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

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A deadly sugar rush

<figure><img width="1920" height="1280" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111016114/636d13aa9c7e80680e0a9934jpeg.jpg" alt=""/><figcaption></figcaption></figure>South-East Asia has achieved the fastest rate of decline in <a href="https://archive.nepalitimes.com/regular-columns/Comment/fired-up-over-tobacco,920" target="_blank" rel="noopener noreferrer">tobacco use</a> among any other region in the world in 20 years, sustaining tobacco control measures during the Covid pandemic, according to a <a href="https://www.who.int/publications/i/item/who-global-report-on-trends-in-prevalence-of-tobacco-use-2000-2025-third-edition" target="_blank" rel="noopener noreferrer">new WHO Global Report</a>.
The region was estimated to have the highest average rate of tobacco use compared to all other WHO regions, with around 432 million users, or 29% of the total population.
However, the average prevalence of smoking among men in South-East Asia went down from 50% in 2000 to 25% in 2020, while tobacco smoking among women saw a sharp decline from 8.9% to 1.6% during the same timeframe, reports the 4th WHO Global Report on Trends in Prevalence of Tobacco Use 2000-2025.
South-East Asia at present has the highest proportion of the population covered by tobacco surveillance to monitor tobacco use prevalence and tobacco control policies. With continued efforts, smoking rates in the region could reach as low as 11% by 2025. 
“Sustained political commitment and relentless efforts by countries to strengthen surveillance, expand tobacco control measures including cessation services to help users quit tobacco are some of the key reasons for success,” said Poonam Khetrapal Singh, Regional Director of WHO South-East Asia.
In Nepal, <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/in-a-puff-of-a-smoke,3739" target="_blank" rel="noopener noreferrer">overall tobacco use went down</a> from 56% of the population in 2000 to 26% in 2020. Meanwhile, 2020 figures put 15% of the Nepali population over 15 years old as smokers.
However, the report lists Nepal among the only two countries in the region, along with India, that are likely to achieve the targeted 30% relative reduction in tobacco use by 2025. 
Nepal introduced its Tobacco Control and Regulation Act in 2011 and has some of the strictest smoking laws. The country is far ahead of other nations in the region with its anti-tobacco campaigns and is among few in the region to have scaled-up tobacco cessation services.
However, Nepal, which has imposed a 27% tax on the retail price of <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/Kicking-butts,329" target="_blank" rel="noopener noreferrer">tobacco</a>, has the lowest rates of taxation on tobacco products in the region. The WHO recommends a minimum 75% tax share of the retail price of tobacco.
For packaging, Nepal has implemented large-sized graphic health warnings on tobacco packs, requiring that they cover 90% of the front and back of packages. Pictorial, or graphic, warnings are one measure contained in the global blueprint for fighting tobacco use: the WHO Framework Convention on Tobacco Control (FCTC). Nepal joined the treaty in 2007. 
The FCTC and MPOWER package, a set of six cost-effective and high impact measures to help countries reduce demand and supply of tobacco, contributed significantly to the implementation and effectiveness of tobacco control measures across the country.
Singh also reaffirmed WHO support to member countries towards tackling non-communicable diseases (NCDs) and <a href="http://archive.nepalitimes.com/news.php?id=18267#.YZYlumBByUk" target="_blank" rel="noopener noreferrer">controlling tobacco</a>, emphasising the importance of WHO’s ‘best buys’— a set of cost-effective interventions for the prevention and control of NCDs.
“The best buys…continue to be at the core of the Regional response, recognising the need for countries to identify &amp; implement the most effective, feasible, and affordable interventions whatever their resource setting,” said Singh.
With sustained and accelerated efforts, and using the power of innovation, countries in the region can fulfill their commitment to FCTC and to the 2030 Sustainable Development agenda, leaving no one behind, read a statement by WHO South-East Asia.
Globally, there are now 1.30 billion tobacco users compared to 1.32 billion in 2015. This number is expected to drop to 1.27 billion by 2025.  Sixty countries are on track to achieving the voluntary global target of a 30% reduction in tobacco use between 2010 and 2025, two years ago only 32 countries were on track.

Tobacco use in South-East Asia declines

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

POOR HEALTH MAKES NEPALIS POORER

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

Poor  health

Where will Nepal be in 2050? It is only 25 years away. The country’s population will be peaking at 36 million, the poverty rate will drop to near zero. Maternal and child mortality rates will fall further. Nepal will be generating up to 40,000MW of hydro and solar power, more than half of that for export. Upgraded highways will improve connectivity, railways will make transport cheaper. Pokhara and Birganj will only be two hours away from Kathmandu. Nijgad airport could be Nepal’s new aviation hub, reducing Kathmandu’s congestion. Nepal will hitch its wagon to the engines of economic growth in India and China. Investment and job creation will reduce outmigration, Nepal's data centres will be powered with surplus electricity. Remote areas will prosper with high-value tourists. That is if all goes well. But if Nepal’s politics remains dysfunctional with incompetent leadership, then the country will muddle along as it is doing now. Society will be more unequal, public discontent may boil over as politicians resort to faith to hide failures, the exodus abroad of youth will continue. Climate breakdown will exacerbate these crises. Global average temperature will have risen to 2.7°C above pre-industrial levels (it is 1.1°C now). The remaining Himalayan icecap will shrink by half, glacial lakes will threaten valleys. The hydrology of rivers will change, reducing dry season flow. Severe and prolonged heat waves in the Tarai will force people to migrate back to the mountains. In the final analysis, it all boils down to a political system that is more accountable, and displays more integrity and efficiency. <h2>Mission 2050</h2> · Melamchi Water Supply Project · Pokhrara International Airport · Bhairawa International Airport · Upper Tama Kosi Hydroelectric Project . Kathmandu-Tarai Expressway What do these biggest infrastructure projects in Nepal have in common? All ended up being more expensive than they should, all have been delayed and are not fully operational, two were badly damaged in climate-related disasters that should have been foreseen. The $800 million Melamchi is Nepal’s most expensive infrastructure project to date. It took 30 years to build, but was nearly destroyed by a glacial debris flow in June 2021. The headworks need major repairs. The 456MW Upper Tama Kosi was severely damaged by a rockfall and floods in last September’s floods. It is still not operating at full capacity, and other hydropower plants were damaged in recent glacial floods. Pokhara and Bhairawa airports were supposed to be the new aviation gateways to Nepal to take the pressure off Kathmandu, and become game changers for tourism and pilgrimage. Nearly three years later, both handle domestic flights. Poor and inadequate design, kickbacks on contracts, cost overruns, failure of diplomacy to get India’s nod on air routes, and lack of planning and marketing have made the airports a pair of white elephants. Some of these setbacks can be blamed on natural calamities, but mostly it is political incompetence and greed, lack of accountability and poor implementation. That is no surprise, since these are the hallmarks of doing business in Nepal, often delaying projects, adding to the cost, and even when completed they are already outdated. That is the story of the last 25 years, are the next 25 going to be any different? Not if governance does not improve. “What we really need for the future is vision, idea, and understanding, and then the domestic capacity to implement them,” says infrastructure expert Surya Raj Acharya, who laments the total absence of technical and planning expertise. “None of our national highways meet technical standards, our cities are unplanned. The priority was never on quality. Politicians sold us short-term infrastructure that have now become a barrier to prosperity,” he adds. One silver lining has been private sector involvement in hydropower, and the energy strategy aims to generate 11,769MW by 2030. But hydropower is high-investment, high-risk due to climate breakdown, and ecologically damaging. “Hydropower is a good example of how government incentives and public-private partnership can work wonders, although we now have to take climate change into account,” explains economist Kalpana Khanal of the Policy Research Institute. She adds, “We now have to identify other key infrastructure areas that also enhance the growth of other sectors.” The National Planning Commission’s periodic plans guide overall social and economic strategy for the country into the coming decade. Nepal’s current five-year plan (2024-2029) has set a target of 7.3% annual economic growth against the current 3.9%, $2,351 per capita income up from $1,456 at present, and poverty reduction to 12%. The plan aims to export nearly half the hydropower generated by 2030, earning the country Rs41 billion annually. But there is no real coordination between line agencies, and bureaucratic lethargy leads to constant delays, says former member of the National Planning Commission (NPC) Min Bahadur Shahi. “Development in Nepal is still very much synonymous with building roads and bridges, and infrastructure is rudimentary,” he says. “Elsewhere in the world, digital infrastructure and governance go hand in hand, we are far behind.” The frustration of a man who served in the National Planning Commission is an indication where the problem lies: in actually executing plans and implementing strategies. “We need to prioritise projects based on our geography, climate, societal needs,” Shahi continues. “We want to push Nijgad airport when we can’t even operate Pokhara and Bhairawa. Have we even studied potential air routes and needs of international carriers?”  <figure><img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250726070744_0547e5a7fd4424b5de8c279cab637ee7ebd9e65f2673b15e6dbd4eb2aa2524f2.jpg" data-media-id="editor_0" data-image-id="20250726070744_0547e5a7fd4424b5de8c279cab637ee7ebd9e65f2673b15e6dbd4eb2aa2524f2" data-rendition-name="original" width="3600" height="2400" loading="lazy" alt="Pokhara airport"><figcaption>NO FLY ZONE: Pokhara airport was supposed to be the new aviation gateway to Nepal but nearly three years after its inaguration, it mostly handles domestic flights. Photo: RADHIKA KANDEL </figcaption></figure>  TARGET PRACTICE Export of hydropower, manpower and lately information technology are the mainstays of Nepal’s economy, and will carry the country to its graduation from Least Developed Country status to a developing country in November 2026, and hopefully to middle-income by 2030. Nepal has an installed capacity of about 3,800MW, most of it from hydropower, and increased adoption of electric cars has reduced the import of petroleum products, decreasing the trade deficit with India. Meanwhile, Nepalis abroad sent home $11 billion in remittances last year, and at least $900 million in backend IT exports. But demographer Yogendra B Gurung is not impressed: “Despite the reduction in the poverty rate, and our improving income status, life expectancy, income, even maternal and infant mortality are not on par with countries with similar economic status.” He says relying on remittances is an unsustainable economic model, vulnerable to external factors and remittances are mostly spent on day-to-day needs, and not invested in productive sectors. Remittance is credited with reducing poverty in Nepal which is down to 20.27% from 42% in 1990. Money sent home by workers abroad has allowed families to afford basic healthcare and education, in turn helping to reduce childhood malnutrition and maternal mortality while improving female literacy. But the progress has stalled in recent years, and many doubt Nepal will meet its Sustainable Development Goals (SDGs) targets. The National Planning Commission has said Nepal is likely to achieve just 60% of the targets by 2030. Sex ratio at birth, which is 112 boys to 100 girls in Nepal in particular, is worrying, as it is much higher than the biological ratio of 105 to 100. This is much more pronounced in Karnali, Sudurpaschim and Madhes Provinces which suffer from historical neglect. Despite a rise in female literacy, patriarchy is still deeply entrenched and the provinces are behind the rest of the country for gender equality, education, healthcare, nutrition and economic opportunities. “Karnali is resource-rich, especially hydropower and the recent discovery of the methane gas, but inequality is much greater,” says Shahi, who is with the Karnali Integrated Rural Development and Research Centre (KIRDARC). “Federalism in Nepal is only on paper, we need a total structural reform to devolve political power to really bring about change.”  <figure><img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250726070744_fd4a218656e1fbf6f13f5f87a47bfe624516c6a0232481b6be77875ae866deb9.jpg" data-media-id="editor_1" data-image-id="20250726070744_fd4a218656e1fbf6f13f5f87a47bfe624516c6a0232481b6be77875ae866deb9" data-rendition-name="original" width="3600" height="2400" loading="lazy" alt="Butwal-Narayangadh "><figcaption>The Daunne section of the Butwal-Narayangadh road notorious for traffic jams and accidents, it has been in never-ending construction for three years. Photo: BISHNU PRASAD GAUDEL / RSS </figcaption></figure>  Despite limited resources, Nepal also suffers from wasteful investment as a result of politically (mis)guided decision-making, instead of people-centric plans and policies, says demographer Gurung. “People are overwhelmingly moving to the cities but our leaders are hell bent on building roads to every village and now there are empty schools in the mountains,” he adds. Nepal needs data-driven planning but its long-term economic vision 2020-44 seems more of a wish-list than realistic goals, including average annual GDP growth of 10.5%, $12,000 per capita income and population under the absolute poverty line at 0. Other goals include raising electricity generation capacity to 40,000MW, access to motor transport to 99%, life expectancy at birth to 80, maternal mortality down to 20% and literacy to 99% and 100% access to the internet, among others. Meanwhile, Nepal is committed to net-zero by 2045 and 100% renewable energy by 2050. “Our planners have no idea what kind of infrastructure we need 20, 30 years down the line to sustain and accelerate growth. We need a big structural change in the political leadership, in technocratic planning, and for policy implementation,” says infrastructure expert Surya Raj Acharya. Meeting such targets would require large investment, and it would be unwise to rely on remittances for the longer run, especially as Nepal’s demographic dividend will diminish as it turns into an aged society by 2065. Reversing out migration requires a favourable investment climate so jobs are created. Good governance marked by accountability and transparency are the basic prerequisite for ease of doing business. But lack of rule of law and illicit funds put Nepal in the grey list of the Financial Action Task Force (FATF), the global money-laundering watchdog. “Everything comes down to a political will. The established parties must realise that if they don’t perform, they will be replaced by alternatives,” says Kalpana Khanal. “In the meantime, we must engage the youth and find ways to retain them as well as attract the diaspora to invest in Nepal.”

Nepal in 2050

MetLife Nepal has signed Rohit Paudel and Indu Barma, the captains of the national men’s and women’s cricket teams, to promote the importance of life insurance.

Metlife signs Nepal cricket captains

The monsoon has got bad press because Nepal’s tourism operators actively told visitors to avoid <a href="https://nepalitimes.com/opinion/managing-the-monsoon?%2F">the rainy season</a>. It is time to change that. The reason can be found right here in the vast alpine meadows of Central Nepal where this time of year you can walk on velvet grass of pastures abloom with delicate pink, red and yellow flowers as the mist rolls up the valley. There is no sound except the hum of bumble bees. &nbsp;&nbsp; There are dozens of places across high Nepal called Chaurikharka, which means yak pasture. But this particular Chaurikharka in Rukum East located at an altitude of 4,000m stands out for its serene beauty, rustic charm and bucolic setting. There is just the occasional chime of <a href="https://nepalitimes.com/here-now/when-yaks-go-so-does-culture">yak bells</a> in the distance, and the sharp whistle of herders corralling sheep. &nbsp;&nbsp; The grass shoots are so fragile that one hesitates to step on them, the rounded ridges appear and quickly vanish in waves of mist. With the<a href="https://nepalitimes.com/here-now/before-the-next-monsoon"> arrival of monsoon</a>, these meadows are a soothing shade of green dotted with millions of <a href="https://nepalitimes.com/review/the-anatomy-of-a-flower?%2F=">multi-coloured flowers</a>. Until very recently, it took a week or so to hike up to places like Chaurikharka, but with the expansion of the road network even to these far-flung mountains in the lap of Dhaulagiri, they are much more accessible. It is just a three-hour uphill from the Mid-Hill Highway on the border between Baglung and Rukum East.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250802130828_a0b06b494d751b2144ffbbf10894ea64b29e8aed844bc8c66171783abfaf4e16.jpg" data-media-id="editor_4" data-image-id="20250802130828_a0b06b494d751b2144ffbbf10894ea64b29e8aed844bc8c66171783abfaf4e16" data-rendition-name="original" width="2048" height="1365" loading="lazy" alt="Visit Nepal in the monsoon"> </figure>  Purists would say that such easy access devalues the sanctity of these remote high meadows, but it also means more people will be moved to treasure the experience, appreciate <a href="https://nepalitimes.com/banner/natures-fragile-gift-to-nepal">the value of nature </a>so they can take steps to protect it.&nbsp; To be sure, the <a href="https://nepalitimes.com/here-now/deadly-monsoon-in-nepal-turns-deadlier">monsoon season can be challenging for road travel</a>. The roads are rough even at the best of times, and in the monsoon they become muddy and treacherous, often blocked by<a href="https://nepalitimes.com/news/monsoon-deluge-in-nepal"> landslides</a>. But that could be precisely the kind of adventure that the more intrepid visitors crave. Improved road connectivity has already made Chaurikharka and places like Badimallika &nbsp;and other sacred lakes in the mountains of western Nepal popular with domestic tourists. What is driving this traffic is the urge to go to exotic new places and share videos and selfies on social media. Several of Nepal’s travel vloggers have visited Chaurikharka and popularised the place, enticing followers on TikTok or YouTube to retrace their footsteps. But even as they become more popular, these fragile and once-remote places should be protected from over-tourism.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250731110736_f97110b7cdc3e7f80d5877690948fc9f4c95a09c583deb23b07355491e6c5446.jpg" data-media-id="editor_8" data-image-id="20250731110736_f97110b7cdc3e7f80d5877690948fc9f4c95a09c583deb23b07355491e6c5446" data-rendition-name="original" width="1083" height="699" loading="lazy" alt="Visit Nepal in the monsoon NT"> </figure>  <h2>INCREASING FOOTFALL</h2> Chaurikharka is located in Bhume Rural Municipality of East Rukum, near the scenic valley of Dhorpatan in Baglung district. Even in the <a href="https://nepalitimes.com/banner/monsoon-culture">middle of the monsoon</a>, there is a steady stream of Nepali hikers trooping to these high pastures – especially during festival days like Saune Sankranti which this year was on 17 July and actually marks the auspicious beginning of the monsoon here. “This year the rains have not been as heavy and there have been some clear mornings when we could see everything from Dhaulagiri to Machapuchre,” says Khageswar Bhandari, who trekked up here from the road. “The flowers, the greenery and the snowy mountain views make this an incredibly unique place.”&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250802130824_1b9e26f2e9853fdfe69154bb42a7c9ea6da4bf4940efc1da99b304dcfbd7d3d9.jpg" data-media-id="editor_10" data-image-id="20250802130824_1b9e26f2e9853fdfe69154bb42a7c9ea6da4bf4940efc1da99b304dcfbd7d3d9" data-rendition-name="original" width="2048" height="1152" loading="lazy" alt="Visit Nepal in the monsoon"> </figure>  Chaurikharka is worthwhile to get to in any season, but it has a different charm during the monsoon. Word has spread and because it is now easy to get to from Baglung or even Pokhara, people have been flocking here.&nbsp; “Holidays and Saturdays see the largest crowds, with up to 500 visitors every day,” says ward chair Mankaji Pun of Bhume.&nbsp; There was a time not too long ago when local herders brought sheep, goats, cows, buffaloes, horses, and mules to graze here during the monsoon. Although there are still livestock around, animals have been replaced by visitors taking selfies. Read also: <a href="https://nepalitimes.com/here-now/the-monsoon-and-nature-s-arithmetic">The monsoon, and nature’s arithmetic</a>, Tom Robertson Ward Chair Pun says infrastructure development is his main priority. A foot trail to Chaurikharka was built last year by the Tourism Division Office in Kohalpur, but access via the Raniwas-Koipa road section still remains challenging.&nbsp; “If we get more budget, we can improve the road and facilities to make Chaurikharka the main tourist attraction of this region,” says Bhume Municipality Chair Hom Prakash Shrestha. “After that, we hope to promote Chaurikharka as a top tourist spot.”&nbsp; Economic activity is also picking up with the arrival of visitors, but there seems to be a need to manage the makeshift sheds made of corrugated sheets that spoil the beauty of the place. Tea shops and lodges are also available but facilities are basic. Kuldeep Neupane took a three-day trip from Ghorahi in Dang to visit Chaurikharka recently, and says: “This is an ideal trip to make a quick getaway and let nature recharge your mind and body. And it is much more fun with a tent, to watch the sunrise over the Himalaya or the mist blowing in.”

Visit Nepal in the monsoon

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

non-communicable-diseases