Philanthropy will never replace<a href="https://nepalitimes.com/news/uk-aid-for-nepal-s-covid-affected-mp4ab6lw"> public aid</a>, but it can be a powerhouse if we use it right. With global development funding under strain, <a href="https://nepalitimes.com/news/e75-million-eu-aid-to-nepal-for-covid-19-ckmyfbkq">European aid</a> budgets being redirected toward defence and rearmament, and the <a href="https://nepalitimes.com/news/how-usaid-cut-affects-nepal">United States rethinking foreign assistance</a> altogether, the aid community has been left scrambling.
The reactions so far have been of two kinds: calls for <a href="https://nepalitimes.com/here-now/philanthropy-in-the-time-of-pandemic">philanthropy</a> to fill the gap, and moralising statements shaming governments for stepping back. Unfortunately, the first is unrealistic, and the second is ineffective.&nbsp;
Private donors cannot solve systemic <a href="https://nepalitimes.com/opinion/12-full-opinion/our-uncommon-future">global challenges</a> alone, and telling politicians that they are morally bankrupt generally does not bring them around to your side. Instead, we need to meet policymakers where they are, sharpen our arguments, and focus on what actually works. The hard truth is that most <a href="https://archive.nepalitimes.com/page/foreign-aid-policy-to-balance-infrastructure-investment-with-social-sector-investment">government aid</a> is not even designed for effectiveness, because it prioritises processes over results. Nor has philanthropy been immune to this impulse.
In early years at the Eleanor Crook Foundation, we funded holistic, multisectoral programs that tried to tackle all causes of malnutrition simultaneously. But the results were underwhelming. The approach looked good on paper, but produced no measurable improvements in <a href="https://nepalitimes.com/here-now/nepal-s-epidemic-of-hunger">malnutrition</a>. So, we learned from that failure and changed course. Now, we direct our funding where the evidence is strongest and the results most immediate.&nbsp;
At the recent Nutrition for Growth (N4G) Summit in Paris, we announced a $50 million commitment, alongside $200 million from other donors, to scale up one of the most cost-effective interventions in global health: prenatal vitamins – known as multiple micronutrient supplements (MMS). This funding will go toward a $1 billion roadmap to ensure access to MMS for pregnant women no matter where they live.
The science on this issue is unequivocal. MMS replaces outdated iron and folic acid (IFA) tablets still given to many pregnant women in low-income countries. With MMS, women receive 15 nutrients, instead of just two, leading to a dramatic reduction in maternal anemia, stillbirth, and low birth weight. The estimated economic returns are $37 for every $1 invested while infant mortality is reduced by nearly one-third.
The global inequities in maternal health are profound. In London, a pregnant woman routinely has access to comprehensive prenatal vitamins. In Lagos, she might receive IFA, or nothing at all. The difference reflects a gap in will, not knowledge. Ending such disparities does not require a scientific breakthrough, just greater investment in already proven solutions.
More than two decades of research, three Lancet studies, and multiple World Bank investment cases have identified roughly ten nutrition interventions that are consistently underfunded despite their proven efficacy. These are not flashy, multisector, utopian initiatives. They are targeted, evidence-based programs that can be implemented immediately to deliver measurable results.
Solutions like breastfeeding support, Vitamin A supplementation, prenatal vitamins, and ready-to-use foods for severely malnourished children belong to a package of interventions that could save at least two million lives over five years if scaled up in nine high-burden countries. Such life-changing results would cost just $887 million per year.
Malnutrition is now the leading driver of <a href="https://archive.nepalitimes.com/news.php?id=16505">child mortality</a> globally, contributing to some three million deaths in 2023 alone. These are not mysterious tragedies. They are predictable and in many cases cost little to prevent. In a world that routinely sends tourists to space, we obviously can afford to ensure that all <a href="https://nepalitimes.com/here-now/saving-one-nepali-mother-at-a-time">pregnant women</a> have access to a $2 bottle of vitamins.
This year’s N4G Summit may be the last of its kind. It was part of a summit series linked to the Olympics, which will next be hosted by the US. With the current <a href="https://nepalitimes.com/editorial/trump-s-second-coming">US administration </a>already signaling that it will not continue the tradition, recent commitments made in Paris have gained new urgency. Vague pledges and political posturing will no longer do.
We are not asking governments to spend like they used to. Rather, we are urging them to look at the evidence and use their remaining budgets for official <a href="https://nepalitimes.com/review/small-is-bountiful?fbclid=IwAR0wRoEdhgYO9qATGiukFQvK2fE6N8rCDZ4CBJBdkTC6_Es-6_mdVHldlic">development assistance</a> to scale up proven, <a href="https://nepalitimes.com/here-now/small-is-still-possible">cost-effective solutions</a>. A modest investment in MMS – representing less than the cost of one week of G7 countries’ defense spending – could save 600,000 lives.
Even with constrained budgets, we have a chance to save millions of lives. But only if we stop trying to do everything, and focus instead on what is the right thing to do.
William Moore is the CEO of the Eleanor Crook Foundation and Chair of Stronger Foundations for Nutrition.

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Philanthropy in an era of declining development aid

When he was a teenager years ago during the war, the Maoists who held sway over the Dalit village of Muktikot in western Nepal promised Man Bahadur Bishwakarma liberation and prosperity. Many like Man Bahadur believed in that utopia, and took up arms like others from the downtrodden Dalit community here. They even renamed the village Muktikot (Fort Freedom) from its original Dumkot. ‘Dum’ is a derogatory term used to address the Dalit community. Muktikot is spread across a steep mountainside with unirrigated terrace farms. Most of the men migrate to India for seasonal work, others never come back. The women left behind had to walk hours for water, and since there were no roads then, travelling to town for government subsidised rice took at least a week. “The Maoists told us that we would find jobs right here in the village, that every household would have tap water, they promised an end to caste discrimination,” recalls Man Bahadur. “That is why I joined the revolution in Grade 10.” He is talking while walking up a steep trail three hours from Muktikot, where his family has been living in a cattle shed after a landslide damaged his house in 2021.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024051804058_bc4d26d047714332fcdd2242229a1227d207a972439e02e3c822aaa118066b3f.jpg" data-media-id="editor_0" data-image-id="2024051804058_bc4d26d047714332fcdd2242229a1227d207a972439e02e3c822aaa118066b3f" data-rendition-name="original" width="1600" height="1200" loading="lazy" alt="Muktikot"> <figcaption>Th remote village of Muktikot in Bajura district in far west Nepal.</figcaption> </figure>  Most of Muktikot’s young population joined the Maoists, convinced that changing the name of the village was proof this was going to be a real revolution. Eighteen years after the end of the conflict, the only thing that has changed for the nearly 2,300 Dalits in Muktikot is the name of their village. Not that there has not been some progress. There are now motorable roads and residents do not have to walk as far as Kalikot or Dailekh to get a sack of rice. More essentials are available in local shops for those with cash. Man Bahadur himself migrates to India to earn money, and had just returned for a break when we talked to him. “I fought for the Maoists in the hope that I would not have to go to India for work, but there are still no jobs here,” he says. “The Maoists promised a mirage.”  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024051804058_fcd64c34f689e7a4d44f285bb6a7b6b28329941e2766440ab208c9039a855d31.jpg" data-media-id="editor_1" data-image-id="2024051804058_fcd64c34f689e7a4d44f285bb6a7b6b28329941e2766440ab208c9039a855d31" data-rendition-name="original" width="1600" height="1200" loading="lazy" alt="Muktikot"> <figcaption>Men in Muktikot preparing to migrate to India for work.</figcaption> </figure>  Birth and death Manbuja Bishwakarma has just turned 20, the minimum legal age of marriage in Nepal. But she has been married since age 13, giving birth to five children, three of whom died. “The babies just died one after the other,” recalls Manbuja, who just had to have more babies in the hope that some would survive. Read also: <a href="https://nepalitimes.com/banner/how-the-climate-crisis-adds-to-child-marriage-in-nepal">How climate crisis adds to child marriage in Nepal</a>, Sonam Lama Her neighbour, 30-year-old Lalkala Bishwakarma has given birth eight times, and only four babies survived. There are women in Muktikot who gave birth to as many as 14 children, and there is not a single mother in Muktikot who has not lost a baby.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2024051804058_dd4d62e65cc4ac88cd46a91a62b9c60bcb2d43bbc5cb5455dc7efe4a7d2ff1b2.jpg" data-media-id="editor_3" data-image-id="2024051804058_dd4d62e65cc4ac88cd46a91a62b9c60bcb2d43bbc5cb5455dc7efe4a7d2ff1b2" data-rendition-name="original" width="1600" height="1200" loading="lazy" alt="Muktikot"> <figcaption>Lalkala Bishwakarma</figcaption> </figure>  Tilakhuni Bishwakarma, 40, had 10 children, and eight of them survived. Sitting outside her home, she is now surrounded by her grandchildren. Despite Nepal’s total fertility rate now dropping to near replacement level, here in Muktikot infant mortality is still high and this means women have more babies in the hope that some will survive. Child marriage and low female literacy contribute to the high rate of maternal and infant mortality. Community health records show that even in 2021, eight out of 45 infants born in Muktikot died. While Nepal’s average infant mortality rate dropped to 33 for every 1,000 babies born in 2022, &nbsp;the rate was 178 in Muktikot. “The most prominent among the many reasons for the high maternal deaths are early marriage and frequent pregnancy,” says Janaki Neupane, a community nurse in Muktikot. &nbsp; Four years ago, Bachchi Bishwakarma died of a hemorrhage while giving birth to her second child at home. Her husband Gorkha says she had barely survived giving birth to their first child. “I was home alone that day, and I took care of her,” Gorkha recounts. “Our child was born, but my wife bled to death.”  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240518040512_4718183318c77de8bb9b719346b9b19c96bef0984055585b00884f741f905c2e.jpg" data-media-id="editor_4" data-image-id="20240518040512_4718183318c77de8bb9b719346b9b19c96bef0984055585b00884f741f905c2e" data-rendition-name="original" width="1600" height="1200" loading="lazy" alt="Muktikot"> <figcaption>Tilakhuni Bishwakarma</figcaption> </figure>  Birthing centres were opened in Muktikot last year to address high infant and maternal deaths, but Nurse Neupane says it still lacks basic equipment and budget. Nirmala Bishwakarma got married when she was 13 and was &nbsp;pregnant soon after. She had her first baby, but soon got pregnant again. “Birth brings death here,” Nirmala, now 20, says simply. Nirmala and her children all look emaciated and she weighs only 33kg. Bajura’s district headquarters in Martadi provides nutritional allowance, but Nirmala cannot afford to travel that far to get it. &nbsp; Nepal’s development indicators, including lifespan (page 1) and poverty rate have shown dramatic improvements over the past three decades. But here in Muktikot, hunger stalks the land. In fact, a recent survey showed that 95% of women, children and young adults in Muktikot are undernourished. Most men, on the other hand, look well fed because they are mostly away in India for work. &nbsp; Only 12% of the land in Bajura is arable, but even then there is lack of irrigation, frequent droughts, and now climate breakdown contributing to the lack of food. “The harvests are just not enough to sustain the families,” says Bharat Bahadur Rokaya, chair of Swamikartik Khapar Rural Municipality where Muktikot is located. Here in the rugged mountains of northern Bajura bordering Humla and Mugu, the families grow millet, maize, and wheat, but Nirmala Bishwakarma says the harvests hardly last a month. “If it was not for the subsidised rice we would have empty stomachs,” she says. Hindrances to hygiene Down the mountain from Muktikot, the green waters of the Karnali River are visible. But the 400 Dalit households here have to share just three community taps for drinking water. Half the households do not have toilets, and defecation in the open is common. Donor agencies have helped build toilets, but these are mostly used to store fodder because there is no water. “How can we use water for the toilets where there isn’t enough for drinking?” asks Ward chair Ajay Bishwakarma. &nbsp; Families have to walk for four hours to bathe and do washing. “We do not wash our clothes for months on end,” says Kushi Bishwakarma, 40.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240518040516_e234d5b4fac4fa24e62e65a35f2eafbfb044a32a5f8ef8172932eca96eeaa17b.jpg" data-media-id="editor_5" data-image-id="20240518040516_e234d5b4fac4fa24e62e65a35f2eafbfb044a32a5f8ef8172932eca96eeaa17b" data-rendition-name="original" width="960" height="733" loading="lazy" alt="Muktikot hygiene"> </figure>  The lack of water has compromised hygiene and sanitation in the village, resulting in diseases like diarrhoea, allergies, and other health issues, especially among children. Lack of water in the village has also led to uterine prolapse among the women in Muktikot since they primarily face the task of ferrying heavy jars of water from the communal taps to their houses The ‘One house, one tap, one toilet’ campaign introduced by the rural municipality this year hopes to solve water-related issues for Muktikot residents. But that is yet another election promise. Testing times This underserved village is not just affected by structural inequality and state neglect. In 2021, a landslide swept away 54 houses in Muktikot, and most families lost homes and what little arable land they had. “Earlier, we at least had a house to live in, now we don’t even have that,” says Muktikot resident Asal Bishwakarma. “We have been living with relatives since. How will we survive?” More than two years after the landslide, not a single house in the village has been rebuilt. Each family was allocated Rs500,000 in relief on an instalment basis, with aid from all three tiers of government.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240518040516_26ebf9b2f52722180b1b403b1410f19ea5c7d0321047b099a574a35519706914.jpg" data-media-id="editor_6" data-image-id="20240518040516_26ebf9b2f52722180b1b403b1410f19ea5c7d0321047b099a574a35519706914" data-rendition-name="original" width="1200" height="1433" loading="lazy" alt="Muktikot landslide"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240518040516_bbe50221dca556ac0e798843d672f1190abafacb82fa792bfec289eeb31ad013.jpg" data-media-id="editor_7" data-image-id="20240518040516_bbe50221dca556ac0e798843d672f1190abafacb82fa792bfec289eeb31ad013" data-rendition-name="original" width="1600" height="1200" loading="lazy" alt="Muktikot landslide"> </figure>  Asal has only received Rs35,000 so far, and has spent it all on buying food. No one knows where the promised money went. Muktikot residents now want their entire village relocated somewhere safer. &nbsp;The local government agrees that resettlement is necessary, but it was unable to find a suitable alternative. “It is not possible to resettle such a large number of people at one go,” says Bajura MP Badri Pandey. “We also cannot create jobs for all of the population at once.” Muktikot might have been declared liberated on paper during a war fought in the name of Nepal’s downtrodden, but this Dalit village is emblematic of promises not kept. Looking around the landslide scarred village he has spent half a century of his life in, Muktikot’s Dhanajay Bishwakarma laments, “We are not even considered humans by the state.”

Muktikot still waiting for liberation

Over the last two decades, Nepal has made notable progress in maternal and neonatal healthcare. The<a href="https://mohp.gov.np/uploads/Resources/Final%20Report-26%20March-%202023-UPDATED.pdf"> maternal mortality ratio (MMR</a>) has declined from 536 per 100,000 live births in 1996 to 151 by 2021.
Driving this process were the country’s <a href="https://mohp.gov.np/program/safe-motherhood-programme/en">Safe Motherhood policy</a>, an increase in skilled healthcare providers, free delivery services for expectant mothers, incentive schemes for antenatal care, as well as postnatal visits.
Other measures, such as birth preparedness packages along with systematic planning for managing potential complications during childbirth, amplified these achievements.&nbsp;
There has been a remarkable rise in institutional deliveries, an increase in antenatal visits, and an impressive 70% of women receiving postpartum care from healthcare providers within the first two days after giving birth.
Quality improvement initiatives such as the Maternal and Perinatal Death Review, minimum health facility assessment standards, routine clinical monitoring, and supportive onsite supervision visits, have been outlined in policy documents and guidelines to elevate the overall quality of care.&nbsp;
However, it is when analysing province-wise MMR. that we still see significant disparities. Maternal deaths are still high in Lumbini Province (207 per 100,000 live births) and Karnali (172). The MMR in Bagmati Province (98) correlates with better figures for higher education, awareness and access to health service and providers.
In contrast, 83% of women in Karnali face challenges in seeking medical care, primarily due to financial constraints and long distance to healthcare facilities.
Half of the maternal deaths in Nepal are of mothers within the age groups of 15-34. Despite the legal marriage age being 20, child marriage is still widespread and contributes to the highest number of pregnancy-related deaths.&nbsp;
Read Also: <a href="https://nepalitimes.com/news/remove-barriers-to-life-saving-drug-to-prevent-maternal-deaths">Remove barriers to life-saving drug to prevent maternal deaths</a>, Marty Logan
The median age of marriage in Nepal is 18.3 years, with the lowest median age in Madhes province at 16.6 years and the highest in Bagmati province at 19.9 years. The Muslim community reports the lowest at 16.5 years, while the Janajati and Brahmin/Chettri communities have generally higher median ages for marriage.
In Madhes and Sudur Paschim Provinces early marriages among girls under 15 contribute to heightened adolescent mortality, mainly due to difficulties accessing timely health facilities. Disparities persist among ethnic groups, particularly among doubly marginalised Madhesi Muslims, who face high mortality rates due to early marriages.
Health facility deliveries have improved from 10% in 2001 to 79% in 2021. But again, progress is uneven and these disparities need to be overcome to<a href="https://nepalitimes.com/editorial/more-equal-than-others"> meet the UN’s Sustainable Development Goals</a> (SDGs) target of 90% institutional delivery rate by 2030.
Wealth inequality and provincial variations, especially in Madhes, pose challenges that need nuanced understanding of women’s reluctance to seek health services.&nbsp;
Despite Nepal’s success in maintaining population growth close to replacement levels, the total fertility rate (TFR) is significantly higher among those without formal education. The proportion of postpartum family planning uptake is also lowest in Madhes and Sudur Paschim at only 0.2%.
Breastfeeding is in decline, with less than three out of five mothers following recommended practices. Regional variations highlight the need for targeted interventions, particularly in provinces like Bagmati, where breastfeeding rates are lower among well-educated city dwellers.&nbsp;
Read Also: <a href="https://nepalitimes.com/here-now/why-has-progress-in-saving-women-s-lives-stalled">Why has progress in saving women’s lives stalled?</a>, Marty Logan
Anemia persists as another risk factor, with Madhes Province again carrying the highest burden.
Comparing Nepal with Bangladesh, India, and Pakistan shows that we are doing better in under-five and infant mortality rates. Nepal’s institutional delivery rate surpasses Bangladesh, but lags slightly behind India.
Even so, alarming disparities persist in neonatal and maternal mortality rates within disadvantaged groups, reflecting inadequate coverage of routine maternal and neonatal health visits and suboptimal care.&nbsp;
This points to both limited access to recommended interventions for disadvantaged women and potential inefficiencies in delivering crucial interventions during routine these visits.
Nepal should prioritise rural pockets of the country and employ a comprehensive strategy that includes delivering antenatal care through primary health care outreach, home visits, distributing essential medicines, vaccinations, and identifying appropriate health facilities for birth preparedness.
Read Also: <a href="https://nepalitimes.com/banner/what-can-be-more-fulfilling-than-saving-lives">“What can be more fulfilling than saving lives?</a>”, Naresh Newar
The quality of antenatal care must be improved by talking about nutrition with pregnant women and families, emphasising awareness of danger signs that necessitate timely health facility visits, and ensuring local governments can efficiently refer complicated cases, with airlifting as a viable option for emergencies.
Adolescent Sexual Reproductive Health with a targeted focus in provinces with early marriages and childbirths combined with education, awareness, and easy access to reproductive health services are imperative.
More effort is needed to meet the SDG target of reducing the MMR to 70 per 100,000 live births. Mitigating disparities among provinces demands political commitment, active local leadership, community engagement, especially leveraging the youth force, and fostering public-private partnerships at all levels.
Surya Bhatta is Executive Director of One Heart Worldwide that works primarily on maternal health in rural Nepal.

Saving more mothers and babies

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

Remove barriers to life-saving drug to prevent maternal deaths

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

When Sajadi Khatun felt the familiar pain, she knew what to do: she, her husband, her mother and a neighbour quickly left their house in Laxmipur village and started the 20-minute walk to nearby Sundarpur Health Post. They did not get far. Ten minutes later, Sajadi delivered a baby boy on the roadside.&nbsp; After delivery, the tired new mother returned to her home on the outskirts of Sarlahi’s district headquarters Malangwa while the rest took the newborn — the family’s fifth child, and third boy — to the health post for a check-up. A nurse visited and found both mother and child health.&nbsp; “I wasn’t worried about giving birth on the roadside," says Sajadi, stoically, although she and her husband had wanted to deliver the new baby in the health post, like her previous three children. The first was delivered at home as there was no health post in the community at the time.&nbsp; Ahead of the last birth, Sajadi had gone to the health post for check-ups (known as ante-natal care, ANC, visits) eight times before her due date. Recently, Nepal increased the recommended number of ANC visits from four to eight, but in 2022 just 68.4% of women in Madhes Province did four or more ANCs.&nbsp; The local Female Community Health Volunteer (FCHV) had also visited her house many times. On the advice of those health workers, Sajadi was eating as healthy as possible to keep up her own weight and that of the baby.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230623080636_18c6ee1ef9c231899017a764b9a89ff1ab5d9d3cd4eb417cf91e4868d2041f1f.png" data-media-id="editor_0" data-image-id="20230623080636_18c6ee1ef9c231899017a764b9a89ff1ab5d9d3cd4eb417cf91e4868d2041f1f" data-rendition-name="original" width="1496" height="828" loading="lazy" alt="Map Sarlahi"> </figure>  At the health post, Sajadi, who is not sure of her age but is probably about 30 according to the FCHV sitting nearby during our interview, also started taking calcium and iron supplements and got a tetanus/diphtheria vaccination. Because the facility did not have an ultrasound machine, she and her husband, who do not own a vehicle, paid to go to a nearby private clinic and get the examination. It revealed no problems but staff there estimated her due date 20 days later than the actual delivery day.&nbsp; We do not know what would have happened if the ultrasound had been done at the health post, and produced a more accurate delivery date, but the roadside birth highlights again how lack of resources plays a role in maternal and child health in Nepal, despite the best intentions of health personnel and, of course, families. There was no ultrasound machine at the health post, and no ambulance to call when Sajadi’s labour started.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230623080612_a44aa91ec02c4b2996c3b0bbdfc17847b279fefd6720b65fb5d2cf0fa5d40e78.jpg" data-media-id="editor_1" data-image-id="20230623080612_a44aa91ec02c4b2996c3b0bbdfc17847b279fefd6720b65fb5d2cf0fa5d40e78" data-rendition-name="original" width="3007" height="2619" loading="lazy" alt="Sajadi Khatun"> <figcaption>New mother Sajadi Khatun, holding her fifth child, talks to nurse Sunita Rai in front of her home near Malangwa in Sarlahi district. </figcaption> </figure>  “The problem is that we don’t have an ambulance in the municipality,” says Auxiliary Nurse Midwife Sunita Rai, who accompanies us to Sajadi’s house. “If we had an ambulance when a woman has a problem like a roadside delivery, we could send it right away and reduce the number of home deliveries.” Sarlahi district, and Madhes Province overall, still have a high number of home deliveries. Statistics from the district health office show that 53.5% of births happened in health facilities in 2021-22. That leaves 46.5% occurring at home or en route to facilities. The Nepal Demographic Health Survey (NDHS) 2022 found that 66.6% of births in Madhes Province occur in a facility versus 79.3% for Nepal overall.&nbsp; “The health situation in Madhes Province is a little worrisome to us, despite all the facilities there,” said the secretary of the Ministry of Health, Roshan Pokhrel. “We’re thinking about giving different targets to different provinces, rather than having a central target,” he added.&nbsp; Nepal is aiming to reach the global Sustainable Development Goals (SDG) target of 70 maternal deaths per 100,000 births. The 2022 rate was 151, according to the NDHS.&nbsp; 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 In Sarlahi, health infrastructure is a key factor affecting maternal health. Medical Superintendent of Malangwa Hospital, Nawal Kishore Jha, told us that the facility has burst its seams. For example, when the Covid-19 pandemic displaced the emergency and in-patient departments, they moved to what was the waiting area, where they remain when we visit in April.&nbsp; Also, two years ago the hospital delivered one or two babies daily, but today it is closer to 20, including a growing number of Caesarean sections, yet the facility lacks a gynaecologist, meaning that non-specialists perform the 3-5 ‘C-sections’ done daily.&nbsp; Reached again on budget day, 16 June, Jha has good news: his hospital will be upgraded to a 100-bed facility. That could mean more buildings, more trained staff and equipment, including a CT scan machine.&nbsp; In case of a maternal emergency, accessing the district hospital — the best-resourced health facility in Sarlahi — should not be an issue as it is only a one-hour drive away from anywhere in the district, unless there is monsoon flooding, adds Jha. Yet as Sajadi’s example shows, lack of resources — like ambulances — can still be a barrier.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230623080636_749b8cb16b39c940e487ba9770a57df181a69ce80f9878240eb273c16e5d4096.png" data-media-id="editor_3" data-image-id="20230623080636_749b8cb16b39c940e487ba9770a57df181a69ce80f9878240eb273c16e5d4096" data-rendition-name="original" width="2880" height="1800" loading="lazy" alt="Mothers of Sarlahi 2"> <figcaption>Women harbest wheat during the pre-monsoon Tarai heat wave recently in Malangwa.</figcaption> </figure>  While Jha and the nurses at health posts all say people’s awareness of maternal health and its potential complications could be higher overall, in the diverse communities near Malangwa, most women and their families are motivated to use health facilities, both to get as healthy as possible before giving birth and for the actual delivery.&nbsp; Besides awareness, living conditions are a major factor, says nurse Kanchen Rai at Laxmipur Khodra Health Post: “We can provide education, but the biggest problem is people’s lack of money. There has been some improvement but the poorest people still don’t have clean water and toilets.”&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230623080620_b68ff8cb3b3aa01e13dd5ae964c1a4b71296a0ac601a42d47eaa2ce4698db618.jpg" data-media-id="editor_4" data-image-id="20230623080620_b68ff8cb3b3aa01e13dd5ae964c1a4b71296a0ac601a42d47eaa2ce4698db618" data-rendition-name="original" width="4032" height="3024" loading="lazy" alt="Rabena Khatun"> <figcaption>First time mother Rabena Khatun with her baby in front og her house near Malangwa in Sarlahi district. ALL PHOTOS: MARTY LOGAN</figcaption> </figure>  “Pockets” that are away from urban areas and further marginalised by diverse factors are where home births still happen, and must be targeted for improvement, says Jha.&nbsp; First-time mother Rabena Khatun, 22, told us she felt “very happy” when she knew she was pregnant. Within three months she had visited the health post for her first ANC, following it up “3 or 4” more times before delivery, accompanied by her mother-in-law.&nbsp; Read Also: <a href="https://www.nepalitimes.com/opinion/midwives-to-the-rescue-in-nepal">Midwives to the rescue</a>, Laxmi Tamang “The nurses told me I should eat more nutritious food so that I gain weight,” she tells us, crouching on the ground outside of her small thatch-roofed bamboo home, cradling her son Ehsan, now 37 days old, on her lap.&nbsp; When Rabena’s labour pains began, she went to the health post with her mother-in-law and two other relatives. After 10-12 hours the baby was born, without complications. Instructed by a nurse, the first-time mother started breastfeeding within 30 minutes.&nbsp; She tells us that no one in her family or community suggested during her pregnancy that she deliver at home, adding, “All the facilities are there (in the health post) so I felt confident.”&nbsp; <h2>Promise of a healthier district</h2>  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2023062308068_9211b4979e6bafea6f5138663b56b17c33b42294bb53e81c7d3280b5a34fe400.png" data-media-id="editor_6" data-image-id="2023062308068_9211b4979e6bafea6f5138663b56b17c33b42294bb53e81c7d3280b5a34fe400" data-rendition-name="original" width="1297" height="664" loading="lazy" alt="saving lives"> </figure>  The Medical Superintendent of Sarlahi District Hospital in Malangwa, Nawal Kishore Jha, sounded upbeat after hearing in the Madhes Province government budget on 16 June that the facility will be upgraded to a 100-bed hospital.&nbsp; “I’m very happy with the decision, it responds to all our demands,” Jha said on a call from Malangwa. The larger facility will receive more trained staff, more space, including to provide maternal healthcare services, and more equipment such as a machine for CT scans.&nbsp; The government also announced it would build two 50-bed hospitals elsewhere in the district, and that all other municipalities would have 15-bed facilities.&nbsp; The budget revealed that Sarlahi will become a 'completely safe motherhood district'. Among other things, that means all births will be in health facilities, accompanied by skilled health workers, and all pregnant women will have the required number of pre and post-natal checkups.&nbsp; “It is possible,” says Jha, “but it will take some time.” <h2>Bumpy ride triggers birth</h2>  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230623070656_11438bd7c592e3d356ed26bfcb7de4ae014f8b23549bcafe2f383d6083c61224.png" data-media-id="editor_7" data-image-id="20230623070656_11438bd7c592e3d356ed26bfcb7de4ae014f8b23549bcafe2f383d6083c61224" data-rendition-name="original" width="2794" height="1608" loading="lazy" alt="Mother of sarlahi 1"> <figcaption>Anita Kumari Yadav with her baby and husband. </figcaption> </figure>  Anita Kumari Yadav had felt a pain for three days that she thought meant she was going into labour for her first baby. She walked to nearby Sisautiya Health Post, but was always told it hadn’t started.&nbsp; On the third day, nursing staff referred her to the district hospital because of the delay. When she arrived with her in-laws after a bumpy ambulance ride, she was told she would need a Caesarean section.&nbsp; “I was scared to have an operation,” says Anita, 20. She called her husband, a bus driver who was en route from Kathmandu. He told the family to wait until he arrived. But they didn’t have to. The baby was born half an hour later, one positive outcome of the bone-jarring ambulance ride, speculates Auxiliary Nurse Midwife Ringku Kumari Raut.&nbsp; Like the other women interviewed in the Malangwa area, Anita diligently did her ANC check-ups, once also visiting the district hospital to have a test confirmed. She took iron and calcium supplements (when in stock) and added fortified flour to her diet to gain weight.&nbsp; Nurse Raut says she is happy with how she and her colleagues managed Anita’s delivery, despite the health post’s limited resources: “Everything is fine now but if something had happened, the hospital had resources and facilities to deal with it.” <h2>Maternal deaths deliver lessons</h2> A day before the central government budget was released on 29 May, officials in the Family Welfare Division (FWD) of the Department of Health were resigned to the fact that the status quo was the most they could achieve in programming for the 2023-24 fiscal year.&nbsp; But Section Chief Gauri Pradhan had her fingers crossed that a verbal promise of more funding would allow the section to expand at least one program — for <a href="https://www.nepalitimes.com/news/3-nepali-mothers-still-die-daily-at-childbirth">maternal and perinatal death</a> surveillance and response (MPDSR).&nbsp; Started in Nepal at the Maternity Hospital in Thapathali in 1992, guidelines were created for the program in 2015 and revised in 2021. Today, MPDSR takes place in 42 districts, both in hospitals and where there are maternal and newborn deaths in communities.&nbsp; The promised funding, from an external partner, will permit the program to expand to more hospitals and communities. Pradhan displays the WhatsApp app on her mobile, which shows a group for reporting of mother and newborn deaths in hospitals and another for community deaths.&nbsp; Asked why this one program is likely to be the only maternal and newborn health initiative in the FWD to expand next year, Pradhan says: “It is the basic thing to take action to learn the cause of death. Without knowing the causes, how can we develop activities to make childbirth safer?”&nbsp; Expenses for this trip were paid by One Heart Worldwide.

Mothers of Sarlahi

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101136/63720cbc9c7e80680e0b7884jpeg.jpg" alt="" width="720" height="540"/><figcaption>Nurses Puspa Pandhak and Sumnima Khapung delivering the baby inside a jeep late at night on 3 March, after concluding that they could not reach the Tehrathum district hospital in time because of the bad road. Photo: DINESH BHATTARAI</figcaption></figure>Puspa Pandhak was just finishing her duty at a rural hospital in Tehrathum district last week when a 19-year-old woman was brought in on a stretcher, writhing in pain.As a birth attendant nurse, Pandhak had performed more than 100 safe deliveries in the past five years, but this maternity case was the first breech she was having to deal with.“As soon as I saw the position of the baby, we decided not to take the risk and take her to Tehrathum Hospital,” Pandhak says.Read also: <a href="https://www.nepalitimes.com/here-now/birth-and-death-during-a-pandemic/" target="_blank" rel="noopener noreferrer">Birth and death during a pandemic</a>, Nunuta RaiBut, as is often the case in rural Nepal, they could not get an ambulance. The condition of the mother and baby was deteriorating, and every second counted.Luckily, a four-wheel drive jeep just happened to pass by and gave them a lift. Pandhak and fellow nurse Sumnima Khapung got on with their patient, taking along their delivery kits.The road was bumpy and dangerous, made worse by the previous day’s heavy rain and the pitch black night. It was already 9:30PM, and they were nowhere near their destination.“It was a rough ride, and we were being thrown about inside the car, but I tried to reassure the young expecting mother since this would be her first baby,” Pandhak recalls.Read also: <a href="https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/" target="_blank" rel="noopener noreferrer">Who will save Nepal's poor new mothers</a>, Rojita AdhikariIn the front seat, the patient’s mother and husband were panicking, and that was not helping at all. Then driver Dinesh Bhattarai also started getting unnerved, and that was not a good sign.It was now nearly 11PM, and it did not look like they would get to the district hospital in time. Pandhak made the tough decision to stop the journey in the small bazar of Tukre.“The trip was becoming too long due to the poor road condition and I knew we would never reach the hospital where an emergency doctor and midwife team were on standby to receive us,” Pandhak recounts. “I was very nervous, but knew that the mother was in bad shape and I needed to help somehow.”<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101136/63720cbe9c7e80680e0b7885jpeg.jpg" alt="" width="1070" height="1600"><figcaption> </figcaption></figure>The two nurses then decided the safest course was to deliver the baby inside the car. In a breech case, the baby’s body is upside down, which means the head is stuck. Pandhak and Khapung tried to help the mother push the baby, while aware that this could injure her.Finally, the nurses managed to carefully pull the baby out, without the mother suffering a serious tear.Read also: <a href="https://www.nepalitimes.com/here-now/saving-one-nepali-mother-at-a-time/" target="_blank" rel="noopener noreferrer">Saving one Nepali mother at a time</a>, Aruna Uprety“I cannot describe the elation and relief that we felt, and I am sure the mother and her relatives were much happier than us, we had delivered a healthy baby inside a cramped car, and mother was also fine,” Pandhak told us on the phone from Tehrathum.After the enroute delivery, the jeep with one extra person on board, continued the journey to Tehrathum District Hospital. When they got there just past midnight, the emergency team could not believe what they saw.Says Pandhak, “They were so proud of us as they took charge of mother and baby at the birthing facility. It was a nerve-wracking experience, but it all ended well.”<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101136/63720cc19c7e80680e0b7886jpeg.jpg" alt="" width="794" height="854"><figcaption> </figcaption></figure>Pandhak and Khapung are on the frontlines of Nepal’s efforts to <a href="https://www.nepalitimes.com/latest/3-nepali-mothers-still-die-daily-at-childbirth/" target="_blank" rel="noopener noreferrer">reduce maternal and infant mortality</a>. Thirty years ago, 10 in 10,000 women in Nepal used to die in childbirth. That number has come down to 2 in 10,000. But progress has now flat-lined, and 1,500 mothers still die during delivery every year in the country.Even though such individual acts of heroism never make it to the news, it is the work of Female Community Health Volunteers, dedicated Skilled Birth Attendants (SBAs) like Puspa Pandhak and Sumnima Khapung, and local governments that are helping save lives every day across Nepal.In this case, it was also the support for renovating and equipping the birthing centre and midwife training provided by the organisation One Heart Worldwide (OHW) to Menchhhyayem Rural Municipality that helped raise the capacity of the two nurses.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221114101136/63720cc39c7e80680e0b7887jpeg.jpg" alt="" width="640" height="853"><figcaption> </figcaption></figure><a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/what-can-be-more-fulfilling-than-saving-lives/" target="_blank" rel="noopener noreferrer">OHW uses a partnership approach</a> with rural municipalities to upgrade birthing centres through cost-sharing to encourage local ownership. When the work is complete it moves on to other districts.“I still feel so relieved and excited that we saved the lives of the mother and baby, and it was also a life-changing moment for me,” Pandhak says. “I feel so happy to see the family so thrilled. This is the greatest reward that a nurse can ever have.”Pandhak says it was the OHW training that gave her the confidence to make the right decision to deliver in the car and not wait to get to hospital. She adds, “The successful outcome has also given us new confidence to deal with complicated cases in future.”

Another baby's life is saved in rural Nepal

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111410114/637204f29c7e80680e0b288djpeg.jpg" alt="" width="1500" height="1000"/><figcaption>Photos: UNICEF NEPAL</figcaption></figure>Despite periods of political and economic instability, Nepal achieved dramatic progress in maternal and child health in the early 2000s becoming an international model.It took great strides in reducing childhood malnutrition, in particular, reducing stunting from 57% in 1996 to 33% in 2016. Maternal and Infant mortality rates also similarly declined, only for much of these successes <a href="https://www.nepalitimes.com/banner/nearly-half-of-nepali-children-still-malnourished/" target="_blank" rel="noopener noreferrer">to stall in the recent years</a>. And this trend has been made worse by the Covid-19 pandemic, states a new UNICEF report.Titled “<a href="https://onlinelibrary.wiley.com/toc/17408709/2022/18/S1" data-saferedirecturl="https://www.google.com/url?q=https://onlinelibrary.wiley.com/toc/17408709/2022/18/S1&amp;source=gmail&amp;ust=1642768390008000&amp;usg=AOvVaw2Qo1HoClES2POc3Qyp2i-7">Nutrition in Nepal: Three decades of progress for children and women</a>”, the report brings together a set of nine original articles that examine the drivers of success and identify where greater policy and programmatic action is needed to achieve the Sustainable Development Goal (SDG) nutrition targets.“Optimal maternal and child nutrition is the basis for developing a resilient society,” says EU Ambassador to Nepal, H.E. Nona Deprez. “The decline in the number of malnourished children, improvements in health facilities and services, and the multisectoral approach used in Nepal over the past three decades are a testament to the Government of Nepal’s commitment to reducing all forms of malnutrition.”A <a href="https://onlinelibrary.wiley.com/toc/17408709/2022/18/S1" data-saferedirecturl="https://www.google.com/url?q=https://onlinelibrary.wiley.com/toc/17408709/2022/18/S1&amp;source=gmail&amp;ust=1642768390008000&amp;usg=AOvVaw2Qo1HoClES2POc3Qyp2i-7">special supplement of the Maternal and Child Nutrition Journal</a> published on Thursday lists some of Nepal’s biggest nutritional achievements. Between 1996-2016, the early initiation of breastfeeding saw an increase from 18% to 56%, and complementary feeding increased from 54% to 77%.During the same period, women taking sufficient iron and folic acid supplements during their pregnancy rose from 6% to 71%. This was combined with earlier and more frequent antenatal care visits.Consistent administering of Vitamin A has saved the lives of an estimated 45,000 Nepali children under the age of five, between 2002 and 2015. Similarly, households using adequately iodised salt doubled from 35% to 77% from 1998 to 2016.Much of this progress can be credited to improvements in household wealth, parental education, and <a href="https://www.nepalitimes.com/banner/toilet-trained/" target="_blank" rel="noopener noreferrer">sanitation</a>. But equally important was increased coverage of health and nutrition services undertaken by successive governments.Nepal Government utilised ground-breaking research to test interventions and overcome challenges, it is also committed to enforcing mandatory legislation such as salt iodisation, writes the journal supplement.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111410114/637204f69c7e80680e0b288ejpeg.jpg" alt="" width="1500" height="1001"><figcaption></figcaption></figure>Mobilisation of <a href="https://www.nepalitimes.com/latest/enlisting-female-health-volunteers-to-fight-covid-19/" target="_blank" rel="noopener noreferrer">Female Community Health Volunteers</a> (FCHVs) across Nepal villages and towns have improved the health of mother and children, so has an investment in sectoral programs including education and sanitation.But there are now new challenges to achieving national and global targets on nutrition, which also threatens to undermine past gains.“The learning from the past 25 years that are incorporated in the supplement will inform and contribute to future improvements. However, we must act now, given the impact that the pandemic has had on the nutritional health of mothers and their children,” says Elke Wisch, UNICEF Representative to Nepal.During the pandemic, most households experienced job losses or reduced income. With the <a href="https://www.nepalitimes.com/here-now/3rd-wave-in-2-years/" target="_blank" rel="noopener noreferrer">Omicron-led third wave</a> spreading across Nepal, the pandemic’s ensuing socioeconomic crisis is long from over.This means reduced dietary intake among children and mothers. School closures will deprive many children of getting one decent meal a day. All this will add to <a href="https://www.nepalitimes.com/banner/nepals-epidemic-of-hunger/" target="_blank" rel="noopener noreferrer">childhood malnutrition</a> which continues to be a major cause of death and retarded mental and physical development among younger populationsAs such, UNICEF has recommended the government to improve the general public’s access to nutritious, safe, affordable, and sustainable diets. It also suggests integrating essential nutrition services into the existing service delivery platforms like family planning, antenatal, delivery and post-natal care and well-child and sick-child care and continuing to mobilise FCHVs to reach more women and children.To disseminate factual information, advice and counselling on infant and young child feeding, <a href="https://www.nepalitimes.com/here-now/3rd-covid-wave-infects-nepals-frontliners/" target="_blank" rel="noopener noreferrer">healthcare workers</a> can also use multiple communication channels such as radio, TV or social media.But perhaps equally if not more important is strengthening local levels so that they can plan, implement and monitor nutrition programs and services, and maintain Nepal's commitment to generating data, information, and evidence to assess progress and inform decisions.

Covid undermines Nepal's mother-child gains

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141136/636cfe469c7e80680e0a0c2ejpeg.jpg" alt="" width="2529" height="1427"/><figcaption>Photo: HIMALMEDIA</figcaption></figure>A white-coated nurse holding a blue and white, half-litre bag of milk stands in front of a small group of mothers seated near the entrance of the Nutrition Rehabilitation Home in Kathmandu.She is explaining the importance of feeding milk to their children, who are lolling on their mothers’ laps. On a table behind the nurse are containers of pulses and legumes and leaning against the wall, charts displaying leafy vegetables.But later, listening to the women’s stories, it is apparent that solving their children’s problems will require more than a healthy diet. Through tears, Chandra, 24, says she brought her son Raju, 21 months, to the Home after a routine hospital check-up found that he was malnourished.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141136/636cfe499c7e80680e0a0c2fjpeg.jpg" alt="" width="3706" height="2170">His father, who Chandra was forced to marry, bought barely enough food for them to survive, says the woman. That deprivation, plus physical beatings and “mental torture” caused Chandra to flee their village home for Kathmandu.Mother and son arrived in January at the 24-bed facility perched on a hill on the outskirts of the city, where housing colonies sprout on former farm fields. In the month since then, Raju has gained 1kg in weight and is much stronger.The boy will stay at the Home for a few more weeks, says Sunita Rimal, coordinator of the Malnutrition Prevention and Treatment Program at the Nepal Youth Foundation, which runs the Home. By then she hopes to have found some work in Kathmandu for Chandra via her informal channels, so that the mother-son pair don’t have to go back.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141136/636cfe4d9c7e80680e0a0c30jpeg.jpg" alt="" width="901" height="786">Epidemic of hungerNina Parajuli, 45, brought her daughter Anushka, 7, to the Home weeks later on the advice of staff at a local non-governmental organisation. Nina had gone there for skills training after losing her house-cleaning job in Kathmandu.She was forced to find work unexpectedly after Anushka was born, when her husband deserted them. The family that hired her ate their first meal of the day only in the afternoon, which meant the girl left for school in the morning having eaten only snacks, while her mother worked. Eventually, Anushka grew dangerously thin and was considered severely malnourished when she arrived.Nina “was too concerned with her own problems to notice,” Rimal explains. Like her husband, she is HIV positive. She also has a heart condition and is on a waiting list for a uterus operation.Though unique, the stories of Nina and Chandra share a common thread — the causes of their children’s malnutrition are multifaceted. Rimal says that is the norm: “Most of the people who come here have other socioeconomic problems.”Past achievements Nepal is celebrated globally for its success in fighting malnutrition from the 1990s until recent years. Most notably, rates of stunting (low height for age) fell from the world’s highest, 68% in 1995, to 36% in 2016.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141136/636cfe509c7e80680e0a0c31jpeg.jpg" alt="" width="2410" height="1064"><figcaption> </figcaption></figure>New research has teased out exactly which development efforts had what impact on stunting. Indirect (also known as ‘nutrition-sensitive’) approaches were surprisingly effective. For example, better educated parents accounted for 25% of the improvement, <a href="https://www.nepalitimes.com/banner/toilet-trained/" target="_blank" rel="noopener noreferrer">environmental factors</a> like building more toilets contributed 12% and economic growth made up 9%.Direct (‘nutrition-specific’) efforts included: improved nutrition of mothers (accounting for 19% of the gain), and maternal and newborn health care (12%), according to the research, published on the website <a href="https://www.exemplars.health/topics/stunting/nepal">Exemplars in Global Health</a>.“The exemplars that we picked were countries that did (development) much faster than others. Nepal is not necessarily the best example but it is an important example,” says Zulfiqar A Bhutta of the Centre for Global Child Health at The Hospital for Sick Children in Toronto, one of the leaders of the research.“One thing is very clear, no one country has done it alone by only investing in health and nutrition sectors,” explained Bhutta via Zoom from Toronto. “And no one country has done it alone by only investing in poverty alleviation strategies. So the truth is that you have to do both in combination.”Nepal has continued that broad approach, investing in health both directly and indirectly, <a href="https://www.nepalitimes.com/banner/nearly-half-of-nepali-children-still-malnourished/" target="_blank" rel="noopener noreferrer">yet the progress has plateaued</a>.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141136/636cfe549c7e80680e0a0c32jpeg.jpg" alt="" width="1628" height="1255">While stunting continues to fall, the 36% rate is greater than the developing country average of 25% and the Asia average of 21.8%. In fact, the country is on target to hit only one of its nutrition goals for 2025 set by the World Health Assembly — for underweight children under 5 — says the <a href="https://globalnutritionreport.org/resources/nutrition-profiles/asia/southern-asia/nepal/">Global Nutrition Report 2020</a>.So what happened?“The one thing that I was surprised by is that inequity has increased,” says Bhutta, “and I have a feeling some of that may have had to do with the urban poor or rural to urban migration.”Nepal, he adds, should work to pinpoint the who’s and why’s of poverty, but otherwise, it should maintain its balanced approach.Investment on nutrition A recent analysis from UNICEF found, however, that spending on indirect approaches to fight malnutrition was rising while declining for direct interventions. This goes against the direction given in the government’s <a href="http://nnfsp.gov.np/PortalContent.aspx?Doctype=Resources&amp;ID=330">Multi-sector Nutrition Plan</a> (MSNP), the blueprint for tackling malnutrition.<a href="https://www.nepalitimes.com/editorial/hunger-for-governance/">Hunger for governance</a>, EditorialThe first phase of the MSNP ran from 2013 to 2017, and the current plan ends next year. The analysis in UNICEF’s <a href="https://www.unicef.org/nepal/media/13296/file/Nutrition%20-%20Budget%20brief.pdf">Nutrition Sector Budget Brief</a> also pointed out that the cost of programs in phase two (Rs48.9 billion) of the multisector plan is just 54% of phase one (Rs88.5 billion). In addition, the gap between budget numbers and actual spending has been growing.Kiran Rupakhetee of the Good Governance and Social Development Division at the National Planning Commission secretariat, helped shape MSNP-II. In an online interview he suggests that rather than the current plan’s budget being too low, the budget for MSNP-I might have been “over calculated at the time”.As to the growing gap between allocations and real spending — it results from many factors, including “rigidities and structural barriers” in the system, he explains.Another major challenge for MSNP-II is federalism, which introduced three levels of government after elections in 2017. “It’s a Herculean task… because at the moment it’s not only one government—we have 761 governments… There are some difficulties in ensuring coordination among them,” adds Rupakhetee.The pandemic challenge The Covid-19 pandemic <a href="https://www.nepalitimes.com/latest/covid-19-leaves-millions-of-south-asian-children-hungry/" target="_blank" rel="noopener noreferrer">has added to the challenge</a>. “It definitely has hampered our activities,” says Rupakhetee, “but we tried our level best to keep the programme going.”For example, parents were trained to measure the arm circumference of infants to detect signs of malnutrition, a task usually done by female community health volunteers, who have been unable to do so due to frequent lockdowns.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141136/636cfe579c7e80680e0a0c33jpeg.jpg" alt="" width="960" height="640"><figcaption> </figcaption></figure>Nepal’s school feeding programme was also modified because of the pandemic, with food rerouted to students’ homes, says World Food Programme (WFP) Country Director Jane Pearce, in an online interview.“Whereas most of the world stopped all of their school meals programmes, Nepal has continued, which has meant that we’re maintaining the nutrition that we’re providing through our locally-managed school meals programmes by giving households take-home rations,” she said.WFP has also teamed up with UNICEF and other UN agencies to press the government to expand its malnutrition treatment to include not only children who are severely wasted (low weight for age) but moderately wasted, says WFP’s Head of Nutrition Anteneh Girma.“With the impact of Covid and others, if they’re not treated they will become severely malnourished, then chronically malnourished, or stunted,” he adds.In June <a href="https://www.nepalitimes.com/banner/nepals-epidemic-of-hunger/">this paper reported</a> on how severe malnutrition was killing children in the poorest communities in Nepal’s eastern plains. It told the story of Raju Devi Sada, whose first daughter died at 3, after being malnourished. A second daughter died soon after birth, a year later.A third daughter is underweight and local health workers have recommended feeding her nutritious food. But Raju Devi cannot afford vegetables, eggs, milk and meat, and what she earns as a daily wage labourer is barely enough to feed the rest of the family.“We have found that up to 70% of children who die every year in Province 2 do so due to malnutrition, and the main reason for that is extreme poverty,” said Kedar Parajuli at Nepal’s Family Welfare Division. “Without alleviating poverty, we can’t solve malnutrition.”WFP is doing mapping, using mobile data, to create what it calls a vulnerability index. It documents people’s access to water and sanitation services, health and other factors, in addition to nutrition, says Girma.He adds, “Our nutrition response, food security response, is informed by that index… it indicates those who are vulnerable for not having access on time, for being exposed to various inequalities.”The private sectorGirma points out that WFP, both in Nepal and globally, supports the multisector approach. In that vein, the UN agency is working closely with the government to establish the <a href="https://sunbusinessnetwork.org/">Scaling Up Nutrition (SUN) Business Network</a> in Nepal. To date, 10 companies, all working in the food industry, have become members.Ending malnutrition and other food-related diseases “will happen only if the private sector is responsible for what they are producing, and producing something safe …  so their engagement, bringing them to the table, is very important,” says Girma.Leading collaboration with the private sector on the ground is <a href="https://www.baliyonepal.com/en/">Baliyo Nepal</a>, a non-profit company that generated headlines when it launched in 2019. The initiative was funded by the Bill &amp; Melinda Gates Foundation through the Chaudhary Foundation, the charity arm of the Chaudhary Group, makers of Wai Wai instant noodles, which are widely considered junk food.<a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/junk-food-is-making-nepali-children-shorter/" target="_blank" rel="noopener noreferrer">Junk food is making Nepali children shorter</a>, Marty LoganToday Baliyo Nepal is set to expand a pilot project that has been running in Lumbini Province since 2020 — raising awareness about nutritious food among school children, including via a cricket program, and educating shopkeepers to sell the nutritious foods in the first phase of its ‘Baliyo Basket’: eggs and a single-portion Rs10 sachet of fortified porridge for infants.“Seventy percent of the sachets in the market were sold, according to the sales report,” says Baliyo Nepal CEO Atul Upadhyay, a nutritionist, in an interview in his Kathmandu office. “The feedback we’re getting from mothers is ‘Now we want it in a bigger package. We can’t go to the shop every day and buy the Rs10 package’.”Upadhyay says manufacturers will start making the larger packs by year end. That is just one of many plans he is cooking up — besides expanding pilot activities to Bagmati and Gandaki provinces, the company will soon be adding to its Baliyo Basket a fortified drink for pregnant and lactating women and fortified porridge for 2-5-year-olds, once they are approved by the government.Upadhyay notes that both the government and private sector are gradually embracing his innovative approach but stresses that new ways to fight malnutrition, like this public-private partnership model, are essential if Nepal is to reach its nutrition targets.“It’s not important who works for nutrition. It’s important that someone works for nutrition, whether it be WFP, Baliyo Nepal, company A, company C — I don’t mind,” he adds.Target StuntingStunting, low height for age, is a sign of chronic undernutrition. It can hinder brain development resulting in reduced mental ability and learning capacity, poor school performance in childhood and lower earnings and higher risks of nutrition-related chronic diseases, such as diabetes, hypertension and obesity, in adulthood.Nepal cut its stunting rate dramatically in recent decades, and it is one form of malnutrition that the country might be on track to reduce in line with coming targets: MSNP-II (2022), World Health Assembly (2025) and SDGs (2030).The UNICEF Nutrition Sector Budget Brief says that the average yearly rate of stunting reduction since 2001 (3.25%) must increase to 3.8% to meet the MSNP-II and WHA targets, and rise to 6.5% to meet the SDG target.According to Kiran Rupakhetee at the National Planning Commission: “The Nepal Multiple Indicator Cluster Survey has brought some encouraging results, but it may still be difficult to make the WHA target... but since the SDGs deadline is quite far away I’m very much optimistic and hopeful that we can meet it.”Stunting rates and targets 2016: Nepal Demographic and Health Survey – 36%2019: Nepal Multiple Indicator Cluster Survey – 31.5%2022:  Target: Multi-sector Nutrition Plan-II – 28%2025:  Target: World Health Assembly – 25%2030:  Target: SDGs – 15%

Marty Logan

A tall order

Besides multiple <a href="https://nepalitimes.com/news/republicans-and-royalists-on-nepal-s-streets">street demonstrations </a>that gridlocked Kathmandu’s traffic for the past weeks, public discourse in Nepal has also been dominated by dangerously <a href="https://nepalitimes.com/here-now/air-pollution-is-more-dangerous-than-smoking">high air pollution levels</a>. Caused mostly by hundreds of <a href="https://nepalitimes.com/news/wildfire-season-starts-early-in-nepal">forest fires </a>raging across the country, the smoke contains suspended soot particles that harms <a href="https://nepalitimes.com/opinion/playing-with-poison">human health</a>. Thursday’s rain have cleared the air somewhat, and many people will soon forget how bad the air quality was. But the time to address the roots of next summer’s fire season is now.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250411060440_d1a119716a9031aadfdd611d299348d436842d376a03e664b8d773957a237524.jpg" data-media-id="editor_4" data-image-id="20250411060440_d1a119716a9031aadfdd611d299348d436842d376a03e664b8d773957a237524" data-rendition-name="original" width="502" height="540" loading="lazy" alt="Wildfires"> <figcaption>EXTINGUISHED: Forest fires raging all over Nepal in the week after 3 March (above) reduced air quality, creating a public health hazard in Kathmandu and across the country. Each red dot is a fire detected by infrared sensors on the NASA Fire Information for Resource Management System (FIRMS) satellite. But the rain on Thursday doused most of the fires (below) with more rain forecast over the weekend.</figcaption> </figure>  The reason everyone was talking about air pollution was because the<a href="https://nepalitimes.com/banner/nepal-is-going-up-in-smoke"> smoke from wildfires</a> was visible. But much more toxic are the invisible and odourless <a href="https://nepalitimes.com/news/nepal-doubles-its-carbon-footprint">gases from vehicular and industrial emissions </a>which have always been there. The theme of World Health Day on 7 April this week was ‘Healthy Beginnings, Hopeful Futures’ dedicated to <a href="https://nepalitimes.com/opinion/comment/saving-more-mothers-and-babies">preventing maternal and newborn deaths</a>. It is estimated that in Nepal, 30% of neonatal mortality can be blamed on air pollution. But that is only part of the story. Harmful as fine particulate matter is to human health, carbon monoxide, nitrogen dioxide, ground-level ozone and other gases in vehicular emissions are more hazardous to health. While the concentration of suspended particulate matter tinier than 1.5 microns (PM2.5) is closely monitored, these toxic gases are invisible, not measured much, and the public is not aware about the dangers they pose. Surface ozone is produced by the interaction of various gases found when <a href="https://nepalitimes.com/news/fossil-fuels-poison-air">burning fossil fuels</a>. Besides being poisonous, ground level ozone contributes up to 0.23°C to <a href="https://nepalitimes.com/here-now/nepal-s-mountains-are-melting">global warming</a> because it is also a greenhouse gas. A new policy brief by the Clean Air Fund titled The Case for Action on Tropospheric Ozone blames surface ozone for a half a million premature deaths every year, 54.8% of which are in South Asia. Ozone also stunts plant growth and reduces crop yields by 26% globally, and 11% loss in <a href="https://nepalitimes.com/news/economic-benefits-of-saving-the-ecology">forest productivity</a>, the report adds.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250411060456_aa02a923f8b27544ae54d0220162678f5bbb5eeb8fc3c466173c22c49b3e9a85.jpg" data-media-id="editor_11" data-image-id="20250411060456_aa02a923f8b27544ae54d0220162678f5bbb5eeb8fc3c466173c22c49b3e9a85" data-rendition-name="original" width="998" height="724" loading="lazy" alt="Gas Chambers"> </figure>  Read also: <a href="https://nepalitimes.com/here-now/bad-air-and-polluted-politics">Bad air and polluted politics</a>, Sonia Awale Ground-level ozone is not emitted directly into the air like other gases, but is formed when oxides of nitrogen (NOx), carbon monoxide (CO) and volatile organic compounds (VOCs) released from automobile tailpipes or industry smokestacks react chemically with each other in the presence of sunlight. The main source of carbon monoxide in Kathmandu Valley are its 1.2 million two-wheelers. “Usually the concentration of carbon monoxide is 200-500 parts per billion (ppb), this has increased up to 3,000 in Kathmandu. Meanwhile, ground-level ozone has gone from 70-80 ppb to 150 ppb,” says Ravi Sahu, regional air quality specialist with the Kathmandu-based International Centre for Integrated Mountain Development (ICIMOD).&nbsp; Sahu says <a href="https://nepalitimes.com/news/no-smoke-without-fire-p7vb9dcj">rampant forest fires of the past weeks</a> have also added to carbon monoxide and ozone in the air, not just the fine particles that make up the visible smoke. He adds, “There isn’t much awareness about <a href="https://nepalitimes.com/banner/poisoning-the-air-we-breathe">ground-level ozone and carbon monoxide</a>, we need to urgently look into it.” A distinction must be made between good and bad ozone. Stratospheric ozone protects living beings from harmful ultraviolet (UV) radiation from the sun.&nbsp; Tropospheric ozone can again be separated into two types: ozone in the free atmosphere which is a greenhouse gas much more potent than carbon dioxide, and ground-level ozone which has adverse impacts on health and agriculture. ‘Cutting tropospheric ozone presents a unique challenge as it requires smart and fast action across multiple greenhouse gases and air pollutants, as well as multiple economic sectors,’ notes the Clean Air Fund's policy briefing. ‘It is a growing and neglected problem that needs an integrated approach on both a local and global level to tackle climate change and air pollution together.’ Dying young There was a time when Nepal made it to international news bulletins only if there were fatalities on Mt Everest. Now, Kathmandu’s bad air frequently makes headlines all over the world. This past week, the concentration of PM2.5 that harms human health was up to 40 times the WHO recommended guideline — adding to the poisonous gases already present from vehicle emissions. The Department of Environment says 40% of the pollution in the past weeks was from wildfires sparked by nearly 6 months without substantial rain over central Nepal. Most of the rest is from vehicular and industrial emissions from Kathmandu itself and across the southern border. NASA’s Fire Information and Resource Management System (FIRMS) which issues daily maps of fires, showed hundreds of blazes raging across Nepal on Wednesday, mainly in Chitwan, Parsa and along the East-West Highway.&nbsp; “If we look at the figures for the last few years, it is clear that wildfires have become the biggest source of air pollution, they are seasonal but have overtaken vehicular emissions,” says urban planner and environmentalist Bhushan Tuladhar. “Forest fires, stubble burning, and open burning of garbage are the bigger problems now. Nepal, India, Bangladesh, and Pakistan are at risk every year, we shouldn’t further delay in finding solutions,” warned air quality expert Bhupendra Das during an event on air pollution organised on 7 March by the Nepal Forum of Environmental Journalists (NEFEJ).&nbsp; Indeed, studies have shown that in winter 60% of the air pollution over Kathmandu is transboundary from the south, and in November it is compounded by smoke from crop residue burning by farmers in India and Pakistan blown in by prevailing winds. Forest fires are a regular pre-monsoon occurrence in Nepal, often intentionally set by farmers and herders to stimulate new grass growth for livestock. Winter rains have failed for eight of the past ten years, and this means the fires often spread out of control. The other reason for the increase in wildfires is the doubling of forest fires to 46% of the country’s area in the past 25 years. But this has happened simultaneously with outmigration, with some mountain districts losing 30% of their population between 2011-2021. With less pressure on forests for fodder and firewood, the undergrowth of community forests is loaded with dry fuel just waiting for a spark. The bowl-shaped topography of Kathmandu, Pokhara and other valleys further concentrates pollutants as they are trapped by surrounding mountains. But a year with a high number of wildfires is usually followed by a year or two with fewer incidents. For example: there were 6,537 fires in 2021 but the following year the number was down to 1,528. There were 5,216 fires last year, this year the number has already reached 1,800, and the trend is likely to be broken. Heavy rains forecast for the coming days are expected to douse some of the fires and clean up the air. But the damage has been done: Kathmandu residents of all age groups this week crowded clinics and hospitals with burning eyes, itchy throats, difficulty breathing, headaches, and dizziness. But in the longer term, soot particles that are tiny enough to jump the blood-air divide in lung capillaries do not just cause Chronic Obstructive Pulmonary Disease (COPD), asthma, but also cancers, heart attacks, strokes, birth defects and other chronic diseases. The latest Air Quality Life Index (AQLI) report by the University of Chicago shows that the annual concentration of PM2.5 in Kathmandu’s air rose from 17.87µg/m3 in 1998 to 31.33µg/m3 in 2022. Air pollution has got worse by 75% in Kathmandu in 25 years. During this time, air pollution has reduced the average life expectancy of Kathmandu’s residents by 3.5 years. According to the Health Effects Institute in Boston, dirty air is among the biggest public health concerns in Nepal killing over 42,100 a year. The adverse impact of high levels of air pollution is not limited to public health, it is seriously affecting tourism. Operators in Pokhara this week said that there were many negative online posts by visitors unable to see the famous panorama of Machapuchre and the Annapurnas even from Sarangkot. Aviation is also affected, as planes have to circle sometimes for hours burning a lot of fuel because of runway visibility being below minima at Kathmandu airport. The higher fuel cost is just passed down to customers, making air tickets in and out of Kathmandu some of the highest in the world. Kathmandu, with a population of four million, has not implemented a concrete policy to curb toxic air despite having formulated various action plans and repeated commitments by the government to protect the environment and control air pollution. The Department of Environment’s 2017 Air Quality Management Action Plan for Kathmandu put forward a policy to reduce air pollution caused by vehicles which was approved by the Cabinet, but has yet to be put to practice. The action included the immediate implementation of the Euro 5 emission standard to reduce pollution emitted by vehicles. However, Nepal has not even been able to implement Euro 4 standards so far. India, meanwhile, has already moved forward with the implementation of the Euro 6 standards. Says Ravi Sahu: “Air pollution in Nepal is not just about air pollution, it has ties to tourism, aviation, the economy so we must be prepared for annual conditions like forest fires, and this requires urgent interdisciplinary collaboration.” &nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250411050452_821d09e283d8a590f1369bfb71b9b7fc6d950726e0651ea86c6488d04deb1742.jpg" data-media-id="editor_15" data-image-id="20250411050452_821d09e283d8a590f1369bfb71b9b7fc6d950726e0651ea86c6488d04deb1742" data-rendition-name="original" width="839" height="784" loading="lazy" alt="Silent Killers"> </figure>  &nbsp;

What is invisible is more dangerous

On Tuesday, leader of the monarchist RPP once again gathered on Kathmandu’s streets to deliver fiery speeches, but this time there was no arson and looting and no need for riot police to fire live rounds or tear gas.
RPP leaders demanded the release of their members including vice-president Rabindra Mishra and MP Dhawal Shamsher Rana were arrested during the violent <a href="https://nepalitimes.com/news/republicans-and-royalists-on-nepal-s-streets">28 March protests at Tinkune </a>which left two dead. 
They denounced the current leadership of the main parties, demanding the <a href="https://nepalitimes.com/editorial/nepal-party-reincarnating-hindu-monarchy">restitution of Nepal as a Hindu kingdom</a>. They also said the government was responsible for the fatalities on 28 March because it provoked its rally with a tear gas attack even before it started.
It has now been revealed that the police fired at least 100 live rounds from high powered assault rifles at the crowd. Twenty-one of the 120 injured received bullet wounds, and most of them were bystanders and people trying to reach home. 
Tuesday protest on the Ring Road in Balkhu was much more subdued, and comparatively fewer RPP supporters showed up. The arson and vandalism in the previous protest appears to have cost some support for <a href="https://nepalitimes.com/news/the-ghost-of-monarchy-returns-to-haunt-nepal">former king Gyanendra </a>especially for the anointment of medical tycoon and bank defaulter <a href="https://nepalitimes.com/news/street-politics">Durga Prasai </a>as ‘commander’ of the Tinkune rally.
Some monarchists acknowledge Gyanendra’s mistakes when was king 2001-2008, but say he has had a lot of time to reflect on his shortcomings and seems more disciplined and committed. His supporters have tried to build on nostalgia among some Nepalis for<a href="https://nepalitimes.com/news/why-invest-in-nepal"> domestic stability </a>and international respect that <a href="https://nepalitimes.com/here-now/if-birendra-was-alive-nepal-could-still-be-a-monarchy">the monarchy</a> commanded. 
“Nepalis were promised better service delivery, opportunities for the underserved, as well as better, more honest use of state resources, but the <a href="https://archive.nepalitimes.com/news.php?id=16992">people in leadership </a>have not been able to deliver on their commitments,” says RPP leader Prakash Chandra Lohani. “The gap between their rhetoric and reality has widened, the people feel betrayed, and the respect Nepali people had previously had for them has changed to revulsion.” 
Indeed, many commentators have warned the three main parties and their <a href="https://nepalitimes.com/editorial/politics-as-usual">serial prime ministers</a> who have ruled Nepal for much of the past 30 years should address rising public anger with them, and see the writing on the wall.
‘<a href="https://nepalitimes.com/news/nepal-government-changes-again">The UML, NC and Maoists</a> must introspect about their conduct,” warns Gunaraj Luitel, editor of Nagarik, in an op-ed this week. ‘These leaders for life may save themselves from simmering public anger, but they will not be able to save the system. The monarchist wave can only be dispelled when citizens are assured of <a href="https://nepalitimes.com/here-now/nepal-s-local-election-gives-power-back-to-people">better governance</a> through <a href="https://nepalitimes.com/latest/real-world-training-for-youth-leaders">younger leaders</a>, and reforms.’ 
Rifts between radical royals who are gunning for a return to <a href="https://nepalitimes.com/here-now/mob-movement-and-mayhem">Panchayat-style absolutism </a>and moderate monarchists who favour a constitutional king have also weakened the movement somewhat. The split between the RPP and RPP-Nepal cost the royalists numbers in Parliament in 2022, and both parties denounced the violence last month, albeit shifting the blame on the government.
The irony is that the same royalists who want to scrap the republican Constitution had formed electoral alliances with the UML during the 2022 elections. RPP-Nepal chair Kamal Thapa contested the 2022 election with the UML. Thapa has not taken part in the last two rallies, saying he will only be a part of a movement under a national flag, and not a RPP party banner.
For his part, the RPP’s Rajendra Lingden is said to be hesitant to censure some of his party’s more radical royalists for fear of fissure within his ranks, despite his aversion to Durga Prasai’s role. 
Analysts have questioned why <a href="https://nepalitimes.com/news/old-is-still-gold-in-nepali-politics">supporters of the monarchy </a>have decided to reestablish an institution that would not ultimately have executive decision-making power. There are doubts about whether authoritarian-minded Gyanendra will be satisfied being a <a href="https://archive.nepalitimes.com/news.php?id=13957">ceremonial king</a>. 
Read also: <a href="https://nepalitimes.com/news/nepal-s-deja-vu-on-black-friday">Nepal’s déjà vu on Black Friday</a>, Sonia Awale
"The Nepali people will not accept <a href="https://nepalitimes.com/here-now/forgotten-woman-who-sheltered-communist-activists">an absolute monarchy </a>at this point of time, and both the public as well as <a href="https://archive.nepalitimes.com/news.php?id=8371">king Gyanendra</a> are fully aware that there is no other possibility beyond a constitutional monarchy," asserts the RPP’s Lohani. “The traditional monarchy’s institutional capacity might have been enough to meet the needs of feudal Nepal, but an absolute monarchy is impossible both in concept and practice in the context of <a href="https://archive.nepalitimes.com/regular-columns/Economic-Class/waiting-for-an-industrial-revolution,784">modern day Nepal</a>.”

New year revolutions

82 in २०८२

Every earthquake, even a minor one, shakes <a href="https://nepalitimes.com/banner/clash-of-cultures-in-bhaktapur">Bhaktapur</a> more severely than other parts of <a href="https://nepalitimes.com/banner/time-capsule-of-kathmandu">Kathmandu Valley</a>, and <a href="https://nepalitimes.com/here-now/nepal-s-traditional-seismic-resistant-designs">seismologists</a> attribute this to its soil structure. It was no different<a href="https://nepalitimes.com/here-now/lessons-not-learned-from-2015-o2etq6zu"> in 2015 when a 7.8M earthquake rocked central Nepal</a>. Brown dust from collapsed buildings blanketed the town like a sand storm. Even 10 years later, the scars of that disaster are all around, even though most of the monuments have been rebuilt.&nbsp; At the entrance to <a href="https://nepalitimes.com/banner/clash-of-cultures-in-bhaktapur">Bhaktapur Darbar Square</a> is the Rameswar temple, where workers are lifting bricks to repair the damage. The Vatsala Durga temple inside the palace complex collapsed, but the all-stone structure has been masterfully restored.&nbsp; The Yaksheswar Mahadev temple is encased in a bamboo scaffold. Piles of bricks and tiles &nbsp;are stacked below it. Some workers are on top of the temple, while others work on the ground mixing mortar. To the north of the Darbar Square is the Fasi Dega temple which has been rebuilt. The 55-window palace and the art museum which were damaged have also been repaired.&nbsp; The <a href="https://nepalitimes.com/news/nyatapola-alight">five-storey Nyatapola</a>, which survived both the 1934 and 2015 earthquakes, just underwent a $6.3 million renovation. In Taumadhi Square below, the Biska Jatra chariot is under construction for upcoming festivities. Some tourists are on it, posing for pictures.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250407090432_8da447f3cf32a67ba22eedda74af74a6636cd001b544a303eb8e5f8adf3115e3.jpg" data-media-id="editor_6" data-image-id="20250407090432_8da447f3cf32a67ba22eedda74af74a6636cd001b544a303eb8e5f8adf3115e3" data-rendition-name="original" width="2000" height="1284" loading="lazy" alt="Bhaktabur rebuilt 10 years after Nepal earthquake NT 1"> <figcaption>All photos: AJAY HAKAJU</figcaption> </figure>  Read also: <a href="https://archive.nepalitimes.com/article/nation/Monumental-loss,2215">Monumental loss</a> At Pottery Square, three workers sit atop an under-construction structure whittling away with chisels. Nearby houses are still supported by wooden beams. Dattatreya Square was also damaged during the earthquake, but has been renovated.&nbsp; <a href="https://nepalitimes.com/here-now/born-again-after-the-earthquake">After the earthquake</a>, the international community rushed in with offers of help. Kathmandu’s Hanuman Dhoka was restored by the Chinese, Gaddi Baithak by the Americans and various countries ‘adopted’ other monuments. But Bhaktapur declined assistance. UNESCO wanted to be involved since Bhaktapur had been a World Heritage Site since 1979. Germany wanted to help with a €10 million grant, since it had spearheaded the Bhaktapur Development Project 40 years ago.&nbsp; “We believed that we should be able to reconstruct our monuments ourselves,” says Ram Govinda Shrestha, an architect with the municipality. Indeed, Kathmandu Valley has historically rebuilt after every major earthquake with its own resources. Architect and conservationist Rabindra Puri says, “It is shameful to let someone else come in and do the reconstruction for us, especially since the manpower and material would be ours anyway. Why use money from elsewhere?”  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250407090436_7f19bc8a185c9f71404db44fba086438d6c29a3acb63a63d027cbdd4053e1b4f.jpg" data-media-id="editor_9" data-image-id="20250407090436_7f19bc8a185c9f71404db44fba086438d6c29a3acb63a63d027cbdd4053e1b4f" data-rendition-name="original" width="2000" height="1123" loading="lazy" alt="Bhaktabur rebuilt 10 years after Nepal earthquake NT 1"> </figure>  The budget for reconstruction came from the government, town entry fees, taxes, and donations. That was the easy part. But this was followed by multiple discussions between the municipality, the National Reconstruction Authority (NRA), the Department of Archaeology, and multiple stages of proposals, designs, estimations, and building. New committees had to be formed at every step. “Part of the reason why there were so many steps is because we have to let the government know that we were working as frugally as possible,” recalls Shrestha. It cost more than $200 million to rebuild the 116 heritage structures that were destroyed and damaged.&nbsp; Nevertheless, Bhaktapur stands as a model of locally sourced reconstruction in every way. Community people themselves got their hands dirty along with domestic workers and learned various aspects of reconstruction. “We showed what is possible when locals feel a strong sense of responsibility,” adds Shrestha. Read also: <a href="https://archive.nepalitimes.com/page/tourists-trickle-back-to-Bhaktapur">Bhaktapur is waiting for you</a>, Peregrine Frissell But while the monuments were rebuilt, it was not the same with residential buildings. Many of them still have cracks running down their brick façades, and some neighbourhoods are still in ruins with small trees and bushes growing from the rubble.&nbsp; More than 300 people were killed and over 2,000 wounded in house collapses in Bhaktapur. There were some dramatic rescues, including of a baby Sonish Awal who was rescued by an APF team 24 hours after being buried under the rubble.&nbsp; Sonish is now 10 years old, and his house has been rebuilt. The government vowed to ‘Build Back Better’ as fast as possible, by removing bureaucratic hurdles and grant Rs300,000 in three instalments, as well as access to loans at low interest. But things did not go smoothly.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250407090436_d503e5c966f33978abf99a0fa8307369d81bcc6a6e5d768cf88b7dee273cb6cf.jpg" data-media-id="editor_11" data-image-id="20250407090436_d503e5c966f33978abf99a0fa8307369d81bcc6a6e5d768cf88b7dee273cb6cf" data-rendition-name="original" width="2000" height="1123" loading="lazy" alt="Bhaktabur rebuilt 10 years after Nepal earthquake NT 1"> </figure>  “Bhaktapur is very dense, so there was a lot of confusion about where property lines ended, and where walls were,” says Biswanath Sujakhu, a municipality engineer. There were also disputes in families with multiple sons who had stakes in the house, as the act treated them as a single household.&nbsp; Many of the disputes have not been resolved yet, which is why there are so many ruins. &nbsp;Homeowners who chose to remake their houses to look traditional were promised further subsidies of up to Rs300,000, but even that was not enough to pay for the Rs5 million or so needed to build a multi-storey cement structure.&nbsp; Banks weren’t giving loans easily, and multiple changes to the NRA chief meant the grants were not easy to access. Many residents took high-interest loans from local cooperatives. Or they were forced to undersell their land plots. “Bhaktapur also had restrictions about the styles and height of buildings, but many houses didn’t comply as people could only work with the money they had at the time,” adds Sujakhu. Nepal Vocational Academy, established by Rabindra Puri two years before the earthquake in 2013, played a crucial role. The academy produced enough masons, woodcarvers, and stone carvers so that there wasn’t a shortage. The students were also involved in <a href="https://archive.nepalitimes.com/regular-columns/guest-editorial/guest-editorial-better-late-than-never,891">reconstruction efforts</a> across the country. Puri has just one gripe: “A lot of old houses that were perfectly fine were torn down for no reason. Those houses are 200-300 years old and could have been restored instead of being reconstructed.” &nbsp; Read also: <a href="https://nepalitimes.com/here-now/in-with-the-old-in-nepal">In with the old in Nepal</a>, Shriluna Shrestha

maternal-health