 roof-support carvings designed by the retired Director of the National Museum in Kathmandu, Mr. C.M. Maskey.&nbsp; They were carved by the best wood carvers in Patan very skilfully. The building has three rooms: the library, the exhibition room, and a smaller workroom which can be used by our newly formed Woman’s Club as well as other groups or classes.’  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025071901074_03d3359c65389d30a0134e9a4862778994121e7e833b7d28b18e06e36fc76ff8.jpg" data-media-id="editor_3" data-image-id="2025071901074_03d3359c65389d30a0134e9a4862778994121e7e833b7d28b18e06e36fc76ff8" data-rendition-name="original" width="629" height="599" loading="lazy" alt="How the Peace Corps changed a volunteer's life"> <figcaption>Mierow with local women in Pokhara in 1969.</figcaption> </figure>  Dorothy promoted her project to influential Nepalis connected with organisations whose support she solicited: The Department of Archaeology, the Department of Agriculture, the Godavari Botanical Gardens; Tribhuvan University’s Science and Education Department, Nature Conservation Society.&nbsp; The museum was opened officially in early 1967. The Annapurna Natural History Museum, the building Dorothy designed and had constructed, is still open and features some exhibits which she created many years ago.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025071901074_54326a8a0685e980e782378076de2f5cd02d2426e9b0d94eed972d3dbe83af26.jpg" data-media-id="editor_4" data-image-id="2025071901074_54326a8a0685e980e782378076de2f5cd02d2426e9b0d94eed972d3dbe83af26" data-rendition-name="original" width="1333" height="1000" loading="lazy" alt="How the Peace Corps changed a volunteer's life"> <figcaption>The Annapurna Natural History Museum.</figcaption> </figure>  Dorothy returned to America in 1967, but she longed for Nepal. In the spring of 1969, she again tried to enroll as a Peace Corps volunteer but was told that as she had spent more than four years, she would not be eligible for another assignment. Undeterred, she persuaded the college in Pokhara to invite her to return as a teacher.&nbsp; UNICEF and the Forestry Department sponsored Dorothy to prepare charts on trees, birds, animals and flowers in colour for distribution to the schools of Nepal. Dorothy, back in the Peace Corps, returned to Pokhara and the Museum in 1972. She formed a friendship with her former geography student from Sikles, Chandra Prasad Gurung, and in 1974, she brought Chandra to America, where he enrolled in Colorado College and studied cultural anthropology.&nbsp; Chandra subsequently earned his PhD in geography from the University of Hawaii and returned to Pokhara to become director of the Annapurna Conservation Area Project. Gurung actively promoted ecotourism, landscape conservation, and biodiversity conservation in Nepal. His life was cut short along with those of 23 other Nepalis and foreigners who perished in a helicopter crash near Taplejung in September 2006.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025071901074_322d3c3ac6f1b08ffa07c44a19998b937a7db9eb43527f7539cf6481e1546314.jpg" data-media-id="editor_5" data-image-id="2025071901074_322d3c3ac6f1b08ffa07c44a19998b937a7db9eb43527f7539cf6481e1546314" data-rendition-name="original" width="2500" height="1000" loading="lazy" alt="How the Peace Corps changed a volunteer's life"> <figcaption>Mierow's four books on Nepal and its biodiversity. </figcaption> </figure>  Dorothy worked with several well-known Nepalis to publish her paintings and photos in beautifully illustrated books. She and Hemanta Mishra of the National Parks and Wildlife Service wrote Wild Animals of Nepal (Ratna Pustak Bhandar, 1976). More than 400 photos Dorothy took on treks to the Everest region, Gosaikunda, Muktinath, Jumla and Rara Lake, as well as travels in the Tarai, appeared in Himalayan Flowers and Trees (Sahayogi Prakashan, 1978).&nbsp; The botanist Tirtha Bahadur Shrestha identified the species. Dorothy and Kesar Lall published This Beautiful Nepal (Sahayogi Press, 1981). Birds of the Central Himalayas (1988) contained Dorothy’s paintings of 250 species of birds found along the areas of the Kali Gandaki River, Pokhara, Chitwan and the central Tarai. Dorothy summed up her life and work in Nepal in Thirty Years in Pokhara (Pilgrims Book House, 1997). Dorothy returned to Pokhara and her adopted Gurung family several times during the 1980s and 1990s to celebrate festivals and meet old friends. Her final years were spent at her mountain cottage in Green Mountain Falls north of Colorado Springs. She died at the age of 79 in August, 2000. Nepal gave new meaning and purpose to Dorothy Mierow’s life. Daniel W Edwards was a Peace Corps volunteer in 1966 and is the author of several books on Nepal. The author thanks Special Collections, Tutt Library, Colorado College.

How the Peace Corps changed a volunteer’s life

Local residents of Mustang, including a sitting MP and several politicians, submitted a petition to Prime Minister KP Oli in Kathmandu this week urging the government to lift the region’s ‘restricted’ status. This is not the first time such a demand has been raised, and as infrastructure the region’s accessibility improved over the years, calls to remove the long-standing restriction have grown louder.&nbsp; Upper Mustang is no longer weeks away <a href="https://nepalitimes.com/here-now/postcards-from-kathmandu">from Kathmandu.</a> Nearly 85% of the road from Beni to Kagbeni has been blacktopped, and one can drive from Kathmandu to Lo Manthang with an overnight stop in Pokhara. Between April 2024 and April 2025, Lower Mustang received 144,745 international tourists, a near 50% increase compared to the previous year. Most of these were <a href="https://nepalitimes.com/opinion/borderlines/nepal-india-trans-boundary-bonds">Indian pilgrims </a>travelling to Muktinath. <a href="https://nepalitimes.com/here-now/comings-and-goings-in-mustang">Mustang</a> is also gaining popularity among Nepali visitors, with 700,000 visiting the region in 2024. A hotel operator in Kagbeni estimated that about 20% of Nepali visitors to Muktinath also travel to Korala, the trade and transit checkpoint on the <a href="https://nepalitimes.com/latest/north-of-the-border">China border</a>. That would mean that nearly 100,000 domestic tourists visit Upper Mustang annually. In stark contrast, international tourist numbers to Upper Mustang (north of Kagbeni) have remained stagnant, hovering around 4,000 visitors per year. The primary reason is the continued enforcement of the region’s restricted status. Foreign visitors must pay a steep permit fee: a minimum of $500 for 10 days, with an additional $50 per day thereafter. Tourism some entrepreneurs, politicians, and residents want these fees to be abolished so Upper Mustang can attract a broader range of international travellers. The success of Lower Mustang, where relaxed restrictions have led to a<a href="https://nepalitimes.com/here-now/boom-time-in-central-tarai"> tourism boom</a>, is often cited as proof of what lifting restrictions could achieve. Upper Mustang is not the only region in Nepal with a restricted status. Several northern areas prefixed with ‘Upper’ (Upper Manaslu, Upper Dolpo, Upper Kanchenjunga, and Upper Arun) also need similar permits and fees. Although no clear official explanation exists, these areas were primarily restricted due to historical inaccessibility, ecological and cultural fragility and security concerns. Read also: <a href="https://nepalitimes.com/news/upper-mustang-opposes-prohibited-areas">Call to scrap Upper Mustang tourist fee</a> In the 1960s and 1970s, these remote regions served as shelters for Khampa guerrilla fighters who launched cross border ambushes on the <a href="https://nepalitimes.com/here-now/the-last-days-of-the-khampa">Chinese military </a>across the border.&nbsp; Though the Khampa have long gone, security concerns rooted in that era seem to persist. The government in Kathmandu is seemingly unaware of the changed political and security landscape. If concerns do remain, they are not made public. One of the main reasons for maintaining the restricted designation is to limit visitor numbers. But with <a href="https://nepalitimes.com/opinion/the-road-out-of-nepal">improved road access and services</a>, as Upper Mustang has seen, this justification no longer holds. When Upper Mustang first opened to international tourists in 1992, it had no formal lodges or hotels, and it took four to five days of trekking from Jomsom to Lo Manthang.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250716120744_4e4405cf10e6f127f90a1cd40feda0b9d8d69efd13093a2563530ca31489ba9f.jpg" data-media-id="editor_8" data-image-id="20250716120744_4e4405cf10e6f127f90a1cd40feda0b9d8d69efd13093a2563530ca31489ba9f" data-rendition-name="original" width="2000" height="509" loading="lazy" alt="Lift restrictions on Upper Mustang"> <figcaption>Photo: DINESH SHRESTHA</figcaption> </figure>  Without a nechyang (a household with traditional friendship), it was difficult to find a place to stay or get a proper meal. Only a few elite households offered accommodation. Today, there are now more than 80 lodges and hotels above Kagbeni, spread across nearly every village. Several upmarket hotels now struggle to stay afloat during the off-season, relying on low-spending domestic visitors to survive. Lo Manthang, once a remote destination, is now just a few hours’ drive from Jomsom, easily reachable by lunchtime for early starters. Once the remaining road sections are blacktopped, travel time will be further reduced. Yet, the government still charges a flat $500 fee for a 10-day permit based on outdated &nbsp;assumptions from a bygone era. There has been no serious review of the permit structure to align with current realities, nor any response to local aspirations to attract more international tourists and <a href="https://nepalitimes.com/here-now/peak-tourism-in-2023-9ukoi8iz">harness tourism for economic development</a>. Concerns about over tourism are valid. There is a risk that increasing visitor numbers could erode Upper Mustang’s <a href="https://nepalitimes.com/here-now/a-million-mantras-in-mustang">cultural heritage</a>, social fabric, and fragile natural environment, precisely the features that make it special. However, the region’s 33 years of tourism experience have been largely positive.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250716120744_5c7e5e05097cd0e5a1027b51c7e3db3be0bd67e0f7cbaea6d2c447b1dacafc8a.jpg" data-media-id="editor_11" data-image-id="20250716120744_5c7e5e05097cd0e5a1027b51c7e3db3be0bd67e0f7cbaea6d2c447b1dacafc8a" data-rendition-name="original" width="1400" height="1050" loading="lazy" alt="Lift restrictions on Upper Mustang"> <figcaption>Photo: MUKESH POKHREL / NT ARCHIVE</figcaption> </figure>  Tourism has contributed significantly to the restoration and <a href="https://nepalitimes.com/here-now/the-history-of-heritage?%2F">preservation of religious and historical sites</a> like the Thubchen and Jampa monasteries in Lo Manthang, the ongoing conversion of the old palace in Ghami into a premium hotel, and the rehabilitation of many monasteries and chortens.&nbsp; These efforts, supported by international donors and heritage experts, demonstrate that tourism—when well managed—can be a powerful driver of <a href="https://nepalitimes.com/here-now/shrinking-tourism-s-ecological-footprint">conservation</a>. The high permit fees have been somewhat effective in limiting international visitors, but they have no influence on the growing number of domestic tourists, particularly during the Dasain and Tihar holidays. The most pressing need now is for all levels of government—federal, provincial, and local—to<a href="https://nepalitimes.com/news/why-invest-in-nepal"> invest in </a>managing tourist flows and maintaining tourist sites. These efforts are essential not only to enhance visitor experience but also to build long-term resilience and sustainability for the destination. Read also: <a href="https://nepalitimes.com/news/greening-nepal-s-tourism">Greening Nepal’s tourism</a>, Hanna Wells Visitor numbers are central to any tourism development strategy that aims to balance economic, social, and environmental goals. Clinging to obsolete policies and concerns to justify Upper Mustang’s restricted status is not only unfair, it also suggests an undemocratic and discriminatory attitude toward a remote district.&nbsp; Shailendra Thakali, PhD, is from Jomsom and is a freelance consultant on protected areas, tourism, conservation, and sustainable livelihoods.

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