The Embassy of Japan in Kathmandu is providing Bayalpata Hospital in Achham district to install up-to-date medical equipment as part of its effort to improve healthcare in remote parts of Nepal. The contract for the assistance was signed on Friday between the new Japanese Ambassador Maeda Toru and Kunda Dixit, the Chair of Nyaya Health Nepal which runs the hospital at Bayalpata.&nbsp; Nyaya Health Nepal was set up in 2008 to improve rural healthcare, and has since provided free world class treatment with specialised care free of cost to 1.3 million patients in the far west region of the country.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250131100116_0c4fea12fa18ebd1952dde7abe53e9de7a6371b8364b6a7ad00ec72267935eb8.jpg" data-media-id="editor_0" data-image-id="20250131100116_0c4fea12fa18ebd1952dde7abe53e9de7a6371b8364b6a7ad00ec72267935eb8" data-rendition-name="original" width="1000" height="667" loading="lazy" alt="Japanese aid for Bayalpata Hospital NT"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250131100116_898086105d50414e81d5a78bf4b436f8ee1005b876fa7deb28988a9bbf625948.jpg" data-media-id="editor_1" data-image-id="20250131100116_898086105d50414e81d5a78bf4b436f8ee1005b876fa7deb28988a9bbf625948" data-rendition-name="original" width="1000" height="667" loading="lazy" alt="Japanese aid for Bayalpata Hospital NT"> </figure>  In that time, the medical need of the region has changed from mainly infectious diseases to lifestyle-related chronic ailments as well as an increase in trauma patients.&nbsp; "I have learnt that Nyaya Health Nepal is improving access to healthcare for underserved communities in rural Nepal, including providing free medical services at Bayalpata Hospital in one of the most remote areas of the country,” Ambassador Toru said at the signing ceremony. “The hospital is the core medical institution in the Achham district and surrounding areas, especially for critical surgeries."  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250131140128_6307d1200c5eecb01964be3a6d6428719d8eee30b801a48c201ad9efe8ae875d.jpg" data-media-id="editor_2" data-image-id="20250131140128_6307d1200c5eecb01964be3a6d6428719d8eee30b801a48c201ad9efe8ae875d" data-rendition-name="original" width="1179" height="1159" loading="lazy" alt="Japanese aid to Bayalpata Hospital NT"> <figcaption>Photo: EMBASSY OF JAPAN</figcaption> </figure>  The $66,263 contract is under the Grant Assistance for Grassroots Human Security Project (GGP) of the Japanese government, and will finance the purchase of a Digital X-ray flat panel unit, USG Machine, &nbsp;and C-arm imaging device that produces high resolution x-ray images of patients in real time.&nbsp; “The grant will help our surgeons and doctors at Bayalpata provide more timely diagnosis, more reliable surgeries and treatment,” Dixit said. "In the last 15 years, the need of the people of Sudurpaschim Province has changed from infectious diseases to chronic ailments and trauma, and the hospital has tried to adapt accordingly in these underserved parts where access and affordability of quality healthcare is a big challenge." &nbsp;&nbsp; Nyaya Health Nepal runs Bayalpata under its Integrated Municipal Healthcare model where community nurses go house-to-house to monitor the status of family members and record it all under its Electronic Health Record (EHR) system. Patients then have to spend money to go to hospital only if it is really needed.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250131100112_bddac95af4869c0cfe696e2f1d804466f956cfe4f8afe8f6da73d444d638b8e4.jpg" data-media-id="editor_3" data-image-id="20250131100112_bddac95af4869c0cfe696e2f1d804466f956cfe4f8afe8f6da73d444d638b8e4" data-rendition-name="original" width="1000" height="667" loading="lazy" alt="Japanese aid for Bayalpata Hospital NT"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250131100112_ec263a04c02ee334986bda08910632e8f1795f7bbfc4cfe5a0b74c6df672696c.jpg" data-media-id="editor_4" data-image-id="20250131100112_ec263a04c02ee334986bda08910632e8f1795f7bbfc4cfe5a0b74c6df672696c" data-rendition-name="original" width="1000" height="667" loading="lazy" alt="Japanese aid for Bayalpata Hospital NT"> </figure>  Nyaya Health Nepal has deployed its EHR in district hospitals in Karnali Province as well, and handed over Charikot Hospital in Dolakha after the 2015 earthquake before handing it over to the Bagmati Province in 2019.&nbsp; Toru, who has been in Nepal for only three weeks, said that the project will provide better medical services to the people of Sudurpaschim and Karnali provinces through trauma care and orthopedic surgeries at Bayalpata hospital.&nbsp; Added Dixit: "This support will go a long way in strengthening our hospital care. Medical equipment are extremely important, especially digital x-ray, as more and more patients come in for trauma care and emergencies."

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Japanese aid for Bayalpata Hospital

Orthopedic surgeon Anil Shrestha’s journey to medicine was laid down well before he was born. His father, noted industrialist Juddha Bahadur Shrestha, had aspired to become a doctor but was turned away from a medical school in India.&nbsp; "It became his mission that one of us, his sons, nephews, or nieces, would don that white coat," recalls Shrestha. That dream fell upon him, the youngest son, and he enrolled at Calcutta Medical College.&nbsp; Freshly graduated he returned to Nepal, where he hoped for a comfortable post at a hospital in Kathmandu. Instead, he was assigned to Jumla, a district which was even remoter and underserved than it is now. But that journey 40 years ago would prove transformative.&nbsp; "It was an eye-opener. I had no idea what rural Nepal was really like. When I reached Jumla, I asked myself why do we become doctors? It is because we have to make a difference," he recalls.&nbsp; The moment that would forever shape his approach to medicine happened at a government-run medical camp. An injured man had travelled from a remote village all the way to Kathmandu for surgery, selling his land to pay for it. He needed to remove his implants but faced a grim reality of having to sell more of his land to afford the procedure.&nbsp; "I thought to myself that we treat the x-rays, but we don’t treat the patients," &nbsp;Shrestha told us in an interview. &nbsp;"What good is a perfectly functioning hand if this man could no longer have a land to plough?" The encounter made the physician realise that healthcare in Nepal should look beyond symptoms and &nbsp;diagnoses, and consider the socio-economic realities of patients. He made it his mission to provide care that didn’t just fix bodies but addressed the underlying factors affecting people’s lives.&nbsp; He co-founded the <a href="https://noh.com.np">Nepal Orthopaedic Hospital</a> in 1998 to provide high-quality surgery at affordable prices. But when he arrived at the site near Gokarna, it was anything but promising.&nbsp; Read also:<a href="https://nepalitimes.com/here-now/nepali-surgeon-with-a-vision-for-the-world"> Nepali surgeon with a vision for the world</a>, Kunda Dixit  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024101613108_1a9d74aa1c1b550ff9db42dd8092f214de353ffbb2eb48549db110201424cafd.jpg" data-media-id="editor_2" data-image-id="2024101613108_1a9d74aa1c1b550ff9db42dd8092f214de353ffbb2eb48549db110201424cafd" data-rendition-name="original" width="813" height="520" loading="lazy" alt="Nepal Orthopaedic Hospital"> <figcaption>Photo courtesy: NEPAL ORTHOPAEDIC HOSPITAL</figcaption> </figure>  "It was just two blocks of a one-story building," he recalls. "They said: Here’s the hospital. Run it. But buildings don’t make hospitals. You need doctors, you need equipment, you need patients."&nbsp; With a bold plan and support of friends and international donors, Shrestha started with 15 beds, providing care to anyone in need, regardless of their ability to pay. Initially, 93% of their operating expenses were covered by international donors but in less than 10 years, it had reversed the figures so that most of the cost was covered by internal resources. The hospital is self-sufficient today and does not turn away any patient that cannot afford the cost. Over the past 25 years, it has given more than $1 million in charity care.&nbsp; But Shrestha’s job was far from over. Realising the chronic lack of proper spinal care in Nepal, he got involved with the <a href="https://sisn.org.np/sirc/">Spinal Injury Rehabilitation Center in Sanga</a> in 2001, offering holistic treatment to paraplegic and quadriplegic patients. It was a leap of faith-started with a few friends, a handful of nurses, and no specialised doctors.&nbsp; "We just knew the need. People, especially women were falling off trees and cliffs, injuring their backs," Shrestha says, “They needed rehabilitation and physiotherapy, and we thought, why wait? You start small, and if you’re doing well, others will help you."&nbsp; Shrestha had long believed that healthcare in Nepal needed to reach the farthest corner, and after working with Nick Simons Institute (NSI) he realised that <a href="https://nepalitimes.com/news/jim-simon-s-gift-to-nepal">partnering with government hospitals</a> can better strengthen the overall health system. Shrestha’s journey took another turn when he was asked to join the board of OneHeart Worldwide, whose mission, to reduce maternal and neonatal mortality in Nepal’s most underserved areas, deeply resonated with him.&nbsp; Read also: <a href="https://nepalitimes.com/here-now/nepal-s-flying-doctor">Nepal's flying doctor</a>, Kunda Dixit  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20241016131020_15d6c1483ea69455b998ba6fd6ecc0ac5eafe3af6effc2214f48f148bee0b540.jpg" data-media-id="editor_6" data-image-id="20241016131020_15d6c1483ea69455b998ba6fd6ecc0ac5eafe3af6effc2214f48f148bee0b540" data-rendition-name="original" width="2048" height="1365" loading="lazy" alt="Spinal Injury Rehabilitation Center"> <figcaption>A caretaker with a patient at the Spinal Injury Rehabilitation Center.</figcaption> </figure>  Shrestha’s approach to leadership is as grounded as his approach to medicine, it was never about control but rather always about enabler-ship. He explains: "Humility is key, and treating staff equally fosters a sense of unity and trust that is essential in difficult times.”&nbsp; He recalls a time at the Orthopaedic Hospital when funds were so tight that salaries could not be paid. The trust was so great that staff worked without pay for three months.&nbsp; Shrestha has a vision to open centres for spinal rehabilitation across all seven provinces of Nepal to provide specialised care – since the number of spinally injured patients rises dramatically because of highway accidents. He wants a health system where each district's hospital is properly equipped and functional, thereby discouraging referral of critical patients to Kathmandu over long and bumpy roads. &nbsp; His message to the next generation of Nepali doctors and social entrepreneurs: "You don't have to wait until everything is perfect to get started. All you need is an idea, and if you see a need, jump into it. Start small and you will always have people to help if you’re passionate and clear about your goals."&nbsp; Shrestha avoids the limelight, and had to be convinced to agree to this profile interview. He says, "When you build an institution, don’t think it’s yours. It belongs to everyone who helped along the way." Read also: <a href="https://nepalitimes.com/here-now/the-barefoot-doctor-of-rolpa">The barefoot doctor of Rolpa</a>, Pinki Sris Rana

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Doctor who does not just treat symptoms

The 14th <a href="https://www.apthc2024.org/">Asia-Pacific Travel Health Conference</a> is set to take place in Kathmandu from 18-21 September, bringing together 200 delegates from 27 countries to explore advances in <a href="https://archive.nepalitimes.com/news.php?id=19282">travel medicine</a> which have relevance for Nepal’s own tourism industry.
The biannual conference is the first in four years after its 13th iteration in New Zealand in 2020 was cancelled due to the Covid-19 pandemic. Previous conferences have been held in Bangkok and in Kathmandu in 2016.
Lessons for the travel industry from the <a href="https://nepalitimes.com/news/nepal-covid-19-impact-worse-than-official-figures">Covid-19 pandemic</a> will be prominent in the agenda of the conference in which experts from the <a href="https://www.istm.org/">International Society of Travel Medicine</a> will also be taking part. Nearly 60 of the 200 participants are from Nepal.
"The careful practice of travel medicine can be an important sentinel for diseases,” says <a href="https://nepalitimes.com/opinion/more-porters-sick-on-everest-trail">Buddha Basnyat, MD</a>, Chair of the Oxford University Clinical Research Unit-Nepal, who is part of the Nepali delegation.
The 3-day event will kick off with a day-long Pre-Conference Seminar on Adventure and Wilderness Travel, as well as separate sessions on mental health strategies and military medicine before the main events next week.
“Travel medicine is very relevant to Nepal because it has always been a desirable tourism destination,” says Pratibha Pandey, MD, of <a href="https://ciwechospital.com/">CIWEC Hospital and Travel Medicine Center</a>, which is a partner to the <a href="https://www.apths.org/">Asia-Pacific Travel Health Society</a>.
She adds: “Outbreaks of diseases like <a href="https://nepalitimes.com/banner/mosquitoes-move-up-mountains-as-the-earth-warms">dengue</a>, issues of <a href="https://nepalitimes.com/news/fatalism-and-fatalities">road and aviation safety</a>, and economic hardships have had an impact on the number of travellers coming to Nepal, which will be reflected at the conference.”
Read also: <a href="https://nepalitimes.com/news/poor-safety-to-hit-nepal-tourism">Poor safety to hit Nepal tourism</a>, Sonia Awale 
Each day of the conference will include three plenary panels, followed by parallel symposia, communication sessions, and interactive workshops. The conference will highlight special groups, including the elderly, pregnant, and otherwise immuno-compromised travellers. 
An ‘ABC’ workshop which will provide participants with the basics of setting up a clinic and explain pre-travel consultations. Other sessions include discussion about vaccines, including a plenary on the changing immunisation landscape, newer vaccine technologies, as well as a seminar on the <a href="https://www.reuters.com/business/healthcare-pharmaceuticals/japans-takeda-partners-with-indias-biological-e-boost-dengue-vaccine-production-2024-02-27/">Japanese Qdenga vaccine</a> against dengue that has not yet been licensed for use in Nepal.
Travel medicine is not just important for tourists coming to Nepal, but also for Nepalis since non-endemic infections like <a href="https://www.nature.com/articles/d41586-024-02912-6#:~:text=Mpox%20is%20caused%20by%20variants,materials%20contaminated%20with%20the%20virus.">Mpox and other diseases</a> can be brought here by visiting carriers.
“We were diagnosing dengue and typhus fever in travellers to Kathmandu who came via Rajasthan or Bangkok in the 1990s, long before these diseases became well-established in the local population,” explains Buddha Basnet, who is delivering a lecture on the <a href="https://nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal">Typhoid Conjugate vaccine</a> and its roll-out in Nepal in one of the symposia.
The conference will also discuss airlift and emergency evacuation and a workshop on the role of the military in disaster and outbreak relief operations — both especially relevant to trekking and mountaineering in Nepal. <a href="https://nepalitimes.com/news/climate-breakdown-linked-to-thame-flood">Climate breakdown</a> has increased the need for better preparedness and rescue.
 Read also: <a href="https://nepalitimes.com/here-now/kathmandu-loses-its-open-spaces">Kathmandu loses its open spaces</a>, Tom Robertson and Nilima Thapa Shrestha
Other sessions include a plenary on sustainable travel in the age of no-jet set and <a href="https://www.nytimes.com/2023/02/06/travel/travel-climate-no-fly-pledge.html">climate guilt</a>, as 4% of greenhouse emissions are from air travel. Workshops will also look into other infectious diseases and the use of AI and Large Language Models like ChatGPT on travel medicine.
Because travel medicine specialises in diseases and health conditions that are acquired during international travel, it involves pre-travel, during travel, and post-travel consultations. Apart from the relevance of travel medicine to provide medical care to visitors to Nepal, there is also the opportunity to advance pre-travel and post-travel medicine for Nepalis.
Says CIWEC’s Prativa Pandey: “Heartbreaking as it is, migrant workers and students are leaving in droves, and many migrants are <a href="https://nepalitimes.com/opinion/comment/saving-kidneys-to-save-nepal">coming back with kidney failure</a>, about which there is very little data or research, so there is an urgent need to address those areas as well in Nepal.”
Read also: <a href="https://nepalitimes.com/news/brain-gain-into-brain-drain">Brain gain into brain drain</a>, Sonia Awale
Some of the participants include the ‘father of travel medicine’ Robert Steffan from Switzerland, Tomas Jelinek of the Berlin Centre for Travel and Tropical Medicine, editor of the Journal of Travel Medicine Annelies Wilder Smith, David Shlim who was Medical Director of CIWEC in Kathmandu 1983-1998, and <a href="https://www.ox.ac.uk/news-and-events/find-an-expert/professor-david-warrell">Sir David Warrell</a> a world expert on snake bite, rabies and infectious disease.

Shristi Karki

Medicine on the move

Ritu got her nursing licence in 2017 and started working at a hospital in Bansbari for a monthly salary of Rs15,000. She had a heavy workload, had no overtime pay and could not always get a day off. &nbsp; Two years into her job, Ritu’s brother fell ill and she took two days’ leave to go to Pokhara to care for him. Nursing her sibling back to health took her two additional days, and when her hospital demanded clarification Ritu was so outraged she quit. &nbsp; Ritu then approached another clinic, where she had to work two weeks as a trainee without pay. After that she was offered a salary even less than her previous job. She was so overworked, she left that job after three months even though she had got only a month’s pay check.&nbsp; Ritu went back home to Pokhara and has been out of work for six years. Her mental health has deteriorated during this time. She told Nepali Times: “Experiencing the exploitation and abuse makes me want to tear up my nursing certificate.” Puja is another Proficiency Certificate Level (PCL) nurse from Nepalganj who got a job through a recruitment office that paid only R12,000 a month. Her middle-income family is in debt after spending Rs1.2 million on her nursing education. Puja reluctantly accepted the job, which was harrowing.&nbsp; There were only seven nurses in the 50-bed hospital, and Puja had 18-hour shifts with no overtime. She quit after a year, and has been without a job at home in Nepalganj for the last six months. “Becoming a nurse was a dream that turned into a nightmare,” she told us by phone. Read Also: <a href="https://nepalitimes.com/here-now/nepali-nurses-gone-and-going-to-the-uk">Nepali nurses gone and going to the UK</a> Anjali Pokharel from Dang got the same nurse job in the same hospital as Puja, but she was offered only Rs11,000. Her monthly hostel rent in Kathmandu alone was Rs12,000.&nbsp; “There is no earning, respect, or professional satisfaction in nursing,” says Anjali. “I never &nbsp;imagined that the nursing sector in Nepal was so bleak.”&nbsp; Another nurse with a decade of nursing experience is working at Ihsan Children’s Hospital in Kathmandu for Rs18,000, and says she was threatened with dismissal when she spoke out about low pay and overwork. She told us confidentially: “Despite great dissatisfaction, nurses are forced to keep working because there is no other choice.” All 20 nurses Nepali Times spoke to for this story said they were subjected to exploitation at their workplaces. Says a nurse currently at Norvic Hospital in Kathmandu: “Most nurses fall ill due to the workload, and many speak of wanting to go abroad for more respect and money.”&nbsp; For Nepal’s aspiring nurses, exploitation begins in the classroom. While the government has set a fee of Rs475,000 for the post-SEE three year PCL diploma course, many nurses spend up to Rs1.5 million to complete the course. The four-year BSc nursing fee is capped at Rs750,000, but nursing colleges set fees as high as Rs2.2 million, tacking expenses for food, accommodation, educational tours, etc.&nbsp; Read Also: <a href="https://nepalitimes.com/opinion/comment/nepal-health-workers-at-risk-of-workplace-hazards">Nepal health workers at risk of workplace hazards</a>, Ramita Marasini Female students are also subject to harassment and disciplinary practices that put restrictions on how they can dress, as well as how they do their hair and make-up. Nurse training itself is book-based with outdated curricula, and many nurses will not have interacted with actual patients throughout their academic career. Seema KC, who works at the Civil Hospital in Bhaktapur, says that the lack of practical knowledge means nursing graduates are incapable of the real-world working environment.&nbsp; This is one reason why even the country’s largest, international-level hospitals keep new nurses on probation at very low wages. The government also does not have a fixed minimum wage for nurses, a loophole private hospitals have taken full advantage of.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240317100332_10a449da404b46c671bc9baef588c76762ef41f787de5cd018a87a7eafe3a24e.jpg" data-media-id="editor_2" data-image-id="20240317100332_10a449da404b46c671bc9baef588c76762ef41f787de5cd018a87a7eafe3a24e" data-rendition-name="original" width="768" height="1024" loading="lazy" alt="Nepali Nurses in UK"> <figcaption>Nepali nurses working in the UK. Nurses have started leaving Nepal in search of better professional and academic opportunities abroad. </figcaption> </figure>  A nurse interviewed for this story said she had been offered merely Rs4,000 at Megha Hospital despite having had previous work experience, while Norvic pays PCL nurses up to Rs16,000 and nurses who have a Bachelor’s in Nursing Science (BNS) Rs25,000. Although working hours for nurses at private hospitals are supposed to be only six hours, many work for twice as long daily. The Nepal Health Service Regulations stipulate that health workers should only work 40 hours per week, and are entitled to compensation and additional service leave if their working hours are extended beyond the set hours. &nbsp; Salaries at government hospitals are better compared to private hospitals, but nurses are reluctant to work there because of lack of opportunities for career progression, and are forced to tolerate lower pay at private hospitals. Exploitation, low pay, high nursing college fees, lack of academic or professional growth are driving Nepal’s nurses overseas in droves.&nbsp; “Most nurses at Teaching Hospital have decided to go abroad because there are more academic and professional opportunities outside Nepal,” says Sarita Poudel, a nurse there. Government hospital directors say three to five nurses resign every week, some to pursue nursing abroad, and some to leave the sector entirely.&nbsp; Read Also: <a href="https://nepalitimes.com/latest/nepali-nurses-now-britain-bound">Nepali nurses now Britain-bound</a>, Radha Adhikari Nepal’s Department of Labour granted work permits to 40 nurses to go abroad in 2013. This number increased to 160 in 2019, 109 in 2020, 287 in 2021 and 582 in 2022. In 2023, 607 nurses received permits to go overseas. However, many nurses who go abroad do not appear in these official statistics. Some have gone abroad on student visas to study other subjects. A nurse working at Vayodha Hospital says she is going to Canada on a non-nursing student visa, adding that she will need nothing more than her Nepali nursing license to sit for the nursing license exam there. Data from the Ministry of Health and Population states that there are 14,099 vacancies for nurses across the country, while there are only 9,951 nurses currently employed. The shortage of nurses is affecting medical care across Nepal. In government hospitals, the nurse-patient ratio is 1:40. The Health Institution Operating Standards stipulates one nurse for four to six beds in the general ward, one nurse per two beds in emergency and postoperative rooms, and one nurse per bed in ICUs and CCUs. Meanwhile, there must be two Skilled Birth Attendants (SBA), trained nurses or midwives per patient in delivery rooms. None of Nepal’s hospitals – private or government – meet this requirement. Bir Hospital alone requires at least 938 nurses for its 550 beds, but only 400 are currently employed. The 350-bed Kanti Children’s Hospital requires 600 nurses but has only 169. It is even worse at the Prasuti Griha maternity hospital which needs at least 735 nurses but only has 154.&nbsp; The minimum service standards of the Health Ministry means Nepal’s government hospitals alone need 32,000 nurses, but have only half that number. The irony is that while the nursing posts remain vacant, many nurses are unemployed. The Ministry of Health’s Nepal Health Workforce Projection, (2022-2030), states that Nepal had produced 72,550 staff nurses until 2021. Excluding those who went abroad or had retired, 50,785 staff nurses were available against an estimated requirement of 39,249 professionals. This means that Nepal should theoretically have an excess of 11,536 staff nurses. According to the report, Nepal will need 43,056 nurses by 2031, including 22,255 who have completed the Auxiliary Nurse Midwife (ANM) diploma course as well as 240 graduate nurses and midwives. There are currently 115,793 registered staff nurses and ANM professionals in Nepal. Meanwhile, new nursing colleges are mushrooming with little regard to meeting accepted standards. They produce 7,000 nurses every year, but few get jobs overseas because they are not deemed qualified enough. The Ministry of Health in 2012 gave medical colleges a deadline until 2016 to build their hospitals of up to 100 beds to employ graduating nurses, but most never followed this directive even after multiple deadline extensions. In response, the Medical Education Commission stopped admissions to institutions that did not have 100-bed facilities, but colleges have been lobbying to be allowed to teach students without meeting those standards. The Nursing Association of Nepal has forced the government to agree to reforms in the sector, but few of those agreements were ever implemented. Nurses who spoke with Nepali Times said that many of their problems would be solved if the Nursing Association of Nepal and the Nepal Nursing Council took more initiative.&nbsp; Mana Kumari Rai, president of the Nursing Association blames the Health Ministry for failing to meet past commitments. Last week’s government change has again brought in Upendra Yadav of the JSP as health minister, but few nurses have hope that things will change for the better any time soon. &nbsp; Some names have been changed.

Nursing grievances against the state

The United States Medical Licensing Examination (USMLE) is a test that those who want to practice medicine in America have to pass. A growing number of Nepalis have been taking the test to emigrate to the US.&nbsp;
Last week, USMLE invalidated test results of some 800 Nepali doctors because of ‘unusual score patterns or variations’.
‘The USMLE program has identified a pattern of anomalous exam performance associated with Nepal, which challenges the validity of test results for a group of examinees,’ its statement said.&nbsp;
Essentially, USMLE was accusing Nepali doctors of having prior knowledge of questions. This sparked outrage among Nepalis in the United States who say it tainted the country's image, and besides there is no way the test questions can be ‘leaked’.&nbsp;
<a href="https://nepalitimes.com/here-now/nepali-doctors-love-for-urdu-poetry">Ramu Kharel</a> is an emergency medicine physician and assistant professor at Brown University. He told us, "We care for the integrity of the program, and do not condone cheating in any form but the decision is not backed by strong evidence and creates biases when there is already a lot of brewing anti-immigrant sentiment.”
Kharel reached out to the USMLE director who told him it was ‘an ongoing investigation’.
“And yet they put out a blanket statement that has tarnished an entire country’s image as well as the credibility of practicing Nepali doctors who have done a lot of good work in the US.”
Several international doctors in the United States back this up, saying irregularities should have been addressed individually instead of singling out a whole country.
‘Some folks are using incidents of what they call “unusual USMLE Scores" to vilify the whole immigrant community who are resilient, hardworking, and knowledgeable as local doctors are. Let's not generalize the acts of a few to whole country and to emigrants,” X'ed Sadiq Naveed, psychiatrist in Hartford, Connecticut.
<div class="embed-block"><blockquote class="twitter-tweet">Some folks are using incidents of &quot;unusual USMLE Scores&quot; to vilify whole IMG community. IMGs are as resilient, hardworking, and knowledgable as AMGs are. Let&#39;s not generalize the acts of a few to whole country and the IMG community.&mdash; Sadiq Naveed (@SadiqNaveed) <a href="https://twitter.com/SadiqNaveed/status/1753917839289753714?ref_src=twsrc%5Etfw">February 3, 2024</a></blockquote> <script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script></div>
<div class="embed-block"><blockquote class="twitter-tweet">USMLE Score Invalidation: In my opinion mistakes of some mustn&#39;t lead to singling out of an entire country🇳🇵. ECFMG &amp; USMLE could have handled the situation better by a making a more generalized statement rather than naming a particular country. &quot;Culprits should be punished… <a href="https://t.co/h7AnANubE6">pic.twitter.com/h7AnANubE6</a>&mdash; Dr Ahmad Rehan Khan (@AhmadRehanKhan) <a href="https://twitter.com/AhmadRehanKhan/status/1754145466608955585?ref_src=twsrc%5Etfw">February 4, 2024</a></blockquote> <script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script></div>
&nbsp;Ahmad Rehan Khan, psychiatrist based in Virginia also tweeted: ‘In my opinion mistakes of some mustn't lead to singling out of an entire country. ECFMG &amp; USMLE could have handled the situation better by a making a more generalized statement rather than naming a particular country.’
Kharel started a <a href="https://www.change.org/p/call-for-usmle-to-redact-and-change-the-statement-regarding-applicants-from-nepal?recruiter=1329972259&amp;recruited_by_id=12774da0-c307-11ee-8897-7bad97cd7eca&amp;utm_source=share_petition&amp;utm_campaign=share_for_starters_page&amp;utm_medium=copylink">petition calling on USMLE to redact or change the statement</a>, and has over 2,500 signatories already. He has approached the Nepali physicians' group in the US as well as the America Nepal Medical Foundation seeking legal counsel.
“The damage is already done, but USMLE at the very least needs to immediately revise its statement and issue a formal apology,” says Kharel. “The truth is that Nepalis are generally well-liked here."&nbsp;
A week before the USMLE statement, <a href="https://nepalitimes.com/here-now/grass-is-greener-overseas-for-nepals-doctors">Nepali Times published a report about doctors emigrating</a> to the US, UK, Canada, Australia and the Gulf, leading to a shortage of specialists in Nepal and weakening an already fragile medical system.
Nepal has an annual turnover of nearly 2,500 MBBS graduates, yet the country faces a severe shortage of doctors. The Nepal Medical Council says 36% of doctors have emigrated, but that seems to be an undercount. &nbsp;
Between April-December 2023, 1,025 physicians left Nepal. Since 2020, 1,578 doctors have emigrated to the UK, and 888 to the US.&nbsp;
There are many push factors, but the lack of professional fulfilment in Nepal is the biggest. Equally strong is the pull of the American dream, with even unskilled Nepalis paying up to Rs6 million to human traffickers to take the illegal backdoor to the US.
<a href="https://archive.nepalitimes.com/news.php?id=19560">Emigrating doctors</a> may earn more than in Nepal, but international medical graduates in the US often do not get to practice specialised medicine of their choice, and are relegated to long hours as general physicians.&nbsp;
“Nepali doctors are emigrating essentially for thankless, blue-collar jobs,” says Bishal Dhakal, cardiac surgeon and founder of Health At Home in Kathmandu. “They do not make a lot of money by American standards and are doing jobs that American doctors do not want to do. Which is why Nepalis being accused of cheating is so tragic.”
Even so, the <a href="https://www.medscape.com">Medscape medical news website</a> on 1 February states that selling and buying USMLE questions online have become rampant with test questions selling for anywhere from $300 to $2,000.
An Indian doctor Ahmad Ozair at Johns Hopkins says his suspicions were aroused when he saw several students from one medical school in Nepal, posting on social media about scoring up to 280-plus.
‘The statistical probability that you would have three or more candidates in the same year, scoring in the 99th percentile worldwide, from a small geographical area is extremely low,’ Ozair <a href="https://www.medscape.com/viewarticle/us-board-discloses-cheating-grads-say-problem-rampant-2024a10002aj">said to Medscape</a>.&nbsp;
Others say the USMLE recall of Nepali test takers was not an ordinary one, and there is photographic evidence of questions leaked at exam centres.&nbsp;
The fact that Nepal’s university exams have regular scandals of ‘question outs’ gave credence to accusations of Nepali cheaters.&nbsp;
J. Bryan Carmody, nephrologist based in Virginia, also took to Twitter to write: ‘This isn’t the usual low-quality “USMLE recalls” - and instead involves screenshots/photos of real questions, taken at test centers by proctors (or after the proctors were paid to look away).’
<div class="embed-block"><blockquote class="twitter-tweet">The cheating in this case involved “prior unauthorized access to secure exam content.” This isn’t the usual low-quality “USMLE recalls” - and instead involves screenshots/photos of real questions, taken at test centers by proctors (or after the proctors were paid to look away).&mdash; Bryan Carmody (@jbcarmody) <a href="https://twitter.com/jbcarmody/status/1752891546553213219?ref_src=twsrc%5Etfw">February 1, 2024</a></blockquote> <script async src="https://platform.twitter.com/widgets.js" charset="utf-8"></script></div>
Medical educator Conrad Fisher of MedQuest Test Prep questioned in an X post the high performance of Nepalis: ‘Of 138 with &gt;275 applying to my program, 86% are Nepali. Of the top 100 applicant scores 92% are Nepali.’
But Bishal Dhakal says Nepalis are used to practicing for exams based on past tests, and it is unfair for USMLE to call it cheating just because of high scores. “If there is an issue with exam centres, that should be dealt with separately without dragging the whole country into it," he adds.
An increasing number of Nepali doctors passing USMLE tests with high marks seems to be making some international graduates in America insecure. He adds, "We are sending our smartest doctors to America, and that didn’t sit well with those benefiting from the Subcontinent quota. A small country is being singled out." &nbsp;

Sonia Awale

Cheated out of the American Dream

Like any mother, Sharmila Chadara just wanted to get home to see her child. It was this primal urge, and other unrelated factors, that directly resulted in her death on the night of 24 November. It was easy for journalists to assume that she had died from ‘the cold’ following the <a href="https://nepalitimes.com/news/deadly-earthquake-hits-w-nepal">earthquake on the night of 3 November</a> that killed 150 people outright in Jajarkot and Rukum West. Many of Sharmila’s neighbours in Ward 4 of Nalgad Rural Municipality and the surrounding mountains were forced to sleep outdoors after their houses collapsed.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240102150116_b6edcb6e1b6f52540dfdbc84bdbc23a1701dc9b1f113b7d5da30cf7f8e277898.png" data-media-id="editor_1" data-image-id="20240102150116_b6edcb6e1b6f52540dfdbc84bdbc23a1701dc9b1f113b7d5da30cf7f8e277898" data-rendition-name="original" width="1500" height="1125" loading="lazy" alt="Jajrkot earthquake"> <figcaption>Damaged homes in Nalgad, Ward 1. Many locals are living in tents, below. All photos: MARTY LOGAN</figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240102150116_d992b10f8725c5d0415191b0606b33f23c2cff8941e495199a2cea5528542da6.png" data-media-id="editor_2" data-image-id="20240102150116_d992b10f8725c5d0415191b0606b33f23c2cff8941e495199a2cea5528542da6" data-rendition-name="original" width="2000" height="1500" loading="lazy" alt="Jajarkot earthquake"> <figcaption>Tents in Nalgad Municipality, Ward 1, Jajarkot. Occupants had their houses destroyed or damaged in the November 3 earthquake.</figcaption> </figure>  A local politician was quoted saying that Sharmila had become the latest post-earthquake victim because she was sleeping under a flimsy plastic sheet as night temperatures dropped. The <a href="https://annapurnapost.com/story/447108/">news was picked up by the media</a>, and there was outrage across the country. Read also: <a href="https://nepalitimes.com/here-now/jajarkot-one-month-after-the-earthquake">Jajarkot: One month after the earthquake</a>, Ramu Kharel and Maggie Doyne Had she survived, Sharmila Chadara would probably be sleeping inside the tiny home of her husband Dinesh in Nalgad located down a dusty path, a 15-minute walk from a narrow road. It was damaged but is habitable.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240102150116_1e7562050e0b55135f28e96726d6a003c699dbf02214b3849c38e64540b7cfd8.png" data-media-id="editor_5" data-image-id="20240102150116_1e7562050e0b55135f28e96726d6a003c699dbf02214b3849c38e64540b7cfd8" data-rendition-name="original" width="2000" height="1500" loading="lazy" alt="Jajarkot earthquake"> <figcaption>The home where Sharmila Chadara lived in Nalgad Municipality. It was damaged in the earthquake but is still habitable.</figcaption> </figure>  Dinesh, 26, sheltered from the sun against the house as he told us about Sharmila’s final trip home. It was on Dasain Tika day in early November when Sharmila felt labour pains and they took a vehicle down to the local hospital.&nbsp; There were no doctors and the couple was advised to go to the hospital in Khalanga, where doctors in turn referred them to Surkhet. Sharmila had twins and it would be a risky delivery.&nbsp; In Surkhet, she delivered the first baby, a girl. The boy was born lifeless. The doctors advised them to keep the girl in the hospital so she would gain weight. After five days, staff noticed that Sharmila, who till then seemed healthy, developed a cough. They diagnosed severe pneumonia and put her in the ICU. But fluid built up in Sharmila’s lungs and she underwent dialysis, recalled Sakuntala Sapkota, the matron at the Surkhet hospital. “She had many ups and downs,” Sapkota told me. Sharmila had five dialysis treatments as she was shuttled back and forth between ICU and the general ward. At one point a doctor told Dinesh and relatives they might not be able to save Sharmila because her body was “completely infected”. After nearly three weeks, Sharmila had enough. She was missing her son and wanted to return to Jajarkot. But staff urged her to stay two more weeks until she was fully recovered. In Ladakh Three years earlier, Sharmila had travelled to Ladakh where Dinesh was working, as were her own parents. It is normal for at least one member of each household in Jajarkot and surrounding districts to migrate for work in India and beyond. Increasingly, many are taking illegal routes destined for the US. In Athbiskot Municipality we met one woman whose brother had been gone a year, and had only made it to Turkey after paying traffickers Rs10 million.&nbsp; Sharmila stayed and worked alongside her husband at a cement factory in Ladakh, returning for the first time this past Dasain. Dinesh remembers her falling ill in India and coughing up blood. A local doctor diagnosed it as ‘weakness’ and gave her medicine.&nbsp; “But she didn’t finish it,” her husband told us. “She never finished medicine, even vitamins. I don’t know why she was like that.” A neighbour remembers Sharmila as being honest and friendly. She did not like working in Ladakh, she added, but the pressure to earn money must have been strong. At the hospital in Surkhet, Sharmila threatened to pull out her IV drip, remove her oxygen mask, and die in her hospital bed if she was not taken home. Dinesh relented and booked an ambulance for the family’s return trip to Nalgad. The oxygen ran out on the way. “I was not even sure if she was breathing,” he recalled. When they reached the hospital emergency in Radi Bazar at 2AM her vital signs were nil, staff told him. Sharmila had died. Dinesh wanted to take her home. He hired a vehicle to carry her to the foot of the hill and rounded up people in the dead of night to carry her on a stretcher, reaching home at 4AM. Sharmila was finally reunited with her son.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240102150120_2713c13b4d2ba22fe28bc1bf96cfbcfd87a7ede9cc67678b67d69efbe4a4d851.png" data-media-id="editor_6" data-image-id="20240102150120_2713c13b4d2ba22fe28bc1bf96cfbcfd87a7ede9cc67678b67d69efbe4a4d851" data-rendition-name="original" width="1125" height="1500" loading="lazy" alt="Jajarkot earthquake"> <figcaption>Dinesh Chadara with his son Ganesh at home in Nalgad Municipality recently.</figcaption> </figure>  Dinesh told us he has not made up his mind about returning to work in India. His in-laws have given him Rs150,000 to pay medical bills and he has borrowed more, but was still in debt. Sharmila’s baby has been released from hospital, and continues to gain weight and get routine vaccinations.&nbsp; Left out in the cold When we visited Jajarkot and Rukum West nearly two months after the earthquake, survivors were still living in tents and plastic shelters.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240102150124_1efe377bce5e1b8b264308d2378871aba0fc34c13046cabc6fffbdb940c7bb86.png" data-media-id="editor_7" data-image-id="20240102150124_1efe377bce5e1b8b264308d2378871aba0fc34c13046cabc6fffbdb940c7bb86" data-rendition-name="original" width="1500" height="1125" loading="lazy" alt="Jajarkot earthquake"> <figcaption>A health post destroyed in Chinabagar, Ward 1, Rukum West.</figcaption> </figure>  A female community health volunteer (FCHV) in Athbiskot told us she was having trouble finding a good tent for a mother just discharged from a health facility with her newborn. Up the mountain, we reached the house of Seema Chand Malla, 28, who was eight months pregnant. Her brother-in-law was hammering together a door for a wooden shelter while waiting for the government’s Rs 50,000 temporary shelter allowance. Sitting on a windy ridge, Seema said: “It’s very cold, but so far we're OK – let’s see what happens.” Read also: <a href="https://nepalitimes.com/news/below-zero-at-ground-zero">Below zero at ground zero</a>, Durga Rana Magar Like many women we spoke to, Seema seemed to be receiving some, but not all, routine health services. She had gone for six pre-birth (ANC) visits, was taking calcium and iron supplements regularly and had been given medicine to prevent worms. As one of her three children, a son, played on her lap, she said her health was good. The local FCHV used to visit to provide vitamins or information about the children’s health, but Seema had not seen her since the earthquake. The family had received one blanket, a small tent, 25kg of rice and some buckets from the government and various agencies. When we returned from Seema Chand’s house four tractors arrived towing carts piled high with sleeping mats, rice and other goods. We saw such relief deliveries mixed with various stages of reconstruction work across the affected areas.&nbsp; Read also: <a href="https://nepalitimes.com/news/demographics-of-disaster-in-nepal-quake">Demographics of disaster in Nepal quake</a>  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240102150116_7f6c045a4fccc3bb87f6746e702f4db8362b2cfd1d960c55e6ed326fe2bca183.png" data-media-id="editor_10" data-image-id="20240102150116_7f6c045a4fccc3bb87f6746e702f4db8362b2cfd1d960c55e6ed326fe2bca183" data-rendition-name="original" width="1125" height="1500" loading="lazy" alt="Jajarkot earthquake"> <figcaption>Seema Chand Malla, with her son, in Aathbiskot, Ward 14.</figcaption> </figure>  In Radi Bazar a crowd had gathered to get the forms needed to apply for government cash for shelters.&nbsp; <a href="https://nepalitimes.com/news/mass-cremations-for-nepal-quake-victims">The damage</a> seemed mostly random, with single houses on village roads reduced to rubble, but there were also whole clusters of homes that had fallen. On a slope overlooking the scenic, glacier-fed aquamarine Bheri River, there was a line of orange and blue tents. New mother Samjhana Bitalu, 19, crawled out from one of them to tell us that her house nearby was <a href="https://nepalitimes.com/here-now/grief-stricken-survivors-are-cold-and-hungry">damaged in the earthquake</a> and uninhabitable.&nbsp; She and her 55-days-old baby Monika were staying here with her husband, who did not want to leave them alone to return to his job in Khalanga. Samjhana said she gave birth at a nearby health post, but no staff visited her afterwards. The only help the family had received was a tent and 25kg of rice from the Ward office.&nbsp; “When it rains it’s hard to keep the baby dry because the water comes inside the tent, and she has diarrhoea,” the mother said. Following local custom, she did not think the baby should receive any treatment before she was two months old. But a health worker urged Samjhana to get medical care for the baby. “It’s more difficult because I have to manage everything alone,” Samjhana said stoically. “Otherwise, everyone would have been together at home.” Nearby, Amrita Gharti, 22, was still living in her in-laws’ house with her husband. She was almost two months pregnant.&nbsp; Amrita previously had a miscarriage, despite being told by ANCs that she was healthy. This time, arriving at her local birthing facility for her first checkup, she was told to return when she was exactly two months pregnant. “They didn’t do my checkup. They were too busy,” she said.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240102150120_e6d6fd29a04a5c3fa20fc6bd50c2236287fce0b7ddce0e508fefb329644ecf91.png" data-media-id="editor_13" data-image-id="20240102150120_e6d6fd29a04a5c3fa20fc6bd50c2236287fce0b7ddce0e508fefb329644ecf91" data-rendition-name="original" width="1125" height="1500" loading="lazy" alt="Jajarkot earthquake"> <figcaption>Amrita Gharti is pregnant and living in her in-laws' house in Nalgad, Ward 1.</figcaption> </figure>  Aruna Chaudhary of the Radha Paudel Foundation spent two weeks in Nalgad providing menstrual kits to 450 women and adolescent girls.&nbsp; Demand for her support was great and the cold was especially hard on children, she told us.&nbsp; “Many children have pneumonia and cholera and have to take medicine,” she added. “There was lots of diarrhoea and many had injuries from the earthquake itself.”&nbsp; Pneumonia and other cold-related illnesses were also growing in Chinabagar where lack of water and sanitation was worsening the situation, especially for <a href="https://nepalitimes.com/news/remove-barriers-to-life-saving-drug-to-prevent-maternal-deaths">women and adolescent girls</a>. Dhani Kumar Giri from the group WOREC was assisting arrivals at a tent while the group also provided care door-to-door. In a nearby tent an organization was providing psychological counselling to those troubled by the disaster. Some good news Around noon on 6 December, Man Kumari Singh arrived with labour pains at the health post in Athbiskot-4 of Jajarkot. She was pregnant with twins, but had been declared healthy during previous visits to the facility. But by 4PM her labour had not progressed and Man Kumari was starting to shake in distress. Staff decided to request a helicopter rescue, but by the time permission was granted from Kathmandu it was too late in the day.&nbsp; Health post staff decided to send her to the municipal hospital in Dali, but doctors there referred her to the mission hospital in Chaurjahari instead. They sent an ambulance carrying two nurses to accompany her. At 1AM that night Man Kumari’s twins were delivered normally. By noon she had been transferred to the ICU at the provincial hospital in Surkhet. Soon after she was moved to the general ward and by 19 December she had recovered and been discharged. The twins were also reported to be in good health. Author thanks One Heart Worldwide for arranging logistics for reporting on this story.&nbsp;

Poverty killed a mother, not the quake

A rapid assessment of the epicentre of the earthquake that hit just before midnight on 3 November shows that lack of accurate information about the status of survivors and their needs continues to be a challenge. Our trip to the hardest hit areas from Khalanga to Nalgad in this remote district in the mountains of western Nepal involved the rescue of a month-old infant whose mother was reported to have died from the cold.&nbsp; There has been inaccurate and sensationalised reporting in the media after people died from the cold. While it is true that winter has set in the mountains and the long term illnesses can be exacerbated by the cold, stress or unhygienic conditions, many of the deaths have been due to acute illnesses and existing preconditions. There have also been reports of relief items being stuck in bureaucratic bottlenecks and piling up in municipal offices instead of being distributed to those in need. While that may have happened in the early days of the earthquake, on this week’s trip that was not what we saw.&nbsp; In any natural disaster, it is important to recognise that the scenario for relief can rapidly change from day to day, thus making a rapid response and clear communication channels vitally important.&nbsp; We are concerned that inaccurate journalism based on hearsay without fact checking can foster an environment of cynicism and criticism, discouraging collaborative efforts. It can also affect the morale amongst first responders, spreading distrust.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20231201131252_0b36cd97d9d54136ebbc601ca2170c1402ec22944d1f8c5d837ba1e3dfc8ef13.png" data-media-id="editor_0" data-image-id="20231201131252_0b36cd97d9d54136ebbc601ca2170c1402ec22944d1f8c5d837ba1e3dfc8ef13" data-rendition-name="original" width="1368" height="1058" loading="lazy" alt="Jajarkot earthquake NT"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20231201131252_9f96af647fb9e343ef22159c2191e7aaac8574f6cce70891237a91d24747fcc2.png" data-media-id="editor_1" data-image-id="20231201131252_9f96af647fb9e343ef22159c2191e7aaac8574f6cce70891237a91d24747fcc2" data-rendition-name="original" width="748" height="1142" loading="lazy" alt="Jajarkot earthquake NT"> </figure>  Read also: <a href="https://nepalitimes.com/opinion/comment/learning-from-jajarkot-what-we-didnt-after-2015-695vpzle">Learning from Jajarkot what we didn't after 2015</a>, Sushil Gyewali Relief must be survivor-centred and not be sensationalised or politicised with fake news. A centralised database that can foster collaboration is being put up with accurate and up to date information on the <a href="https://jajarkot.himalayandisaster.org/">Jajarkot Earthquake Response website</a>. Partners on the ground can also fact-check and debunk false reports, and we urge reporters to seek out these primary sources instead of relying on sensationalised clickbait. Rubble and destruction&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2023120112124_66e5ce77ae433644dabf10e3391e39021e92857248896af39bf19ad128e05e8b.jpg" data-media-id="editor_4" data-image-id="2023120112124_66e5ce77ae433644dabf10e3391e39021e92857248896af39bf19ad128e05e8b" data-rendition-name="original" width="1333" height="1000" loading="lazy" alt="2023 Jajarkot after earthquake NT"> </figure>  As we approached the epicentre with three vehicles filled with jackets, sanitation kits, blankets, the destruction was shocking. Even in the relatively accessible areas like the district headquarter of Khalanga the houses are still in ruins. A month after the earthquake the rubble still has not been cleared. Things get worse the deeper we go into the mountains. On the way to Nalgad, there are rows upon rows of destroyed houses. Most people are living under tarp and bamboo tents, in one of them there were seven members of a family huddled inside. One man in Kalanga had broken his arm, and was sifting through the rubble of his home with his other hand. He was sheltering in a nearby school with many other neighbours.&nbsp; A school in Nalgad was still functioning, and students were attending classes in tents. Their school was damaged and there was fear of aftershocks.&nbsp; Multiple political groups and nonprofits are helping clear the rubble in places, but no active rebuilding has started yet.&nbsp; Read also: <a href="https://nepalitimes.com/here-now/grief-stricken-survivors-are-cold-and-hungry">Grief-stricken survivors are cold and hungry</a>, Sagar Budathoki CGI-based temporary homes might be better than tents for this winter. But rapid, affordable, earthquake resistant and sustainable rebuilding must start as soon as possible using the experience and plans developed after the 2015 earthquake. Rural municipalities must be key partners in all rebuilding efforts. Relief organisations can divide up their efforts to avoid duplication. There are prototypes for <a href="https://www.dezeen.com/2015/07/11/prototype-bamboo-shelter-nepal-earthquake-victims-built-by-unskilledworkers-three-days/amp/">winterised temporary shelters</a> and <a href="https://habitatnepal.org/wp-content/uploads/2019/10/Bamboo-Temp-Shelter-Nepali-web.pdf">long term solutions</a> for reconstruction: Immediate Relief and Humanitarian Aid&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2023120112124_fa55e5f5c7e0c08e34679ea94f7eee9d393899fe41c45d32ca0d8b3b52d00ee6.jpg" data-media-id="editor_8" data-image-id="2023120112124_fa55e5f5c7e0c08e34679ea94f7eee9d393899fe41c45d32ca0d8b3b52d00ee6" data-rendition-name="original" width="1333" height="1000" loading="lazy" alt="2023 Jajarkot after earthquake NT"> </figure>  Nepal has a one-door policy currently to manage aid coming into disaster zones. Each district’s disaster relief committee is led by the Chief District Officer (CDO), who is in charge of relief items coming to the region. Jajarkot district has received tons of relief material, and local distribution was initially the bottleneck. There are still reports of items not getting to those that live in remote and roadless areas.&nbsp; We saw this week that the distribution management appeared to have improved. Items lying in municipality offices and district offices were in the process of being delivered. The municipal system makes it easy to coordinate with local ward chairs to find the areas of acute need.&nbsp; Our trucks had to be registered with the CDO with an itemised list and approved for further transport deeper into the district. The process seemed seamless. In Nalgad municipality, where few relief organisations are present, the mayor’s office and the Nepal Army have coordinated with NGOs to distribute blankets, clothes to more remote regions.&nbsp; Read also:<a href="https://nepalitimes.com/news/earthquake-vacates-villages-in-nepal"> Earthquake vacates villages in Nepal</a>, Anita Bhetwal The municipalities are coordinating better, and working closely with relief aid partners. But there is still a need for logistics management and strategic distribution of relief material to difficult to reach villages. Special care must be given to villages at higher altitudes where it will soon start snowing. Relief organisations must respect the one-door policy, and not bypass this effort to coordinate relief and avoid waste and overlap. The Ward chairs have their feet on the ground and are the best source for exact need. They should be made partners in all aid distribution locally.&nbsp; Healthcare&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2023120112124_b094ac6d0dfcdc924f571e1308307ebaa4b6b1d2b7d5c0ebcfe290466cd3abf0.jpg" data-media-id="editor_10" data-image-id="2023120112124_b094ac6d0dfcdc924f571e1308307ebaa4b6b1d2b7d5c0ebcfe290466cd3abf0" data-rendition-name="original" width="1333" height="1000" loading="lazy" alt="2023 Jajarkot after earthquake NT"> </figure>  Jajarkot has a well-equipped district hospital, and each municipality has a &nbsp;health centre. There are smaller health posts in wards within the municipality. The nearest high level facility with ICU capacity is in Surkhet.&nbsp; Jajarkot district hospital had a large number of traumas during the first weeks after the earthquake. The hospital has five medical officers, and one MDGP (consultant) physician, and can provide basic emergency care, maternal and child care including caesarean section and vaginal delivery, and has a robust pharmacy. The hospital’s patient census was not impressive during our visit.&nbsp; The Nalgad municipality health centre was busy with only one medical officer available. Large tents from UNICEF had been erected outside for additional inpatient ward and emergency space. There seems to be a gap from the district to support the local municipality's needs.&nbsp; We came across many groups coming to Jajarkot to conduct health camps. Though increased engagement has benefits, it is not so useful to have camps near the health centres or the district hospital as there are already facilities there. &nbsp;Doctors told us that they had extreme excess of certain supplies and not enough of others.&nbsp; Read also: <a href="https://nepalitimes.com/banner/in-a-disastrous-state">In a disastrous state</a>, Sonia Awale Groups organising health camps should focus on two areas: 1) bring specialist care that otherwise does not exist in this region, 2) reaching areas away from local health infrastructure. They must also coordinate with the district hospital and municipality health centre to assess their utility. Funds used for health camps could instead help strengthen local health facilities. The districts should divert some of their resources (doctors, nurses, etc) to some of these busy health centres in local municipalities like Nalgad. It does not make sense for one doctor to see a large number of patients in Nalgad, while the district hospital is not busy.&nbsp; Safeguarding Women and Children  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2023120112124_2e48aaab35412bd26e577239a96e036781290ce1391da4a9b5d90d44410d9a63.jpg" data-media-id="editor_12" data-image-id="2023120112124_2e48aaab35412bd26e577239a96e036781290ce1391da4a9b5d90d44410d9a63" data-rendition-name="original" width="1800" height="1000" loading="lazy" alt="2023 Jajarkot after earthquake NT"> <figcaption>Ramu Kharel (left) and Maggie Doyne with locals in Jajarkot. The infant whose mother died was brought down and is recovering in ICU in Surkhet.</figcaption> </figure>  There are a large number of pregnant and postpartum women in the most affected areas in Nalgad, Rukum and Kuse. Recent news items have used false narratives to gain viewership, but there is a real need for access to appropriate ante-natal and postnatal care, which was an issue that existed before the earthquake in underserved areas of western Nepal. Jajarkot hospital, the municipal health centres are both equipped to care for most of these women. Various groups are providing warm clothes for the most vulnerable and prioritising these women for safe winterised shelters is a must.&nbsp; There are child protection units and National Child Rights Council (NCRC) offices at each municipal office. When a child, adolescent, pregnant or postpartum woman is in potential or imminent danger, it is critically important that officers be notified immediately.&nbsp; The NCRC works directly with government bodies, police, licensed shelters, and relief agencies to ensure that the woman or child is taken out of danger. NCRC and Kopila Valley are able to work together directly to safeguard the children in distress. The involvement of NCRC also prevents child smuggling and safeguards against family separation, exploitation, and human trafficking. The use of trained trauma informed social workers and child protection officers is critically important when discerning information and keeps the child’s rights and protection at the centre.&nbsp; Available health centres must be equipped with in-facility and outreach programs to identify and care for the most vulnerable in the region. This disaster could be used as an opportunity to equip and build a system around the municipal health centre and district hospitals to create innovative models like <a href="https://www.nyayahealthnepal.org/">Nyaya Health Nepal’s</a> community health care model in Achham, where community health workers are trained and equipped to provide care at home. Read also: <a href="https://nepalitimes.com/opinion/rebuilding-resilience-7-years-later">Rebuilding resilience 7 years later</a>, Anil Pokharel When someone is really ill, taking the patient to Surkhet might be the only way but the road is long and hard. A streamlined approach to access government services like helicopter rescue must be available in this post-disaster setting.&nbsp; A robust ambulance and EMS service from either the municipal health centre and/or Jajarkot district hospital must be made.&nbsp; Water and Sanitation&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2023120112124_186d4e99aa2c91f173de7e0e430b03a24c1099075fdbfeae8ead9b770cee9ca6.jpg" data-media-id="editor_15" data-image-id="2023120112124_186d4e99aa2c91f173de7e0e430b03a24c1099075fdbfeae8ead9b770cee9ca6" data-rendition-name="original" width="1333" height="1000" loading="lazy" alt="2023 Jajarkot after earthquake NT"> </figure>  Even before the earthquake, Jajarkot and surrounding districts were hit by a cholera epidemic in 2009 that killed over 300 people, many of them children. Running water and sanitation has always been a major concern and this danger has been exacerbated with the earthquake aftermath in the dry season.&nbsp; None of the temporary tents and shelters we saw had appropriate water access and hand washing stations. Donor agency temporary toilets were dirty with no hand washing. Water and hygiene must be a priority for development groups going forward. Relief groups must put WASH in their priority.&nbsp; After meeting survivors, relief workers and local elected officials we saw a resilience and a determination to bounce back. The items we took to Nalgad are being strategically distributed in coordination with municipality offices to reach those in most need.&nbsp; We were able to locate the one-month-old infant in Nalgad municipality’s Ward 8. The infant is now getting safe ICU level care now in Surkhet, and is doing better.&nbsp; Read also: <a href="https://nepalitimes.com/editorial/shaking-things-up">Shaking things up</a>, Editorial Resources for aid information and reporting can be found <a href="https://aidpulse.org/aidboard">here</a>. Important phone numbers:&nbsp; National Child Rights Council: 01-5550121&nbsp; Chief Minister Karnali: 985804444&nbsp; Chief District Officer Jajarkot: 9858047777&nbsp; Mayor Nalgad: 9842236335&nbsp; Mayor Kuse: 9858937755&nbsp; District Hospital Khalanga: 089-430188&nbsp; Ambulance: 102&nbsp; AIN (Federation for NGOs): 01-4468128&nbsp; Poison information center: 01-450-2011&nbsp; Suicide Hotline: 1166&nbsp; Police: 100 Ramu Kharel (ramu_kharel@brown.edu) is an emergency medicine physician with global health and public health expertise, and decade long experience in disaster response within Nepal. He is an assistant professor at Brown University, and is founder of <a href="http://www.hapsaglobe.org/">HAPSA Nepal</a>. Maggie Doyne is the co-founder of the <a href="https://blinknow.org/">BlinkNow Foundation</a> and, and has worked for 18 years in the Karnali region caring for at-risk children through community development efforts. She is a CNN Hero and author based in Surkhet.

Jajarkot: One month after the earthquake

As a nurse, Anju Chaudhary has to often test the limits of her skills when dealing with <a href="https://www.nepalitimes.com/here-now/another-babys-life-is-saved-in-rural-nepal">complicated pregnancies</a> that arrive at the government hospital here in Katari.&nbsp; She is also the leader of a team of nurses who are on duty for 24 hours a day, seven days a week, caring for patients. Chaudhary has helped deliver over 1,000 babies and <a href="https://www.nepalitimes.com/banner/saving-nepali-mothers-and-babies-district-by-district">prevented the deaths of many mothers and newborns</a>. But no case was as challenging as that of Sharmila Surkheti. One morning in March, the 30-year-old Dalit woman arrived at the hospital, weak and bleeding profusely.&nbsp; “We had never seen a mother in such a near-death situation, but we were prepared, and we got into action immediately to save her life,” recalls Chaudhary. Surkheti had already been pregnant 13 times in her young life. All six of her newborns were delivered at home, and she had undergone seven abortions. Barely a year ago, she had another baby who died at childbirth. Read also: <a href="https://www.nepalitimes.com/here-now/who-will-save-nepal-s-poor-new-mothers">Who will save Nepal's poor new mothers?</a>, Rojita Adhikari This year, she decided to try to risk her own life to try for another son but there was post partum haemorrhage after the baby was born. Her husband helped get her to Katari Hospital while leaving behind the newborn. It was a two hour walk from home. There was no General Physician at the hospital that day so it was up to Chaudhary and her nurse team to save her life. A quick decision had to be made. They used the bundle approach in postpartum haemorrhage (PPH) management to control the bleeding. As a chronic anaemic patient, the mother had a low haemoglobin of only 6.1, which was alarming. To save her life, the nurses planned to take Surkheti to a better-equipped hospital in Gaighat but the family could not even afford transportation. Read also: <a href="https://www.nepalitimes.com/here-now/nepal-s-rural-lifeline">Nepal's rural lifeline</a>, Sonia Awale Her blood pressure dropped alarmingly low, and the nurses immediately created an emergency fund to pay for the private ambulance to reach Gaighat. She also needed blood transfusion, but Surkheti’s husband was malnourished and there were concerns about his health. The nurses then found a male colleague at the hospital who agreed to donate his blood. They closely monitored the mother, and her haemoglobin improved to 8.8. The hospital’s Acting Medical Superintendent, Dr. Gaurab Shah, an MD Pathologist, also put a lot of effort into managing a blood donor.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230902040916_6d4eb5e618d116e1cbcc72776152080ad55f53e026f67be55044f350d2849c2e.png" data-media-id="editor_4" data-image-id="20230902040916_6d4eb5e618d116e1cbcc72776152080ad55f53e026f67be55044f350d2849c2e" data-rendition-name="original" width="2100" height="1500" loading="lazy" alt="Nurses in rural Nepal"> </figure>  The next day, the nurses gave her iron tablets, B complex, and vitamins and she was sent home. But during a post-natal home visit, the nurses were dismayed to see the utter poverty of the Surkheti’s family, including her husband and six children. Read also: <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health">This is how to upgrade Nepal's rural health</a>, Sewa Bhattarai Given her anaemic state and being very weak, Surkheti was unable to produce milk and had been feeding biscuits to her baby which worried the nurses. The family had no money to buy formula milk.&nbsp; So the nurses started collecting cash from their own pockets and started a fundraiser through online requests and on the phone. But there was very little response, and the six nurses put in their own money to save the mother and baby.&nbsp; “The greatest gift for me was to hear the words of gratitude from the mother who survived the ordeal,” says Chaudhary modestly. Despite her training as a <a href="https://www.nepalitimes.com/multimedia/saving-nepali-mothers-on-mother-s-day">Skilled Birth Attendant</a> that she had done many years ago, Chaudhary had no knowledge of uterine balloon tamponade, which can help in the treatment of PPH.&nbsp; After graduating from her nursing education, she was transferred to Bir Hospital where she never got the chance to work with mothers and babies, as she was too busy handling injuries and accidents in the emergency department. It was only after she moved back to Katari Hospital in Udaypur that her career path changed with the help of the non-profit <a href="https://www.nepalitimes.com/banner/what-can-be-more-fulfilling-than-saving-lives">One Heart Worldwide</a> (OHW). She received an invitation from OHW to attend its Simulation-based Mentorship Program in 2017 which allowed her to learn new skills. “I feel fortunate that my team was there to help Surkheti, and today, both she and her baby are healthy,” she says.&nbsp; Indeed, at a time when many Nepali nurses aim to migrate abroad the nation should be thankful for the dedication and passion of nurses like Anju Chaudhary.&nbsp;

Saving one Nepali mother at a time

<div class="embed-block"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20230228150236/63fe12359c7e80680e0da510jpeg.jpg" alt="" width="1400" height="933">Anandaban Hospital in Lalitpur that treats mainly leprosy patients. Photo: KUNDA DIXIT</div> No one would argue against Nepal needing to boost its budget for public health, but given the low allocation and poor management of government hospitals, the question arises: what do we do until politicians get their priorities right? Over the past few decades, health expenditure in Nepal has been consistently less than <a href="https://www.jointlearningnetwork.org/wp-content/uploads/2021/12/Nepal-JLN-General-Gov-Expenditures-23092021.pdf">one-tenth of the nation’s GDP</a>. If it was not for community level work by Female Community Health Volunteers and the effort of dozens of nonprofits medical care would be beyond the reach of most Nepalis. At present, <a href="https://www.jhas.org.np/jhas/index.php/jhas/article/view/267">70% of the medical expenditure</a> for people is met out-of-pocket. There are many instances where even middle-class households are pushed below the poverty line because they have to use all their savings, sell property or borrow money to meet hospital expenses of family members. When health financing relies heavily on such payments, people fall into the ‘medical poverty trap’, as their treatment costs are uninsured and expenses not reimbursed. In remoter parts of Nepal, families have had to sell property even to pay for fractures or simple operations for relatives who have to be taken to private city hospitals. Non-profits and international charities have stepped in to fill the gap left by the government’s incapacity to make quality healthcare more affordable and accessible. Stable healthcare infrastructure therefore relies on non-government funding and altruistic intervention. Subsidies by not-profits can be seen in virtually every sphere of healthcare in the country. From primary healthcare centres in the countryside to high-end hospitals in the cities, many would not be able to function without support from charitable organisations. The partnership is largely financial, and usually pay for services in underserved areas of the country for excluded communities. <div class="embed-block"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20230228150236/63fe12399c7e80680e0da511jpeg.jpg" alt="" width="1500" height="1000"> </div> <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/">Bayalpata Hospital</a>, in Accham district, for instance, is a model public-private partnership that can thrive when state-of-the-art medical interventions are melded with philanthropy. This government-owned hospital is managed by Nyaya Health Nepal (NHN) and provides absolutely free healthcare for 100,000 patients annually. In Kathmandu valley itself, the <a href="https://nepalcleftandburncenter.org/">Nepal Cleft and Burn Center</a> at Kirtipur Hospital is providing valuable service for cleft palate surgery and treatment of burns patients, and is run by a non-profit. It is Nepal's first teaching hospital specialising in deformity-correction reconstructive surgery. <a href="https://www.nepalitimes.com/banner/new-treatment-offers-hope-for-nepals-leprosy-patients/">Anandaban Hospital in Lalitpur </a>run by The Leprosy Mission, is one of South Asia’s finest facilities for leprosy treatment, and receives many referrals from in and out of Nepal every year. It uses a new technique called Leukocyte Platelet Rich Fibrin (LPRF) that helps cure lesions of leprosy patients much faster. United Mission to Nepal has been managing several hospitals across rural Nepal for the past 60 years, most notable being in Tansen and Okhaldhunga. These hospitals are testament to how healthcare facilities that place philanthropy front and centre in their operational modality can deliver quality treatment better than public hospitals across Nepal. While support from foreign non-profits has become part and parcel of a well-managed hospital in Nepal, foreign grants alone cannot transform healthcare in every corner of the country. After all, they are just temporarily doing the government’s job. Nepal’s Constitution guarantees free basic health care for every citizen, but that has only remained a lofty unfilled goal in many parts of Nepal. The only alternative is to build a self-sustained funding system to run medical facilities, and the easiest way to achieve this while a universal national insurance scheme comes to fruition, is to rely on domestic and international volunteerism and philanthropy. Philanthropy is in fact deep-rooted in Nepal’s sociocultural structure and the country in fact stood <a href="https://www.cafonline.org/docs/default-source/about-us-research/caf_world_giving_index_2022_210922-final.pdf">56th in the World Giving Index, 2022.</a> This means that Nepalis are, on average, more likely to donate to charity than people in more than half of the world’s countries. The only problem is that they do not have much money to spare, and whatever they give is not enough to take care of the enormous burden of need. <div class="embed-block"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20230228150236/63fe123d9c7e80680e0da512jpeg.jpg" alt="" width="1400" height="1050"> </div> Channeling locally raised funds into innovative healthcare projects through philanthropic organisations is one way to go about encouraging local giving. The problem lies in that local donors, because they do not trust Nepali &nbsp;charities resist donating institutionally. Corporates that would like to donate are also held back because there is no provision for tax deductible donations to charity – possibly because the government does not have a transparent way to ensure that it will not be misused. This has propelled hospitals and health projects in Nepal to turn to external, international sources of funding. One example is the <a href="http://archive.nepalitimes.com/news.php?id=11436">Nick Simons Institute</a> (NSI) that backstops 44 hospitals and health care centres across Nepal because its founder had a special personal attachment to Nepal. Outside funding also inhibits Nepali donors who think there is plentiful foreign funds. To change this dynamic, Nepal needs to alter the culture of giving. This change starts by building local trust. If local donations are to be pooled effectively, their givers need to trust healthcare projects and believe in the value they will create. This comes along with the need for the state to strengthen tax incentives to encourage philanthropic giving. But aside from local individuals and communities, for-profit companies also have a major role to play. In 2017, when <a href="https://kathmandupost.com/money/2017/01/28/bfis-told-to-spend-1-percent-of-profit-on-csr-activities">Nepal Rastra Bank mandated banks and financial institutions </a>to use at least 1% of their net profits for philanthropic activities, it was a major step to encourage corporate altruism. A 2021 <a href="https://www.nrb.org.np/contents/uploads/2021/08/CORPORATE-SOCIAL-RESPONSIBILITY-IN-NEPALESE-BANKING-INDUSTRY.pdf">survey</a> conducted by the Nepal Rastra Bank found that 41% of banks and financial institutions in a sample expressed commitment to support various deprived sectors, with health being the second most popular choice after education. However, these companies need to find more ways to engage in Corporate Social Responsibility activities focussed on healthcare. This may include incentivising doctors to serve in remote locations where urgent medical attention is most needed, investing to upgrade teaching methodologies and improve access to medical literature, supporting non-mainstream illnesses such as autism and dementia, and subsidising follow-up health checks instead of one-time health camps aimed purely for image building. <div class="embed-block"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20230228150240/63fe12419c7e80680e0da513jpeg.jpg" alt="" width="1400" height="650"> </div> Healthcare innovation is another area where funds are needed since the government is not fulfilling its mandate. As digitisation dominates healthcare, there is a need for modern healthcare infrastructure, including research and innovation centers to innovate. But more pressing is that access to even basic health facilities remains a formidable challenge in rural Nepal. Local philanthropy, from individuals, communities, and companies allows local context and culture to shape health projects, increasing community ownership. It leverages the collective interests of local donors, making them feel directly involved in development. Local funding has the added benefit of kindling trust among rural people in the healthcare infrastructure they invest in. Transparent philanthropy can encourage rural communities to seek services from these establishments. This may further discourage informal at-home diagnosis and witch-doctor consultations, which a recent study in Humla found <a href="http://www.journaldmims.com/temp/JDattaMegheInstMedSciUniv173616-3680661_101326.pdf">was the case for 50% of patients</a> in the district. To be sure, it is not that the government has not made efforts. In public hospitals, primary healthcare is free of cost. But it only covers very basic services. Most hospitals are overcrowded, and lack minimum service standards. Private hospitals are state-of-the-art and provide international standard medical care, but are so expensive that they are out of reach of most Nepalis. Local altruism, could bridge the gap between these two extremes. It can fill the healthcare need, but also nudge the government and private sector to prioritise quality care over all else. Yugottam Koirala and Yugeshwor Koirala are twins, and are from the Punyaarjan Foundation. <a href="https://www.punyaarjanfoundation.org.np/">punyaarjanfoundation.org.np</a>

Altruistic healthcare models in Nepal

<img width="800" height="438" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20230228150236/63fe119b9c7e80680e0da4eajpeg.jpg" alt=""/>Nurse Sabita Gyawali goes to school bright and early as the first rays of the sun hit Mt Dhaulagiri to the north, and she gets to work right away. Shen the students start arriving, she checks that they follow cleanliness routines, and teaches them how to wash hands properly. She provides first-aid to those who need it, and is responsible for the students’ physical and mental health. But her main priority is to make sure that no student has brought junk food for lunch. In fact, she has prohibited packaged chips and noodles from the school grounds.   Gyawali has been a nurse for nine years, much of it at Kathmandu’s Sahid Gangalal National Heart Center. In 2019, she came to Baglung to work at Bidya Mandir Secondary school under the Health Ministry’s new 'One School, One Nurse' program.  Once there, Gywali designed the school’s lunch menu and already there has been a positive change in the eating habits of students – even teachers.  “Initially, students from elementary to high school would eat packaged store-bought lunch, she explains. “It was very difficult to wean the children off their junk food habit, but it is now under control.”The World Food Programme (WFP) has been managing school meals across Nepal for 45 years, and the government has been gradually assuming responsibility and expanding the project. Now, thanks to the initiative, students don’t go home for lunch anymore and attendance rates have increased, resulting in fewer dropouts.However, there are challenges. The Rs15 per student charge for lunch is beyond the means of some students who have working parents, or are in single parent households, and there is not enough time to bring a tiffin box.  For some students, this means coming to school on empty stomachs. For others, it was cheaper and more convenient to buy quick-and-easy junk food.  <img width="1350" height="2400" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20230228150236/63fe119e9c7e80680e0da4ebjpeg.jpg" alt="">“The budget provided by the government was low enough that only little snacks or small meals used to be served," notes Gyawali, who then came up with a lunch menu that would fit the budget.And while the school lunch menus made by the government might be applicable to rural schools, they do not work for public schools in urban areas with the same budget.The other problem is not having enough nurses. There are 82 public schools within Baglung Municipality, out of which only five secondary schools have nurses. <img width="1232" height="693" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20230228150236/63fe11a19c7e80680e0da4ecjpeg.jpg" alt="">Ram Prasad Khanal, the head of the municipality's health department, says that the municipality has asked the state government to appoint nurses to all the schools. “Every school that has a nurse has shown positive growth,” notes Khanal.At Bageshwari Secondary School in Bhaktapur’s Chyamasing, students have stopped consuming junk food for lunch due to the efforts of nurse Sajina Manandhar. “It is very difficult to take students off instant noodles, but we have managed to do it.”The ‘One School, One Nurse’ program is run by the Nursing and Social Security Division under Nepal’s Department of Health Services (DoHS) and aims to  encourage children to have a balanced diet and improved hygiene. The program also supports adolescent sexual and reproductive health, as well as mental health.“The school nurse program has brought about a noticeable improvement in nutrition-related problems, mental health, menstrual health, and even school dropout issues,” says Bala Rai, a senior hospital nursing administrator at the Nursing and Social Security Division.But there is a long way to go. So far, only about 1,000 schools out of 10,644 public secondary schools nationwide have appointed school nurses.The DoHS measures nutrition impact through 'anthropometry' — measuring the heights and weights of children to determine whether or not they are malnourished. A recent Demographic Health Survey (DHS) revealed that 25% of children under five have stunted growth while 8% are underweight as compared to 36% and 10% respectively in 2016.There is improvement, but more can be done, and the government has set a target to reduce the growth stunt down to 15% by 2030.   <img width="800" height="450" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20230228150236/63fe11a59c7e80680e0da4edjpeg.jpg" alt="">The survey also revealed the program, which involves nurses also making home visits, has been instrumental in identifying children who have learning disorders, mental health issues, or those who have been victims of domestic violence. Illnesses have been identified and reported to hospitals, and it has also become easier to educate adolescents about sexual and reproductive health."We have appointed health-in-charges to each class so that students feel comfortable speaking to and about themselves,” explains Sajina Manandhar. “We continuously meet with those in charge, and provide them information related to reproductive health and family planning.”Nurse Anamika Sharma says that the number of girls who miss school while having their period has gone down by 90% since she began working as a school nurse, largely because it is easier for female students to ask for pads at school. Menstrual health counseling is also more readily available.Binu Kakshapati is the School Nurse Focal Person of Bagmati Province, and says the attendance of female students has gone up since the province began distributing pads in public schools. “Students have started to become more open to using pads since the government started distributing them in Bagmati,” she adds.In some schools, nurses even fill in when a math or science teacher is absent. Bala Rai says she had to send a circular to the local units to ask them to stop forcing nurses to do jobs that they are not there to do.Translated from the Himal Khabar <a href="https://www.himalkhabar.com/news/133436" data-saferedirecturl="https://www.google.com/url?q=https://www.himalkhabar.com/news/133436&amp;source=gmail&amp;ust=1676366852671000&amp;usg=AOvVaw2z3rWSO2Xmif-YMO_MB9wL">original</a> by Shristi Karki.

Nurses ensure nutrition for Nepal’s children

Just few days into office, President Donald Trump has brought about a work-stop to ongoing USAID supported projects and complete stop to new grants or aids. The executive order was justified under Trump’s ‘America First’ promise, and it has shaken up recipient countries, including Nepal. Since 1951, USAID has provided $1.5 billion in aid to Nepal. The breakdown for recent years is $105.94 million for 2020-21 and US$ 125 million in 2018-19. In 2022, USAID and Nepal signed a five-year Development Objective Agreement worth $659 million (pictured, above).&nbsp; Some of the key sectors where USAID has supported and supports Nepal with aid include health, education, agriculture, infrastructure; economic growth, humanitarian aid and women and children empowerment. All of these projects will be affected, and grants disbursement suspended. According to USAID’s Country Development Cooperation Strategy (December 2020-December 2025), the overall goal of the USAID’s development cooperation in Nepal is to realise ‘A more self-reliant, prosperous, and inclusive Nepal that delivers improved democratic governance and health and education outcomes.’ Four identified development objectives are:&nbsp; i) More Effective, Participatory, and Equitable Democratic Ecosystem ii) Broad-Based and Inclusive Economic Growth Fostered iii) Inclusive Health and Education Systems Strengthened iv) More Equitable and Improved Natural Resources and Disaster Risk. Under these development goal and objectives as per the data available under Government of Nepal’s Aid Management Platform (AMP) there are currently USAID supported 21 key projects ongoing in Nepal.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250126090140_0bd9163cb9826464409887995eb8f2eff42c7cf1269610c3761773cde59ff52c.jpg" data-media-id="editor_0" data-image-id="20250126090140_0bd9163cb9826464409887995eb8f2eff42c7cf1269610c3761773cde59ff52c" data-rendition-name="original" width="1005" height="825" loading="lazy" alt="USAID fund in nepal after Trump"> </figure>  These 21 projects with some data missing totals a commitment of $178,140,467 from 2021-2029 in Nepal. Of these commitments $89,115,031 (about half) have already been disbursed. With Trump’s executive order the rest of the 50% is now going to be on hold until the review is completed and further decisions are made by the new US administration.&nbsp; Most development goals of USAID in Nepal are embedded with key principles like ‘equity’ and ‘inclusive’. With the Trump government’s aversion to the previous emphasis on Gender, Equity, Inclusion and Accessibility (GEIA) principles, projects focusing on those issues will be hit hardest. USAID upheld policies and actions that promoted equal access and opportunities for all people, with an emphasis on the Tarai, gender issues, family health and through contractors on human rights and democracy. The impact on Nepal’s development aid will be substantial, affecting livelihoods in incomes generated by USAID supported projects. Individual independent consulants already received notices over the weekend that the work they were &nbsp;doing under a USAID contract is subject to work-stop now.&nbsp; The question is whether the 5-year Country Development Cooperation Strategy for Nepal that finishes by end-2025 will go ahead. And when the new post-2025 Strategy is formulated, it is certain that the Trump’s administration will not entertain GDEI, which so far has been people-centered and not political.&nbsp; Kishor Pradhan is an independent development consultant concentrating on development information and knowledge management issues. <a href="mailto:kishorpradhanktm@gmail.com" target="_blank">kishorpradhanktm@gmail.com</a>

How USAID cut affects Nepal

They are rare, they are elusive and they are so well camouflaged, they are difficult to see, even when they are right there. That is why <a href="https://nepalitimes.com/opinion/comment/nepal-brings-back-the-snow-leopard">snow leopards</a> are called the ‘Ghosts of the Himalaya’. And because they are also regarded as being sacred, they are called ‘God’s Pets’.&nbsp; Nepal has <a href="https://nepalitimes.com/news/does-nepal-really-have-too-many-tigers">tripled its tiger population</a> in 12 years since 2010. There have been successive years with zero rhino poaching and the numbers have bounded back. But few know about the country’s success story with snow leopard conservation. Preliminary data from an on-going census shows that Nepal ranks fourth among the 12 snow leopard range countries in central and South Asia. This is despite the country having just 2% of the total area where snow leopards can be found.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250127070148_0f22a5439d56e5db58d8f65789ee4ff5e87a29c898d5e8cbff60bf8f1814af4b.jpg" data-media-id="editor_2" data-image-id="20250127070148_0f22a5439d56e5db58d8f65789ee4ff5e87a29c898d5e8cbff60bf8f1814af4b" data-rendition-name="original" width="1311" height="724" loading="lazy" alt="snow leopards in Nepal NT 1"> <figcaption>Despite possessing just 2% of the snow leopard range across Central and South Asia, Nepal has the fourth highest number of elusive mammals in the world. Photo: TASHI R GHALE </figcaption> </figure>  Nepal also leads in <a href="https://nepalitimes.com/news/satellite-tracking-snow-leopards-in-nepal-to-study-climate-impact">snow leopard research</a>. Less than 3% of the snow leopard range has been studied through camera traps and genetic studies, but it is Nepal that has done the most. <a href="https://nepalitimes.com/here-now/nepal-leads-in-snow-leopard-study">Over 100 Years of Snow Leopard Research</a> by the World Wildlife Fund (WWF) in 2021 showed that 74% of the snow leopard habitat in northern Nepal has been the subject of research into the species. “We are leading globally when it comes to snow leopard conservation and study, starting from 2013 in Kanchenjunga using GPS to study their habitat,” says <a href="https://nepalitimes.com/here-now/conversation-with-mr-conservation">Ghana S Gurung of WWF Nepal</a>. “We also found via camera traps they went as high as 5,800m and as low as 2,600m.” There are an estimated 300-500 snow leopards across high mountain Nepal with Dolpo, Manang and <a href="https://nepalitimes.com/banner/participating-to-save-kangchenjunga">Kangchenjunga</a> the main hotpots for the endangered species. Unlike with tigers and rhinos which are poached by wildlife traffickers, snow leopard killings are mostly retaliatory for killing livestock. Snow leopards attack yaks, sheep and goats of herding communities in the mountains. One of the most effective methods to protect the species from traps and poisoning is to help local communities build mesh wire corrals. The San Francisco-based <a href="https://snowleopardconservancy.org/">Snow Leopard Conservancy</a> through the Nepal group <a href="https://www.mountainspirit.org.np/">Mountain Spirit</a> has designed and tested portable corrals that can move with herders.&nbsp; “They move all year around so that the livestock have enough pasture to graze on, which is why it was important that our improved corrals could be dismantled and moved around,” explains Shailendra Thakali of the Snow Leopard Conservancy. The team consulted herders in Manang and Mustang while developing the corrals based on traditional design, with a stone base but wire mesh on the sides and the roof as well as strong wire gates for secure closure. They are also using fox lights to deter activities at night.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025012803018_4a166ea1124008cfcf551ffd59c5841acb2bc9c443d9fbe56490b280492eb441.png" data-media-id="editor_9" data-image-id="2025012803018_4a166ea1124008cfcf551ffd59c5841acb2bc9c443d9fbe56490b280492eb441" data-rendition-name="original" width="2244" height="1246" loading="lazy" alt="corraling"> <figcaption>Improved corrals in Manang and Mustang made up fo mesh wires to protect livestock from snow leopard attacks. Photo: PURNA MAN SHRESTHA</figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250127070152_009bc57c5d2244a393a8423d56098f921ed29b8d0a60a9c15422dd58615b5e5b.jpg" data-media-id="editor_10" data-image-id="20250127070152_009bc57c5d2244a393a8423d56098f921ed29b8d0a60a9c15422dd58615b5e5b" data-rendition-name="original" width="4032" height="3024" loading="lazy" alt="snow leopards in Nepal NT 1"> <figcaption>The corrals are portable allowing herders to move them as they take livestock for grazing in high Himalayan pastures. Photo: PURNA MAN SHRESTHA</figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250127070152_3b84ce156de1ed1deea79d23a15c1a3dfa5a412dca3644deec1333bda7f91cd0.jpg" data-media-id="editor_11" data-image-id="20250127070152_3b84ce156de1ed1deea79d23a15c1a3dfa5a412dca3644deec1333bda7f91cd0" data-rendition-name="original" width="1500" height="1125" loading="lazy" alt="snow leopards in Nepal NT 1"> <figcaption>Local herders in Manang and Mustang were consulted while developing improved corrals. Photo: BRIAN PENISTON</figcaption> </figure>  Tourism and agriculture in Manang and <a href="https://nepalitimes.com/here-now/comings-and-goings-in-mustang">Mustang</a> dropped during the pandemic, and the Conservancy also helped herder communities with alternative livelihoods.&nbsp; “We trained them in basic hotel business such as lodge management skills but more importantly to restore abandoned pastures by planting jimbu which is highly valued for cooking in Kathmandu and Pokhara,” says Brian Peniston, also with the Snow Leopard Conservancy. “The tourist figures have now increased considerably and this has directly benefited 1,000 households in three municipalities.” <a href="https://www.wwfnepal.org/">WWF Nepal</a> has also collaborated with the Department of National Parks and Wildlife Conservation (DPNWC) to train locals in Dolpo and Kangchenjunga to make their own mesh wire corrals with subsidies on raw materials.&nbsp; WWF has partnered with Amchi traditional medicine practitioners to promote conservation of snow leopard in mountain communities where people trust faith healers. School eco-clubs also involve youth in conservation.&nbsp; “We must trust communities and promote local ownership when it comes to wildlife conservation, and if it were not for the communities there, snow leopards would be long gone,” says Gurung of WWF Nepal. “It is important to revive the belief that snow leopards are sacred because they are god’s pets, tie them up with the spiritual, cultural and traditional belief of the people.” Community-managed livestock insurance schemes have attained zero retaliatory killings in Kangchenjunga where WWF and the government has sent up an endowment worth Rs10 million to compensate herders for snow leopard kills. A similar scheme is being implemented in Dolpo which has double the density of snow leopards compared to Kanchenjunga.&nbsp; But the compensation mechanism is cumbersome and often inefficient. Claimants need to provide photographic evidence with tags of the livestock still attached but snow leopards often go for the head and tags are lost. The evidence has to be submitted promptly, and this is difficult for herders in isolated villages.&nbsp; Insurance agents are based in headquarters like Chame in Manang and are not willing to travel all the way up. Similarly, photographic evidence needs to be assessed by veterinarians who are also reluctant to go to remote areas that take up days. “The compensation policy hasn’t changed in the last 20 years,” says <a href="https://nepalitimes.com/review/snow-leopard-redux">Tashi R Ghale</a>, high-altitude wildlife photographer and conservationist. “Here in Manang, herders would get Rs6,000 in compensation for a yak when the market rate was Rs20,000. The market rate is now Rs150,000 but they still get only Rs6,000. Even then, they have to wait for months.” Brian Peniston feels improving and tailoring compensation suitable to the landscape is of utmost priority, and the schemes need to be more accessible and effective as well as herder friendly. He adds, “Local governments should be handed authority in these matters, and it should be equal parts trust and verify. It is over-verification at the moment.” Climate breakdown has added to the challenge of snow leopard conservation. Either blizzards or winter droughts mean fewer prey for the mountain cats, this in turn has also led to leopards preying on livestock. Usually, the wild prey to livestock ratio in a snow leopard diet is 70:30. Blue sheep (pictured below) are the main prey species for snow leopards, but there is now competition with lowland spotted leopards which have moved up the mountains, while the Himalayan wolf has descended. The prey density may not have decreased, but predator species have more than doubled.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250127070156_f23ed8414be46782c90df4198d46c30f423d63d59f97343f89760283011c7c0b.jpg" data-media-id="editor_15" data-image-id="20250127070156_f23ed8414be46782c90df4198d46c30f423d63d59f97343f89760283011c7c0b" data-rendition-name="original" width="1400" height="1050" loading="lazy" alt="snow leopard conservation in Nepal"> <figcaption>The climate crisis has meant that lowland spotted leopards which have moved up the mountains, while the Himalayan wolf has descended, leading to a reduced number of blue sleep which is one of the main prey species for snow leopards. Photo: SHAILENDRA THAKALI</figcaption> </figure>  Other disrupters include <a href="https://nepalitimes.com/multimedia/the-human-cost-of-nepal-s-yarsa-gold-rush">overharvesting of yarsagumba</a> and increased movement in this fragile landscape, with adverse impacts on all wildlife, not just snow leopards. Expansion of the road network to the remotest corners of the country is another concern, adding to the risk of human-wildlife conflict and poaching.&nbsp; “There has been much research on snow leopard behaviour in the last 30 years but what we haven’t done nearly enough is study human behaviour,” says Peniston. Despite the challenges, the rebound of snow leopard populations has increased the opportunity to <a href="https://nepalitimes.com/banner/trekking-to-save-nepals-snow-leopards">snow leopard viewing eco-tourism</a>, as is being practiced in Dolpo.&nbsp; Says <a href="https://nepalitimes.com/review/ice-to-water-alv4lorf">Tashi R Ghale</a>: “Local communities here in Manang and Dolpo are doing what they can, but the Nepal Tourism Board needs to step in to promote snow leopard trekking and tourism. The co-benefits would motivate communities to protect the big cats.” &nbsp;&nbsp;&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250127070156_698d64632273185cecbcaca626c7c49861ba54a0930119843792572f01114942.jpg" data-media-id="editor_19" data-image-id="20250127070156_698d64632273185cecbcaca626c7c49861ba54a0930119843792572f01114942" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="snow leopard conservation in Nepal"> <figcaption>FIND ME: Elusive in nature, snow leopard sightings are rare and often only detected on camera traps (below). Spot the snow leopard in this picture taken by conservationist Tshiring Lhamu Lama in Dolpo, a hotspot for big cats in Nepal. Photos: TSHIRING LHAMU LAMA</figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025012708018_42acdb2ba0c5941b1c3a89ede1bac048808d6424f4c70aadb68df6ab5176bbb6.jpg" data-media-id="editor_20" data-image-id="2025012708018_42acdb2ba0c5941b1c3a89ede1bac048808d6424f4c70aadb68df6ab5176bbb6" data-rendition-name="original" width="2041" height="1314" loading="lazy" alt="Snow leopard conservation in Nepal"> </figure>  &nbsp;

Ghosts of the Himalaya

In December, the Nepal government announced it would not allow a Beijing-appointed Tibetan spiritual leader, the Panchen Lama, to attend a Buddhist conference in Kathmandu. Immigration at the airport was put on high alert to ensure he did not try to sneak in.&nbsp; Coming soon after Prime Minister K P Oli’s visit to China, that decision underscored Nepal’s precarious tight-rope act in addressing religio-political sensitivities in its relations with China. The Panchen Lama episode can be seen as a test for Nepal’s handling of the succession of the Dalai Lama, who turns 90 in July. “When the time comes to find a successor to the Dalai Lama, Nepal will face a larger policy dilemma,” predicts Sudheer Sharma, author of two recent books on Nepal-China relations. “The government is still unclear what it will do if the successor is chosen from the Tibetan community in Nepal, or from China or India.” <a href="https://nepalitimes.com/news/dalai-lama-gets-block-of-glacial-ice">The Dalai Lama</a> is the spiritual leader of Tibetan Buddhism and a symbol of Tibetan identity; he is revered as the manifestation of Avalokitesvara, the Bodhisattva of Compassion. He was born in 1935 in northeastern Tibet and was formally recognised as the Dalai Lama in 1940.&nbsp; He has been living in exile in Dharamsala for the past 65 years after fleeing Lhasa following the Chinese takeover. He has been allowed to make a low-profile visit to Lumbini only once in 1987, and never after that due to objections from China.&nbsp; Nepal does not have a national strategy to handle the presence of <a href="https://nepalitimes.com/news/nepal-s-sherpas-mourn-tengboche-abbott">religious leaders</a>. If there are policies, they are ad-hoc or undeclared, depending on the government of the day in Kathmandu. The Nepal government, under Chinese pressure, even prevents public celebrations marking the Dalai Lama’s birthday on 6 July. “The Dalai Lama’s attempts to visit Nepal again have been stopped &nbsp;since Nepal thinks he is not only a religious leader, but a political figure as well,” says Sharma. “There is no discussion in Nepal’s political circles regarding the succession of the Dalai Lama. The topic is regarded as a non-issue.”&nbsp; Over the years, the Dalai Lama has made various statements regarding his succession. At times, he has suggested that he will write a will to select a successor from within the Tibetan community. On other occasions, he has hinted that the next Dalai Lama could be chosen from a “free country”, and could even be a woman.&nbsp; The Panchen Lama succession in 1995 could provide a hint about how the post-Dalai Lama era will play out. The Panchen Lama is the second most important spiritual leader in Tibetan Buddhism, and heads the <a href="https://archive.nepalitimes.com/news.php?id=18580">Tashilhunpo Monastery in Xigatse</a>, the epicentre of the 7 January earthquake, located 250km away from Lhasa.&nbsp; The Panchen Lama traditionally has the role of finding the next Dalai Lama, but the previous Panchen Lama (Lobsang Trinley Lhundrup Choekyi Gyaltsen) has been missing since 1995, after the Chinese installed their own candidate (Gyaltsen Norbu). The present Panchen Lama’s visits are carefully planned, and he has made only one foreign visit so far, to Thailand. “Nepal did not permit Panchen Lama’s visit as he is Chinese Communist Party-appointed, thus making him a political figure,” says Amish Mulmi, author of the book All Roads Lead North.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250124090148_3bb3d803c04c34657d0ac9759ca904073f75734a446506f8a57e50178b381c00.jpg" data-media-id="editor_3" data-image-id="20250124090148_3bb3d803c04c34657d0ac9759ca904073f75734a446506f8a57e50178b381c00" data-rendition-name="original" width="1087" height="697" loading="lazy" alt="Dalai Lama NT"> </figure>  What China was trying to do through the Panchen Lama’s visit for the Nanhai Conference in Kathmandu last month was to project its soft power, and perhaps prepare the ground for the Dalai Lama succession. But the ban raised the question of what Nepal will do if there is a visit by Hindutva figures from India at events in Nepal.&nbsp; Religious leaders and figures from various faiths regularly visit Nepal for devotional events, meetings and conferences. Their trips are often significant for promoting dialogue and cultural exchange, and cannot be banned under the Constitution. “We did the Nanhai Conference, and in future religious leaders will definitely visit Nepal. The question arises whether or not to allow them to engage in political activities or not,” says Mulmi. “Religion has always been political. So Nepal must not take easy decisions and must think it through.” Although Nepal and Tibet fought wars in the past two centuries, they share deep-rooted and ancient cultural, religious and trade ties. After the Chinese annexation of Tibet 70 years ago, Kathmandu gradually started dealing directly with Beijing.&nbsp; Today, Nepal is the only country with a consulate in Lhasa, a city from where the only direct international flight is to Kathmandu. Over the years, these ties have evolved, with shifts in trade dynamics and people-to-people interactions reflecting broader regional and global changes. Despite this, the historical bond between Nepal and Tibet remains a significant aspect of present-day bilateral relations with China, and this is why the selection of the next Dalai Lama has resonance here. “It is clear that China has been trying to adopt Tibetan Buddhism as a soft power. It is trying to co-opt Tibetan Buddhism on the lines of China’s ambitions and narratives,” explains Mulmi.&nbsp; The Dalai Lama’s <a href="https://archive.nepalitimes.com/news.php?id=14733">considerable following</a> in Nepal, India, Europe and the United States is an irritant for Beijing. Recent Sino-American tensions have therefore given the spiritual ownership of Tibetan Buddhism a geopolitical dimension, and in this the Dalai Lama succession will become an important factor.&nbsp; Relations between Washington and Beijing during the second Trump term will have a bearing on this. As a buffer state between India and China, Nepal has historically tried to maintain equidistance between the two powers.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025012308014_95372c819980513e21490c3abe2aa8e712af6c89c5829e04d5f57880ad4f2a23.jpg" data-media-id="editor_5" data-image-id="2025012308014_95372c819980513e21490c3abe2aa8e712af6c89c5829e04d5f57880ad4f2a23" data-rendition-name="original" width="2500" height="1000" loading="lazy" alt="What (or who) after the Dalai Lama NT"> <figcaption>THEIR HOLINESSES: The Dalai Lama, who will be 90 in July (left), and China-installed Panchen Lama (above). Traditionally, it is the Panchen Lama who has a role in finding a new Dalai Lama. Photos: TENZIN CHOEJOR (left) / CHINAN NEWS SERVICE (right)</figcaption> </figure>  But China has rarely stuck its neck out for Nepal. Despite repeated requests for military help during its war with the British East India Company in 1814-16, the emperor in Beijing refused.&nbsp; Explains Sudheer Sharma: “China did not want to get involved with the British. They thought of their own national interests then, and they are thinking of their own national interests now with India.” During the Khampa Uprising in the 1960s, Kathmandu was also squeezed between American support for the guerrillas and China’s objections to Nepal being used as a base. But with the Nixon-Mao rapprochement in 1972, the Americans stopped helping the Khampas. Nepal then yielded to pressure from Mao Zedong to mount a military campaign to drive them out.&nbsp; Nepal was left to manage and host Tibetan refugees, and balance that with China’s security concerns. Explains Amish Mulmi: “Nepal has pretty much done everything China has asked to do, including deporting Tibetans. China doesn’t need to be insecure, but Nepal needs to maintain a careful balance.” Today, despite Donald Trump’s chest-thumping and <a href="https://nepalitimes.com/editorial/trump-s-second-coming">threats of a tariff war against Beijing</a>, he and Chinese President Xi Jinping are on the same page regarding democracy and freedoms. Which may mean Washington could once more leave the Tibetans in a lurch, and this could have a direct bearing on the Dalai Lama succession sequence. The United States' shifting foreign policy has often been criticised for leaving allies and partners to fend for themselves. Trump may revive his pressure on Japan, Korea and Taiwan to pay for the US defence umbrella.&nbsp; Nepal’s stance on the Tibetan community relies on marking boundaries and offering protection. During Chinese President Xi Jinping’s visit to Nepal, China proposed that Nepal sign an extradition treaty which Nepal politely refused. “Nepal has tactfully not let the Chinese side extend a longer hand on the Tibetan issue,” says Sharma. “Possibly, we are learning our lessons from history.” The question of who will choose the successor to the Dalai Lama will be decided by geopolitics, and China’s increased stature as a global economic power.&nbsp; Beijing could insist on sticking to tradition to let its candidate for the Panchen Lama make the final decision. This would allow it to move the seat of the Dalai Lama from Dharamshala back to Lhasa. The present Dalai Lama could also appoint his own candidate, but that person will not be allowed into Tibet by China. In that case, we may have a situation where there are two Dalai Lamas.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250127030140_c9048725407641601bc68568db19e48197154cd6396f39d67ab113d94c26e675.jpg" data-media-id="editor_7" data-image-id="20250127030140_c9048725407641601bc68568db19e48197154cd6396f39d67ab113d94c26e675" data-rendition-name="original" width="1910" height="757" loading="lazy" alt="Voice for the Voiceless Dalai Lama"> <figcaption>Dalai Lama's latest book Voice for the Voiceless details his dealings with China over the last seven decades. </figcaption> </figure>

What (or who) after the Dalai Lama?

Between the 1980s and 2000s, over 5,000 <a href="https://download.ssrn.com/11/01/06/ssrn_id1736064_code1383023.pdf?response-content-disposition=inline&amp;X-Amz-Security-Token=IQoJb3JpZ2luX2VjEBkaCXVzLWVhc3QtMSJIMEYCIQCiYUc7BuJ7zaDn%2BOTCFOWBgNKqYarnapqY%2FWZbamFVsgIhAOC%2FPFXHR9Dx6xTicWMj5%2BJXdIEGZ7LxKRyjrCe61Ng9KsYFCPL%2F%2F%2F%2F%2F%2F%2F%2F%2F%2FwEQBBoMMzA4NDc1MzAxMjU3IgzWD1Y1XNz2kaOS3jEqmgX0TbxyBTTrZrpd%2B5N72pFzJAwc%2BxTF8Dc0GnVG2tUGUYyxBt1YmfEqAw5cdOuRCZV23SSKkJwndg9IwI3yrjZGBp9XKxg4lK4Vq0Qy9RMmma5hNCVnA2T0MwGghlnmkgWPZA5ouZPiKFAecf4PE5qml2fu1wj72LEAig5R77cN6nC6%2BxTcygMiuiHrR9yZB4RyvTD9s58avGqUcn9hcIUdku3ydvAGVEgczzgEMCesRMtSgqzHz3E9bju9QLR5RpcDRp0wptfQ89uGXgyBGLCX%2BAl6uareSxQCSaDOthP4PmswWI7y7kBJbQp1pZq8r56Yoa3Qf5WVtmxbsWmDtbOsaSBa0yB6EIS8RKFGeQ%2Bcz%2BnEsOoPHIS%2BqO1k1%2BQuihjN0T66SnWFo8rl8Cv2g4GghY9p9DR3wopBJ6cE%2FtDJMY%2BZ03LkUwS%2Fc7ckyaRpfPX5g6Bb9J56a%2BNA5lnIV5o%2Fpjp%2BZJaVIvEzciyzzTwP58wznmcy3xppvK%2BwXBzBR96cPMXKTdNv9%2FqJ5jlnsgSRJpHWE3UyHbFucwQYXi19i7mCglFSuSkkL5Tg9nQWvXpuP9Z9VmMlQfQ%2F%2FpsfA6KlL81K3UK%2Bp%2FJB2mxQD9SYexZvAf1g21NUSF%2F8I19orsNrT6LutAnoJU%2FOTgO3qMbdgnR%2FuBytI3POnQAEIfbG0Za%2FrEDJ9j8CEbasNXsBMqkx8JKGRG2PUHMRC2xl5Z%2BNIbpsqGB8t%2BvAt40osDpgZStiyeiGdC1nMakUzZtBjWlttzoirCdemwPKJ8M%2BEohj2%2BLEN92yaOKdFewns0gjh%2BUxcotGvBo%2F7QZFappBNjLlR0PyanjcuB4MndEQjeIrd67ntscTKiLDI%2FfzwCHulsl6nbMpewpWFAYwg67guwY6sAGb3VJ2q%2F36hWhrVa8igP2hswnnLlcIU2uhOZa5ge2hCXkUYhL1BcSJfoWy2LwrWCXtdFo%2BT7KMU3p6O3jySdxSop8F4iO%2BJBiXVjSiXm%2FqZo3ri8sVwUgo4ksJI%2BT4AbfK3D3VGYapBgU5LdX%2FjkNwSVoR1vz4vMIyF56i7MKeYG1nFLgc0l9cIjrQI6eY869uIbgZ1XKqqBsuavCbYjSbSy7dMP0QSym%2FgmoWILGE0Q%3D%3D&amp;X-Amz-Algorithm=AWS4-HMAC-SHA256&amp;X-Amz-Date=20250103T172339Z&amp;X-Amz-SignedHeaders=host&amp;X-Amz-Expires=300&amp;X-Amz-Credential=ASIAUPUUPRWE65YAH56X%2F20250103%2Fus-east-1%2Fs3%2Faws4_request&amp;X-Amz-Signature=9b654b526e0779da4fa9f54e2fcde04ac9f7e91fb50d4f8094b1039ebb19e21b&amp;abstractId=1736064">Nepali children were adopted abroad</a>, primarily to the United States, France, and Spain. While international adoption was intended to provide vulnerable children with better opportunities, child trafficking and irregular practices prompted Nepal to suspend adoptions in 2007, and overhaul its policies. By 2010, stricter regulations aligned with the <a href="https://www.hcch.net/en/instruments/conventions/specialised-sections/intercountry-adoption">Hague Adoption Convention</a> drastically reduced adoption numbers. Today, many of these children, now adults, are returning to Nepal in search of their roots, only to encounter a society that no longer recognises them, legally or socially. Behind the statistics lie the <a href="http://hdl.handle.net/1854/LU-01GRNPPXAC1Z3AETV9HARNCG5Q">deeply personal and emotional journey</a> of adoptees returning to reconnect with their past, seek family, and rediscover a sense of belonging. These stories reflect a broader struggle for identity and the complexities of bridging two worlds. Maya Adopted at 9 by a family in Barcelona, Maya carried fragmented memories of her early life in Nepal including the painful recollection of the day her mother and sister vanished, leaving her and her younger siblings behind. She had faint images of her mother, elder sister, and the village where she once lived. In June 2017, Maya came to Nepal accompanied by Chandra Kala and two friends, Jay and Vikram. With only a few photographs of her mother Tulsi, her elder sister Pargati, and her brother-in-law Kamal, along with a street name, Maya arrived in Birendranagar after a 20-hour bus ride from Kathmandu. “Now that we’re close, I feel like I can’t face them,” she confessed to Chandra Kala, wrestling with anxiety about what she might uncover. “I’m nervous. I don’t know if I’ll recognise them or if they’ll recognise me. I don’t know how they’ll react or what they’ll say. And then there’s him [Kamal]. I have such bad memories of him. I don’t know if I can handle this.” Chandra Kala reassured her, reminding her of her courage and the importance of this moment. Maya and her companions asked around the town with little success until a shopkeeper recognised Kamal and directed them to a nearby village. Jay went to confirm and returned excitedly, shouting, “It’s her! It’s your sister!” Maya froze, paralysed by fear and anticipation but she pushed ahead. At the village, Maya’s sister Pargati initially struggled to recognise her. Jay introduced Maya: “Do you recognise her? This is your younger sister. She’s come all the way from Spain to find you.” Slowly, realisation dawned, and the two women embraced, bridging the decades of separation with tears and disbelief. The next day, Maya met her mother Tulsi in an emotionally overwhelming reunion. Tulsi rushed into the room and embraced Maya tightly, sobbing uncontrollably: “Mero chhora-chhori, gaye, gaye… my children they went, they went …” Once the tears subsided, Tulsi and Pargati began recounting the heartbreaking circumstances of their separation. After the death of her husband, Tulsi faced relentless judgment in their village when Kamal stayed with the family before his marriage to Pargati. The villagers accused Tulsi of impropriety, calling her पापी (sinful) and demanded that the family leave. “We didn’t want to leave, but the village didn’t want us here,” explained Pargati. “We left intending to bring you and your siblings later. But when we returned, you were gone.”  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250103120140_da7482d222e0a03b783c5e1df25536ed416d7b7475442e7fd40e54451572142e.jpg" data-media-id="editor_3" data-image-id="20250103120140_da7482d222e0a03b783c5e1df25536ed416d7b7475442e7fd40e54451572142e" data-rendition-name="original" width="384" height="512" loading="lazy" alt="Searching for a homeland away from home NT"> <figcaption>An adoptee and companion return to Bal Mandir in Kathmandu after 19 years. Photo: CHANDRA KALA CLEMENTE-MARTINEZ</figcaption> </figure>  Tulsi recalled how she had entrusted Maya and her siblings to relatives, hoping they would be cared for temporarily. However, when she returned, the children had been sent away without her knowledge. “I only trusted them because I had no other choice,” Tulsi said through tears. “I didn’t know they would send my children away. What kind of mother does that make me? They called me a bad mother, but what else could I have done?” The reunion brought healing and answers but it also exposed the societal pressures that had fractured Maya’s family. Despite the challenges, Maya spent the rest of her visit bonding with her sister, nieces, and younger half-sister, Sunita, slowly bridging the gaps created by time and distance. Maya’s journey was a testament to the courage required to confront the past, the pain of uncovering difficult truths, and the hope of rebuilding connections once lost. Her story highlights the enduring emotional complexity faced by adoptees navigating their history and identity. Ashmita Unlike some adoptees whose main focus is reuniting with their biological family, 26-year-old Ashmita’s priority has been to uncover the institutional details surrounding her adoption. She wanted to understand what the orphanage and the government knew about her background and why so much information seemed concealed. “I just want to know where I come from,” she said. “Even if I never find my biological family, having a better sense of the places and people connected to my story would mean so much.” For many adoptees, returning to Nepal is not just about reconnecting emotionally, it is about seeking formal recognition as members of the Nepali community. However, the legal framework in Nepal often fails to acknowledge their unique status.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250103120144_bf0158b7829cf5db44382d7386d3b123032adad3f9e10e28096b80cd09170ba6.jpg" data-media-id="editor_4" data-image-id="20250103120144_bf0158b7829cf5db44382d7386d3b123032adad3f9e10e28096b80cd09170ba6" data-rendition-name="original" width="384" height="512" loading="lazy" alt="Searching for a homeland away from home NT"> <figcaption>A mother reunites with her don after 18 years. Photo: CHANDRA KALA CLEMENTE-MARTINEZ</figcaption> </figure>  In Nepali law, adoptees are left in limbo: their birth parents are not considered legal parents, and their ties to the country are effectively erased upon adoption. This lack of recognition creates significant hurdles, particularly in two key areas: accessing pre-adoption records and obtaining Non-Resident Nepali (NRN) status. Despite international norms like the Convention on the Rights of the Child, which guarantees the right to know one’s origins, institutions often refuse to cooperate. Orphanages and non-profits in Nepal, which hold critical pre-adoption records such as birth certificates and citizenship documents, frequently withhold this information, reflecting the systemic reluctance to provide transparency. In numerous cases, records that should include family names, addresses, or relinquishment agreements were either incomplete or falsified. These practices not only prevent adoptees from reclaiming their histories but also perpetuate their disconnection from their heritage. Ashmita’s initial requests for information from her adoption agency were met with delays and incomplete responses. When she turned to the orphanage where she spent her early years, she encountered even greater resistance. At one point, the director of the orphanage issued veiled threats. Nevertheless, Ashmita persisted and managed to find the name of the individual who had brought her to the orphanage. However, the person had disappeared, leaving yet another gap in her story. A breakthrough came when Ashmita accessed a police report that suggested she might have been born in a different municipality than the one in her adoption records, prompting her to seek help from local authorities. The police took an interest in her case and began investigating possible connections to her birth family. While progress was slow, they meticulously followed leads to help her trace her origins. “It’s not easy,” Ashmita said of the process. “But every small step feels like I’m piecing something back together.” She also noted that societal perceptions could add to the difficulty. At times, she felt questioned about her identity and her right to seek answers. “People have asked me why I care so much or even suggested that I’m not Nepali anymore because I was adopted abroad,” she reflected. Ashmita’s story is a complex account of persistence in the face of institutional and personal challenges. While her search has not yet provided all the answers she seeks, it continues to offer her insights into her early life and the systems that shaped her adoption journey. &nbsp;“These records are sealed for a reason. They are not meant to be reopened,” said a government official. Even an NGO representative said: “It’s better for everyone if the past remains in the past.” An orphanage director asked: “Why are you asking these questions? This is not your place anymore.” Hari Prasad Sacré The Non-Resident Nepali (NRN) card is a lifeline for Nepali diaspora members, granting them residency and property rights in Nepal. Yet, adoptees are notably excluded from this framework. While the law stipulates eligibility for individuals whose parents or grandparents were Nepali citizens, it makes no provision for adoptees whose legal ties to their Nepali parents were severed by adoption. When Hari Prasad Sacré, a Nepali adoptee, sought to obtain an NRN card at the Nepal Embassy in Belgium, he encountered officials unfamiliar with processing an NRN request from an adoptee. His case was the first of its kind, setting a precedent but also highlighting the systemic barriers adoptees face. "You are not eligible; your surname is Sacré, it is not a Nepali name," an embassy staff said.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250103120140_9bdc24b7e34930059f895048ab7dc0ad3ca23b16907c572f01a8d5404a5feac5.jpg" data-media-id="editor_5" data-image-id="20250103120140_9bdc24b7e34930059f895048ab7dc0ad3ca23b16907c572f01a8d5404a5feac5" data-rendition-name="original" width="446" height="512" loading="lazy" alt="Searching for a homeland away from home NT"> <figcaption>Hari Prasad Sacré receives tika from his father Khul Prasad Adhikari during Dasain, a few weeks after receiving his NRN card. Photo: HARI PRASAD SACRÉ</figcaption> </figure>  Sacré’s situation was legally ambiguous. Although his biological parents, including his father, Khul Prasad Adhikari, are alive and he maintains contact with them, he no longer had “legal” ties to Nepal due to the adoption process. Carrying a Belgian surname the embassy staff was initially convinced the adoptee couldn’t claim Nepali origin. Nepali law, which does not recognise biological parents as legal guardians once a child is adopted, created complications for the NRN application. To navigate this complexity, Sacré relied on a testimony from his father. Issued by a local government body in Kaski, the testimony affirmed that Hari had been put up for adoption and was of Nepali origin. While this enabled the embassy to approve his NRN card, the process was unnecessarily protracted and emotionally charged, highlighting the inadequacy of current policies to accommodate the unique situations of adoptees. Sacré’s case represents a rare instance where biological parents were alive and willing to provide testimony, but many adoptees are not as fortunate. A large number of adoptees were declared “orphans” during the adoption process, even when their parents were alive. This severed their legal ties to Nepal, stripping them of documentation that could later prove their origin. For others, the absence of living biological relatives or access to their original adoption records creates insurmountable barriers. Without clear documentation or a family member to vouch for their Nepali heritage, adoptees are excluded from the NRN framework. This denies them the rights and privileges afforded by the card, including property rights, legal recognition, and a formal connection to their homeland. Current laws fail to account for the complexities of adoptees’ legal status, leaving them disconnected from their cultural and legal heritage. Adoption papers, as evidence of Nepali descent, should be accepted as proof, granting adoptees rightful access to the NRN card and ensuring their inclusion in Nepal’s diaspora. Such reforms are crucial to ensure that all adoptees, regardless of their circumstances, can reclaim their heritage and establish a sense of belonging in Nepali society. Without these changes, the systemic exclusion of adoptees will persist, perpetuating inequities and denying them the opportunity to step up as active members of the Nepali diaspora. Sacré’s case serves as both a precedent and a call to action. It exemplifies the challenges and triumphs of adoptees navigating complex bureaucracies and advocates for a more inclusive and equitable approach to reconnecting adoptees with their homeland. Nepal can draw inspiration from South Korea, where the government has actively supported the reintegration of adoptees into their society. The F4 visa, established through efforts by organisations like the Global Overseas Adoptees’ Link (GOA'L), grants adoptees the right to live and work in Korea, while dual citizenship acknowledges their dual identity as members of the diaspora and their country of origin. GOA’L further fosters reconnection by offering language classes and cultural exchange programs, creating opportunities for meaningful reintegration and belonging. As Nepal refines its NRN citizenship framework, explicitly including adoptees could address the severance of legal and cultural ties caused by international adoption. Such inclusion would provide adoptees a pathway to residency, citizenship, and rights, enabling them to reconnect with their heritage. Complementing this with programs for language acquisition, cultural immersion, and historical education would honour Nepal’s responsibility to the approximately 5,000 children sent abroad. Nepal could establish a dedicated organisation similar to South Korea’s GOA’L and help adoptees access pre-adoption records, navigate legal processes, and engage in cultural exchange initiatives. It would also serve as a bridge between adoptees and Nepali society, fostering mutual understanding and collaboration. This article is based on doctoral studies by <a href="http://hdl.handle.net/1854/LU-01H4Z85GPS63ZWDJ3WB2E6KS70">Hari Prasad Sacré</a> and <a href="https://www.tandfonline.com/doi/full/10.1080/10357823.2022.2142932">Chandra Kala Clemente-Martínez</a>. Hari Prasad Sacré, PhD, is a postdoctoral researcher at Ghent University in Belgium, specialising in cultural translation, multilingualism, and identity in education. His PhD, Reading Illiteracy, explored fractured multilingualism and illiteracy in displaced identities such as adoptees, with work published in leading journals like Critical Arts and the European Journal for Cultural Studies. Chandra Kala Clemente-Martínez, PhD, is a postdoctoral researcher at the AFIN Research Group, Autonomous University of Barcelona, with a PhD in Social Anthropology. Her research focuses on family strategies, reproductive decisions, and adoption, with extensive fieldwork in Spain and Nepal examining adoptee reunions and related governance and rights.