Here in the mountains of far-western Nepal, the biggest threat to life and limb is gravity. Women collecting fodder fall from trees, boys grazing goats fall off cliffs, heavily loaded tractors plunge from dirt roads carved out of steep slopes. There is nothing to be done about those who die on the spot. But for the severely wounded there is only one hospital: Bayalpata. And it is there that <a href="https://www.youtube.com/watch?v=CJzWlnYd0ZM&amp;t=8s" target="_blank">orthopaedic surgeon Mandeep Pathak</a> is the last hope for many wounded people. Pathak, 42, is too modest to tell us how many lives he has saved over the past 10 years he has worked at Bayalpata. But hospital records show he has performed more than 4,000 operations in the past decade, many of them so patients did not suffer permanent physical disabilities. Pathak also did 800 major life-saving surgeries in that time. “I treat patients with injuries, but I wish I could also treat poverty,” Pathak says, emerging from Bayalpata’s surgical theatre one recent afternoon. <div class="embed-block"><iframe width="700" height="415" src="https://www.youtube.com/embed/CJzWlnYd0ZM?si=s_rkbU4YDaw87gqH" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe></div> Sudurpaschim Province in Nepal’s far-west is far away from everything: from Kathmandu, from adequate medical care, from food security, and far from the reach of government services. It has suffered state neglect for centuries, its men mainly migrating to India for seasonal work to families who depend on subsistence agriculture. Pathak remembers the searing sadness he felt when a patient once told him, “Doctor, I sold the last of my rice to pay to come here, please give me a medicine that I can take on an empty stomach.” Pathak was born in Kathmandu, and after getting his MBBS from Kathmandu University, he got an MD from The Philippines. At a time when many Nepali doctors and staff nurses were emigrating, Pathak did not just return to Kathmandu but decided to go to one of the remotest districts in Nepal to serve those most in need. The hospital was established in 2009 in the village of Bayalpata, and has been managed by the non-profit <a href="https://www.nyayahealthnepal.org/" target="_blank">Nyaya Health Nepal (NHN)</a> as a public-private partnership treating 100,000 patients a year for no fees at all. NHN is now preparing to hand over the running of the hospital to the Sudurpaschim provincial government so its <a href="https://nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health" target="_blank">model of hospital management</a> can be replicated.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250414130456_b59dabd4604a24426a55fe91c0e5866b5029858bdb4c4028c331557aeb5408ae.jpg" data-media-id="editor_4" data-image-id="20250414130456_b59dabd4604a24426a55fe91c0e5866b5029858bdb4c4028c331557aeb5408ae" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="Bayalpata hospital"> <figcaption>Bayalpata hospital in Achham.</figcaption> </figure>  People from not just Achham but surrounding districts, and from as far away as Humla, bring patients to Bayalpata, sometimes walking for days. Some with complicated pregnancies are brought in stretchers, young children with broken arms walk into the emergency, and sometimes there are mass casualties when a tractor or bus falls off a road. And Pathak is always there with his team performing triage, and doing orthopaedic surgeries that would be difficult even in Kathmandu. Recently, his team did a hip replacement at <a href="https://nepalitimes.com/banner/state-of-the-art-rural-hospital" target="_blank">Bayalpata Hospital</a>. Mild mannered, modest, soft-spoken, hard-working, professional are the words families of patients who have been treated at <a href="https://nepalitimes.com/here-now/nepal-s-rural-lifeline" target="_blank">Bayalpata Hospital </a>use to describe Mandeep Pathak. But the surgeon is too busy to let all this get to this head.&nbsp; Asked why he does not emigrate like his peers or get a lucrative position at a private hospital in Kathmandu, Pathak answers simply, without a trace of self-importance, “I do not think I could get the satisfaction or sense of fulfilment anywhere else.” When travelling to attend medical congresses overseas or visit family in Kathmandu, Bayalpata has other doctors to take care of patients, but many wait patiently till Pathak returns for their consultation or surgery.&nbsp; When he returns from seminars abroad after learning the latest skills, Pathak’s suitcases are not full of clothes or presents, but titanium bone implants, external fixation rods, or intramedullary nails to be used in <a href="https://nepalitimes.com/news/altruistic-healthcare-models-in-nepal" target="_blank">surgeries at Bayalpata</a>.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/2025041414040_5356278472c1eb2b9e4af1d593d6234cc8dc5e5161a8c614197c01abefadbd80.jpg" data-media-id="editor_8" data-image-id="2025041414040_5356278472c1eb2b9e4af1d593d6234cc8dc5e5161a8c614197c01abefadbd80" data-rendition-name="original" width="2048" height="1368" loading="lazy" alt="surgery"> </figure>  Before Bayalpata Hospital was established, most people suffering broken bones had to travel down to Dhangadi or Nepalganj for treatment. No more. Although Pathak’s specialisation is orthopaedic oncology, he is mostly treating fractures and rejoining broken bones.&nbsp; Now as Bayalpata’s Hospital Director, Pathak also has administrative and fundraising duties. He has to take the 10-hour ride down to Dhangadi often to meet various Sudurpaschim ministries to release the hospital’s budget — that is sometimes more difficult than the most complicated surgery. Recently, he had to cancel an appointment with the Chief Minister to rush back to Bayalpata because there was a patient who needed emergency surgery. “I told myself, let me save this patient first, then I will try to save the hospital,” he recalls.&nbsp; Once, when he had to be away for a month on emergency surgery training in the US, the family of a 90-year-old woman who had dislocated her hip after falling from a staircase was waiting for him to return. Her son told Pathak: “Doctor, either put her out of her suffering, or cure her.” Pathak told him it was too dangerous to operate at her age, but the son said his mother was in so much pain it was worth the risk. The operation was touch-and-go, but it was successful. The woman who had been brought in on a stretcher, walked out of the hospital three days after the operation.&nbsp; A few months later, a 27-year-old woman was brought into the ER bleeding profusely from an arm mangled by a thresher machine. Even in that state, she was breastfeeding her baby. Pathak welled up seeing this display of selfless motherhood, as he wheeled her into surgery. She needed three operations, but now has full use of her hand. <div class="embed-block"><iframe width="700" height="415" src="https://www.youtube.com/embed/xJdxLD0hBqo?si=mOpM2R_DsYL88Lfg" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe></div> It is the sense of achievement from such recovery that keeps Mandeep Pathak here in this isolated village in the middle of nowhere. Bayalpata Hospital has not just saved lives, it also saves families from poverty because they do not have to take sick relatives to expensive city hospitals.&nbsp; In January, a woman was brought to Bayalpata with both hands broken. She said she had taken a fall, but Pathak did not believe her. When alone in the surgery, she finally admitted that her husband had beaten her.&nbsp; It was her husband who had brought her to hospital for treatment, but she refused to file a police report. Pathak quietly put both her arms in casts, thinking about the poverty, patriarchy and injustice in society that he is unable to treat.

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The healer of far-western Nepal

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

Pratikshya Roka Magar was a sickly baby ever since she was born in a faraway village in Rukum district. As years went by, the girl’s spine started to bend. Her mother Namrata Roka had given up hope that her daughter would ever get better when she heard about a Japanese doctor who was conducting a mobile health camp in the village.&nbsp; Partikshya was seven years old in 2013 when Japanese physician Ryukichi Ishida examined her, and diagnosed a rare case of spinal scoliosis that ultimately affects the lungs and heart.&nbsp; Now 17, Pratikshya has undergone six major operations in which two rods were inserted to her spine to straighten it. The Japanese benefactor has since been supporting her financially, and checks up on Pratikshya routinely.&nbsp; Read also: <a href="https://www.nepalitimes.com/here-now/nepali-doctors-love-for-urdu-poetry">Nepali doctor's love for Urdu poetry</a>, Abdullah Zahid  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230817070836_da4e6800792c2aba1c4f41e664f24db51fbc25142c2e41e46b77e2da9d602f29.jpg" data-media-id="editor_1" data-image-id="20230817070836_da4e6800792c2aba1c4f41e664f24db51fbc25142c2e41e46b77e2da9d602f29" data-rendition-name="original" width="1504" height="1000" loading="lazy" alt="Ryukichi Ishida NT"> <figcaption>Photo: SUMAN NEPALI</figcaption> </figure>  “He is like god for us,” says a grateful Namrata. &nbsp; Pratikshya is not the only one who has received Ishida’s healing touch in these mountains where the health system is still rudimentary, and the ravages of the Maoist conflict still linger. During voluntary work with tuberculosis control while walking through Nepal’s remotest districts in 1968 as a 21-year-old medical student, Ryukichi Ishida made a promise that he would return one day to serve the people of this country. Back in Japan, while heading the orthopaedic department at Osaka's Ueda-Shimotanabe Hospital, he constantly felt the tug of Nepal. In 2006, he left his family and a satisfying job to fulfil his pledge to return to Nepal. A question that had nagged him all those years was why medical care around the world, including in Japan and Nepal, was not more equitable. Read also: <a href="https://www.nepalitimes.com/news/paul-farmer-on-my-mind">Paul Farmer on my mind</a>, Bibhav Acharya  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230817070836_6a2d16dbb69aaaf7f900a41835ca9e091d427f2de37a1411b5df7199749fcf6c.jpg" data-media-id="editor_3" data-image-id="20230817070836_6a2d16dbb69aaaf7f900a41835ca9e091d427f2de37a1411b5df7199749fcf6c" data-rendition-name="original" width="1494" height="1000" loading="lazy" alt="Ryukichi Ishida NT"> <figcaption>Photo: JHUMLAWANG VILLAGE FOUNDATION NEPAL</figcaption> </figure>  Ishida was inspired by his physician father who also ran a clinic in the most underserved part of Japan. He has travelled through Dolakha, Jumla, Jajarkot, Rukum and Rolpa, conducting free medical camps carrying just a backpack — just like when he trekked through Nepal as an idealistic student all those years ago. He has been working at Rolpa's Jaljala Health Post since 2011, a place so remote that even Nepali health workers are reluctant to be posted there. The facility has since been turned into a hospital and research centre and is in the process of becoming a 15 bedded municipality hospital.&nbsp; The hospital has Nepali staff, but none of them stay more than a year. “The only thing constant here is Dr Ishida and his commitment to serve the people,” says Ajay Magar of the Jhumluwang Village Foundation, a non-profit that conducts health camps in collaboration with Ishida.&nbsp; Read also: <a href="https://www.nepalitimes.com/review/the-good-doctor-0pqhzm7t">The good doctor</a>, Lisa Choegyal  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230817070836_909cd240e9e4ea3b0da86e6038a2a163f6d5e9e94df5117008cbdbf0cf8946f6.jpg" data-media-id="editor_5" data-image-id="20230817070836_909cd240e9e4ea3b0da86e6038a2a163f6d5e9e94df5117008cbdbf0cf8946f6" data-rendition-name="original" width="1531" height="1000" loading="lazy" alt="Ryukichi Ishida NT"> <figcaption>Photo: JHUMLAWANG VILLAGE FOUNDATION NEPAL</figcaption> </figure>  Besides treating patients, Ishida has also supported locals like Sahanshila Buda Magar who is the first female MBBS graduate from Thawang thanks to a scholarship he provided.&nbsp; Sahanshila, 27, got her degree from Changsha Medical University in China, and is undergoing a three-month training at Patan Hospital. She plans to go back home and work at the Jaljala Hospital. &nbsp; Ishida says the staffing challenges of remote area facilities in places like Rolpa can only be met by producing their own crop of young doctors with a commitment to the place they belong.&nbsp; Despite his years of experience as an orthopaedic surgeon, Ishida believes in integrating modern medical practices with traditional healing, especially for bone-setting and birthing. Read also: <a href="https://www.nepalitimes.com/banner/nepals-far-sighted-eye-care">Nepal's far-sighted eye care</a>, Sonia Awale  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230817070836_03aa6692c46a7850cb8d05acb0e89f7928a5dab973fcfa466ab9417fcd85c165.jpg" data-media-id="editor_7" data-image-id="20230817070836_03aa6692c46a7850cb8d05acb0e89f7928a5dab973fcfa466ab9417fcd85c165" data-rendition-name="original" width="3711" height="2770" loading="lazy" alt="Ryukichi Ishida NT"> <figcaption>Photo courtesy: RYUKICHI ISHIDA</figcaption> </figure>  The only reward Ishida has for his work is the respect and affection of Thawang's people. Villagers refer to him simply as “हाम्रो डाक्टर” (our doctor) — indicating they have ownership over a surgeon who they consider to be rightfully theirs. That same recognition is not reflected in the way the Nepali state regards Ishida. Now 76, and increasingly frail, Ishida has applied unsuccessfully for honorary Nepali citizenship. His visa requires Ishida to make frequent expensive trips back to Japan, and says he no longer wants to go back and forth.&nbsp; When he is away on his visa run, Rolpa’s villagers count the days for Ishida’s return so they can be treated. The surgeon does not take a salary, lives frugally and depends on the Jaljala Hospital for food and lodging.&nbsp; “I was born in Kobe, but I want to die here in Thawang,” says the soft-spoken Ishida. “This is my home now.” Read also: <a href="https://www.nepalitimes.com/here-now/an-eye-for-two-eyes">An eye for two eyes</a>, Yugottam Koirala

Pinki Sris Rana

The barefoot doctor of Rolpa

It is nearing 6PM and Mandeep Pathak is on the daily evening round of the in-patient ward at <a href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital">Bayalpata Hospital</a> in Achham District. The section is crowded with patients young and old.&nbsp; Most have respiratory problems, women with limbs broken in falls from cliffs, some have diabetes, and there is a psychosis patient in an isolation ward. There is wailing from the delivery room of the maternity ward. Pathak’s mobile phone buzzes. He listens, and rushes off to the emergency room. A crowded tractor has fallen off the road and there are mass casualties. The wounded soon arrive, and Bayalpata’s staff go into practised triage mode.&nbsp; The team declares a 12-year-old boy dead on arrival. Others are rushed into x-ray and readied for splints and plaster casts. Some are discharged after treatment to join crowds of waiting relatives outside. Read also: <a href="https://www.nepalitimes.com/opinion/is-free-health-care-possible-in-nepal/">Is free health care possible in Nepal?</a> S P Kalaunee  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230520000536_f8555f89919f26435edcbab7f4f0d99c2314a6c4ebea79795c3987a6571cd56f.jpg" data-media-id="editor_2" data-image-id="20230520000536_f8555f89919f26435edcbab7f4f0d99c2314a6c4ebea79795c3987a6571cd56f" data-rendition-name="original" width="1400" height="823" loading="lazy" alt="Bayalpata Hospital"> <figcaption>Orthopaedic oncologist Mandeep Pathak consulting a patient at Bayalpata. Photo: NEPALI TIMES ARCHIVES</figcaption> </figure>  Patients in this isolated hospital in a corner of <a href="http://archive.nepalitimes.com/news.php?id=17650#.WreWXNRua70">one of Nepal’s most remote districts</a> are from all over Sudur Paschim and Karnali Provinces. One 8-year-old girl with a broken arm has been brought here by her father from Humla, after walking four days to get to a road. In the 14 years since it was established, word has spread that Bayalpata provides high quality service free of cost, and the hospital is treating 100,000 patients a year with a team of dedicated staff, surgery, lab, pharmacy and a high dependency unit.&nbsp; In the maternity ward is a 35-year-old new mother who is quietly taking her supper. She has a shining smile as her husband fusses over her. They are now happy parents of twin boys, their fourth and fifth children.&nbsp; A few beds away is another young mother recuperating from a caesarean delivery. The husband is not happy — the baby is a girl and they already have two daughters. Hospital staff try to persuade him to get a vasectomy, but he still wants to try for a son.&nbsp; Read also: <a href="https://www.nepalitimes.com/editorial/poor-health-makes-nepalis-poorer/">Poor health makes Nepalis poorer</a>, Editorial Unlike private hospitals in Nepal, some of which have up to 80% caesarean deliveries, at Bayalpata most births are natural. Doctors do caesareans only on complicated deliveries, or on referral patients. In one recent case a 17-year-old mother died <a href="https://www.nepalitimes.com/here-now/born-by-the-roadside-in-nepal">on the way</a> to Bayalpata from Bajura district. She had twins, only one of whom survived. Another woman who was 30 weeks pregnant suffered a stillbirth, but because it was a girl, the mother-in-law and husband did not look too perturbed.&nbsp; A mother who gave birth after a difficult delivery was nearly bleeding to death from postpartum haemorrhage. While doctors tried frantically to save her life, the family was celebrating the birth of a son.&nbsp; Despite improved literacy, patriarchy is still entrenched in these remote mountains of far west Nepal. Boys are sent to school while girls help with house chores and raise their little brothers. When children fall sick, the boys are likely to be taken to an expensive private hospital in Dhangadi, while girls are brought to free institutions like Bayalpata. 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 <div class="embed-block"><div><div style="left: 0; width: 100%; height: 0; position: relative; padding-bottom: 56.25%;"><iframe src="//cdn.iframe.ly/api/iframe?url=https%3A%2F%2Fwww.youtube.com%2Fembed%2FCJzWlnYd0ZM&key=87ca3314a9fa775b5c3a7726100694b0" style="top: 0; left: 0; width: 100%; height: 100%; position: absolute; border: 0;" allowfullscreen scrolling="no" allow="accelerometer *; clipboard-write *; encrypted-media *; gyroscope *; picture-in-picture *; web-share *;"></iframe></div></div></div> “The paradox here is that girls are getting world-class treatment while boys have to settle for less than optimal healthcare at private facilities,” says Mandeep Pathak, one of few orthopaedic oncologists in Nepal who has been working at Bayalpata for eight years. Pathak examines a 14-year-old girl from Mugu on whom he operated to remove a benign but complicated tumour that had restricted her mobility for the past two years. As he does his evening rounds, Pathak tells us: “Our patients are among the poorest and neediest and from the <a href="https://www.nepalitimes.com/editorial/devolution-for-development">remotest part of the country</a>. They would not have got a correct diagnosis, let alone get timely and affordable treatment otherwise.”&nbsp; The only cost families have to bear is for transport to the hospital. The hospital even provides free food for one relative accompanying the patient. Read more: <a href="https://www.nepalitimes.com/here-now/grassroots-democracy-promotes-good-health/">Grassroots democracy promotes good health</a>, Sagar Budathoki  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230520000536_e8cebc3bbce1465eda92a1bffc6b0129b91ab7fa1ead7f2282eadcfd0b01115e.jpg" data-media-id="editor_10" data-image-id="20230520000536_e8cebc3bbce1465eda92a1bffc6b0129b91ab7fa1ead7f2282eadcfd0b01115e" data-rendition-name="original" width="2592" height="1944" loading="lazy" alt="Bayalpata Hospital"> <figcaption>Program Associate Bhawana Bogati during a community visit.</figcaption> </figure>  <h2>Community Care</h2> Bayalpata Hospital is managed by the non-profit <a href="https://www.nyayahealthnepal.org">Nyaya Health Nepal (NHN)</a> in partnership with the provincial and municipal governments.&nbsp; Although the hospital gets much of the attention, NHN’s emphasis is on the community that provides door-to-door care to families in Achham. There are up to two <a href="https://www.nepalitimes.com/news/enlisting-female-health-volunteers-to-fight-covid-19-b4qlgy1e">Community Health Workers (CHW) </a>for every ward who regularly visit families to monitor the condition of pregnant women, provide ante-natal care, or check up on those with chronic conditions. This reduces the pressure on the hospital, and also saves families money.&nbsp; CHW can even assist while community nurses perform lab tests including for HIV, hepatitis, urine, sugar, protein, pH level, haemoglobin so patients do not have to come to hospital. The nurses even provide psycho-social counselling, since mental health is still not discussed openly. Aside from healthcare, the female CHWs also demonstrate the important role women can play in this socially conservative society. Jamuna Saud, a 24-year-old CHW, is visiting families in the village of Patalkot, and recording data of patients on her Electronic Health Record app that provides physicians at Bayalpata with instant information on the medical condition of patients in case they need to be taken to hospital. “We are still a male-dominated society here, as you can see, but things are improving,” says Saud, as she climbs up the trail to another family’s homestead. “I have seen families sending daughters to school because they see us being respected for our job. They are starting to treat their own daughters better.” Read also: <a href="https://www.nepalitimes.com/banner/altruistic-healthcare-models-in-nepal">Altruistic healthcare models in Nepal</a>, Yugeshwor Koirala and Yugottam Koirala  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230520000536_b59dabd4604a24426a55fe91c0e5866b5029858bdb4c4028c331557aeb5408ae.jpg" data-media-id="editor_14" data-image-id="20230520000536_b59dabd4604a24426a55fe91c0e5866b5029858bdb4c4028c331557aeb5408ae" data-rendition-name="original" width="1500" height="1000" loading="lazy" alt="Bayalpata Hospital"> <figcaption>In 14 years, Bayalpata hospital has treated 1.2 million patients free of cost. Photo: NEPALI TIMES ARCHIVES</figcaption> </figure>  The work of NHN’s community health program is already seen in Achham district’s health parameters. After a dip during the pandemic, institutional deliveries have climbed again to 80%, and this has sharply reduced <a href="https://www.nepalitimes.com/opinion/newborn-deaths-and-a-vision-for-a-post-pandemic-nepal">maternal and child mortality</a>.&nbsp; “Mother and child health is our main focus and ensuring that we follow the progress of pregnant women means most now go to Bayalpata to deliver,” says Program Associate Bhawana Bogati, 28.&nbsp; The hospital which recently marked its 15th anniversary has so far treated 1.2 million people free of cost, and sustainability continues to be the biggest challenge for Bayalpata’s public-private partnership with the local government. Half the annual budget still comes from international donors. But more than anything else, Bayalpata is a working example that free quality medical care is possible. Other government district hospitals have larger budgets, treat fewer patients and charge fees. Given the remoteness of Achham, the other challenge is retention of doctors and paramedics. Flights to Sanfebagar are unreliable, and a jeep ride to Dhangadi takes 10 hours. Says surgeon Bhaskar Pant of HAMS Hospital in Kathmandu and a board member of NHN: “Bayalpata is a rural lifeline, we need hospitals like these in the remotest corners of Nepal and to run them we need medical staff who are willing to be posted here.” &nbsp;&nbsp; Read also: <a href="https://www.nepalitimes.com/banner/taking-wealth-out-of-health">Taking wealth out of health</a>, Anita Shrestha Jamuna Saud  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230520000536_fa3a215b0130ef026aa9f62b74904ceccd78962b7f6b325f709da8e74ce04301.jpg" data-media-id="editor_17" data-image-id="20230520000536_fa3a215b0130ef026aa9f62b74904ceccd78962b7f6b325f709da8e74ce04301" data-rendition-name="original" width="2592" height="1944" loading="lazy" alt="Bayalpata Hospital"> </figure>  Her baby son is only nine months old, but Community Health Worker (CHW) Jamuna Saud is already back to making door-to-door visits to advise other expecting mothers about safe delivery. Her visit today to Patalkot village, a 3 hour drive through rough roads from Bayalpata, is hindered by a sudden thunderstorm, but she is not bothered. “You need to eat for two now, it will not be good if you skip meals,” says Saud as she counsels Pabitra Auji who is six months pregnant with her first baby and looks undernourished. “Fruits, leafy vegetables, meat and egg, and don’t forget to take your iron capsules.”&nbsp; Saud has been a CHW for four years. She had originally wanted to be a doctor or a nurse, and was a class topper in school, but her family could not afford medical school fees. Moreover, young women in her community were expected to get married, not go to college. “Mine was the only family in the neighbourhood that let girls go to school,” recalls Saud. “But my parents passed away when I was in the 9th grade and my brothers were not planning to educate me further. I cried until they admitted me to +2.” Saud moved to Sanfebagar and paid her own way through college, supporting herself by doing odd jobs. She is happy to have been accepted by Bayalpata’s <a href="https://archive.nepalitimes.com/news.php?id=19559">community health program</a>, and feels a personal sense of achievement that childhood diarrhoea, malnutrition and respiratory infections among babies is decreasing, while more women accept family planning advice. Over the years, Saud has seen changes among women like her in Achham. Girls are no longer restricted to just doing housework and producing babies. She says, “I am proud to have contributed to raising the living standard of people here even if by the tiniest bit.” Read also: <a href="https://archive.nepalitimes.com/article/editorial/health-tip-editorial,4032">Health tip</a>, Editorial Ramita Bogati  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230520000536_a967ed31fa4880fa2fdad2765c288c191890294af92823d94b5d2b11f2aed6b7.jpg" data-media-id="editor_20" data-image-id="20230520000536_a967ed31fa4880fa2fdad2765c288c191890294af92823d94b5d2b11f2aed6b7" data-rendition-name="original" width="2592" height="1944" loading="lazy" alt="Bayalpata Hospital"> </figure>  The story of Florence Nightingale was the inspiration for Ramita Bogati, who always wanted to be a nurse herself. Back in her village, girls were actively discouraged from going to school, and were married young so as not to be a drain on the family. “My parents did not actually want to send me to a school but my mother’s side of the family were educated, and many of them were in medicine,” says Bogati. “But I had to prove myself to change my father’s perceptions about what women should be allowed to do.” Today, Bogati is one of 10 Community Health Nurses at Bayalpata overseeing 70 community health workers with her colleagues. Her passion for the job and the importance of the service she provides is all the encouragement she needs. She does not envy her staff nurse classmates who have flown to Australia and other countries. &nbsp; On a typical day, Bogati is involved in early detection of chronic and infectious diseases, tuberculosis and hypertension so that the poorest in the community do not have to borrow money for treatment or, worse, have their lives shortened due to the lack of diagnosis and treatment. Bogati has seen tangible <a href="https://archive.nepalitimes.com/news.php?id=14071">impact</a> of her work in birth spacing. In the past, women here used to give birth to as many as 15 children, and most died young. Now, they give birth to fewer but healthier children. “As a nurse, the concept of community health was new to me but I have seen that we need to look beyond those who are able to come to Bayalpata. If they cannot come to hospital, the hospital needs to go to them.” Read more: <a href="https://archive.nepalitimes.com/article/nation/national-health-insurance-not-as-easy,4028">A national health insurance scheme is not as easy as it looks</a>, Sonia Awale

Nepal’s rural lifeline

<figure><img width="960" height="720" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141132/636cfdc59c7e80680e0a0c02jpeg.jpg" alt=""/><figcaption>Suman Thapa conducting an eye examination on a patient at Chaurjhari Hospital in Rukum, where EK Ek Paila is working with the local government. Photos: EK EK PAILA</figcaption></figure>It is the aftermath of disasters that <a href="https://www.nepalitimes.com/here-now/lockdown-brings-out-the-best-in-nepalis/" target="_blank" rel="noopener noreferrer">bring out the best among Nepalis</a>. And so it was after the <a href="https://www.nepalitimes.com/latest/reviewing-lessons-of-the-2015-nepal-earthquake/" target="_blank" rel="noopener noreferrer">2015 earthquake</a>, volunteer groups sprang up spontaneously and organised relief through social media.Among them was a loosely structured group of like-minded Nepalis who used their medical expertise to provide emergency help to areas destroyed by the earthquakes. But while many such volunteer groups faded away, the volunteers continued to expand their work — calling themselves Ek Ek Paila (one step at a time).“After seeing the devastation in 2015, I thought it’d be best to use my expertise to provide medical help and do more rather than just provide relief,” says <a href="http://archive.nepalitimes.com/news.php?id=11828#.YSRhqS8w3u0" target="_blank" rel="noopener noreferrer">Suman Thapa</a>, an ophthalmologist who helped set up Ek Ek Paila.  Now, with the pandemic, Ek Ek Paila has been trying to bring health services to parts of Nepal which have rudimentary medical care even at the best of times. “After hearing about infected people having virtually no access to Covid-19 treatment in rural areas where we had previously held health camps, we created a Covid Health Package and took it to them,” Thapa adds.<a href="https://www.nepalitimes.com/latest/rural-nepal-fights-back-covid-19/">Rural Nepal fights back Covid-19</a>, Masta KC <figure><img width="1000" height="745" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141132/636cfdc89c7e80680e0a0c03jpeg.jpg" alt=""><figcaption> </figcaption></figure>The package consists of medication, relevant information, and a direct hotline to volunteer doctors to answer any questions they might have about symptoms, tests and vaccines. The demand for the packages has now snowballed, with local governments in more districts approaching for help. Ek Ek Paila raised Rs7 million for the distribution of the Covid Health Packages — all from local donations. In fact, that is what makes the non-profit different from most other charities in Nepal, it relies almost completely on donations from Nepalis. “If foreigners and international organisations want to donate to Ek Ek Paila, we do not say no,” Thapa explains. “But 99% of the funding for Ek Ek Paila comes from local donors.” The fact that Thapa is also an accomplished musician, and a lead guitarist in the band ‘The Blue Fret’ helps with fund-raising concerts. “I had always wanted to be a musician, and being a doctor was actually the next best thing for me,” admits Thapa, grinning through his mask during a recent interview at Ek Ek Paila’s new Community Health Centre in Kathmandu.Ek Ek Paila had a humble start after the earthquake six years ago. Thapa contacted some friends and found fellow doctors who committed to spending one weekend a month for a year to provide medical care to <a href="http://archive.nepalitimes.com/blogs/kundadixit/2015/05/18/survivors-help-survivors/" target="_blank" rel="noopener noreferrer">survivors</a> in remote villages <a href="https://www.nepalitimes.com/banner/langtang-copes-with-quake-and-covid/" target="_blank" rel="noopener noreferrer">badly hit by the earthquakes</a>. In the first year alone, Ek Ek Paila organised 12 health camps in Sindhupalcok, Dolakha, and other districts. <figure><img width="1000" height="707" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141132/636cfdcb9c7e80680e0a0c04jpeg.jpg" alt=""><figcaption> </figcaption></figure>Nepal’s mountainous terrain has posed a <a href="https://www.nepalitimes.com/here-now/environmental-destruction-is-a-medical-emergency/" target="_blank" rel="noopener noreferrer">significant challenge in health care delivery</a>, made worse by government neglect and poor governance, and exacerbated during crises like the earthquake and pandemic.   All medical professionals who volunteered at health camps paid for their own trips, equipment, and even for the medicine that they prescribed. But after the 12 health camps, the regular volunteers decided to officially register Ek Ek Paila, creating a Nepali-driven and funded organisation to expand its services. Today, volunteer doctors and medical personnel also perform surgeries, including <a href="https://www.nepalitimes.com/banner/nepals-far-sighted-eye-care/" target="_blank" rel="noopener noreferrer">complex eye operations</a>, in rural health camps and carry more equipment with them, increasing diagnostic accuracy. Ek Ek Paila’s camps have become mobile primary health care centres.   <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 “What has made our work easier despite the political paralysis in Kathmandu is that with federalism, local governments are empowered and collaborate in holding health camps,” says Thapa, who has experience with rural health camps organised by <a href="http://archive.nepalitimes.com/article/Nepali-Times%20Buzz/sanduk%C2%ADruit%C2%ADtilganga,2574" target="_blank" rel="noopener noreferrer">Sanduk Ruit</a> of the Tilganga Institute of Ophthalmology.  Local governments top up the donations from the Ek Ek Paila members themselves and other local funding to run the camps. They provide Ek Ek Paila teams of 30 or so people with accommodation and two meals a day. They also help organise the space in which the health program is conducted and help disseminate information.  <figure><img width="1000" height="705" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110141132/636cfdcf9c7e80680e0a0c05jpeg.jpg" alt=""><figcaption> </figcaption></figure>Ek Ek Paila also collaborates with other non-profits like Sparsha Nepal and the ear-nose-throat surgery specialists, Impact Nepal. Ek Ek Paila’s new non-profit Community Health Centre in Thapathali provides affordable health care to those who cannot afford hospital fees. With the flow of patients increasing, and the challenge of making the centre sustainable a tier system for small consultation fees subsidises free treatment for those who cannot afford it.The Community Health Centre was funded through private donations, including the building itself which belongs to one of the founding members. Overhead costs are low because medical personnel all volunteer their services. Besides the vital service it provides, Ek Ek Paila has also led by example to foster <a href="https://www.nepalitimes.com/here-now/youth-led-feeding-campaign-spreads-across-nepal/" target="_blank" rel="noopener noreferrer">volunteerism and philanthropy among Nepali </a>individuals and companies. Foreseeing the<a href="https://www.nepalitimes.com/banner/vaccines-variants-and-a-third-wave/" target="_blank" rel="noopener noreferrer"> third wave</a>, Ek Ek Paila is expanding its Covid Health Packages to reach more people in hard-to-reach places. The non-profit also is in talks to manage primary health centres in Jajarkot and Sindhupalchok districts. Says Thapa: “Ek Ek Paila has brought Nepalis together from all walks of life, it has helped people in need of affordable health care and given donors and volunteers a sense of satisfaction for having contributed. As for me, this is the most fulfilling thing I have done in my life.”To donate to <a href="https://www.ekekpaila.org/" target="_blank" rel="noopener noreferrer">Ek Ek Paila</a>: <a href="https://www.ekekpaila.org/page/5/donate" target="_blank" rel="noopener noreferrer">https://www.ekekpaila.org/page/5/donate</a>

Step by step for rural health care in Nepal

<figure><img width="760" height="486" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914114/636ba5ae9c7e80680e0736dajpeg.jpg" alt=""/><figcaption>Govinda KC, Nepal’s crusading surgeon and health activist, plastering a patient's ankle at the Mugu District Hospital on Sunday. He saw 177 patients for free in five days before travelling on to Jumla on foot. Photos: ACHYUTRAJ BHANDARI</figcaption></figure>Health reform <a href="https://www.nepalitimes.com/banner/risking-his-life-to-save-lives/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/risking-his-life-to-save-lives/&amp;source=gmail&amp;ust=1597224179931000&amp;usg=AFQjCNFQK2JWnimNdv8w4s23TLpC78KGKQ">activist Govinda KC</a>, who has been on 17 hunger strikes to pressure the government to make medical care more affordable, has been holding free clinics for patients in hospitals and COVID-19 isolation wards in western Nepal ever since the pandemic started.KC arrived in Gamgadi on 5 August after walking two days from Jumla, and immediately started free consultations with patients, performing emergency operations at the Mugu District Hospital. He has seen 177 patients since then, and performed three operations.<a href="https://archive.nepalitimes.com/regular-columns/One-To-Many/Truth-be-told%20,749" data-saferedirecturl="https://www.google.com/url?q=https://archive.nepalitimes.com/regular-columns/One-To-Many/Truth-be-told%2520,749&amp;source=gmail&amp;ust=1597224179931000&amp;usg=AFQjCNFtSQBKZtB-vcam4Nsz2wAtqOnl4A">KC is himself an orthopaedic surgeon</a>, and has made it his life’s mission to make medical care free and accessible to the Nepalis who need it the most. His hunger strikes were protests against <a href="http://archive.nepalitimes.com/blogs/kundadixit/page/5/" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/blogs/kundadixit/page/5/&amp;source=gmail&amp;ust=1597224179931000&amp;usg=AFQjCNHY_jV_4K2jz-1PFUWl9VPIgc1DvA">government interference in the health sector</a>, and <a href="http://archive.nepalitimes.com/article/editorial/Kleptocracy-kills,3161" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/article/editorial/Kleptocracy-kills,3161&amp;source=gmail&amp;ust=1597224179931000&amp;usg=AFQjCNH9lmHQky6NGRYp5QvehHAAxtSGGQ">collusion between politicians and tycoons</a> involved in medical education that was driving up costs.  As word spread that KC had arrived at the Mugu District Hospital last week, patients from surrounding villages started pouring into Gamgadi to have relatives examined. He has also been training resident surgeons on surgical procedures.“For us, he is god,” said 17-year-old Gagan Bham from Rara, whom KC operated on for a fracture in his ankle. <img width="1050" height="635" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914114/636ba5b09c7e80680e0736dbjpeg.jpg" alt="">Also from Rara is 10-year-old Reshma Bham who had broken her hand while grazing livestock last year. KC operated on her, and straightened out her arm which is now plastered and in a sling.“We lived up in the mountains and did not have the money get her treated. We were afraid our daughter would be disabled for life, Dr KC was sent here by god,” said Reshma’s mother Danta, who added that she had heard about KC’s arrival by chance on the radio.After working without a break for 12 hours a day, on Monday KC returned on foot to Jumla.  KC has been on a tour of remote northwestern Nepal, where health care is neither accessible not affordable for a majority of people. The need for medical attention has gone up since quarantine centres and isolation wards have been set up for COVID-19 patients in the region, most of whom are returnees from India.KC has not been welcomed everywhere. Last month, a government health post in Rimi of Dolpo district refused to let the crusading doctor see patients there, saying he did not have government permission.  KC nevertheless saw some patients before travelling on to Bajura.One of KC’s hunger strikes was in Jumla two years ago where he demanded that medical colleges should be opened in every province in Nepal, and he wanted the Karnali Institute of Health Sciences to be the centre for Karnali Province. He broke his hunger strike after government assurances in 2018. But seeing no progress has been made to fulfil that demand, last month in Jumla he threatened to go on another hunger strike.

Govinda KC treats patients in remote Nepal

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110911110/636b7a7e9c7e80680e064764jpeg.jpg" alt="" width="850" height="567"/><figcaption>Pic: IRIN</figcaption></figure>At time of writing at noon on 21 March there were 785,855 confirmed cases of COVID-19 around the world, and 37,826 fatalities in just three months.The speed of spread and the size of population and geography affected is unprecedented in human history, after it spread from Wuhan in December.Nepal was actually only the fifth country to report its first case of COVID-19 in a student who came from Wuhan. Even though only five positive cases have been found in Nepal so far with one of them recovered, Nepal was the first country in South Asia to declare a lockdown on 17 March.There are surely more infected people out there, but for some reason there has not been a major outbreak with large numbers of elderly and vulnerable people crowding our hospitals, as has happened elsewhere.However, for us working in a community hospital here in remote Accham district the COVID-19 pandemic and need to break its transmission chain comes on top of pre-existing public health crises. For Nepal, there are multiple competing priorities – the foremost of which is <a href="https://archive.nepalitimes.com/article/editorial/Nepal-%20Multidimensional-Poverty-Index,4115" data-saferedirecturl="https://www.google.com/url?q=https://archive.nepalitimes.com/article/editorial/Nepal-%2520Multidimensional-Poverty-Index,4115&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNHM5h3YUBoz4XSN7_uHJ3E6Fr6WUQ">poverty</a>.<a href="https://www.nepalitimes.com/here-now/returnees-may-be-taking-coronavirus-to-rural-nepal/" target="_blank" rel="noopener">Returnees maybe taking coronavirus to rural Nepal</a>, Mukesh Pokhrel and Sonia AwaleAlthough the percentage of Nepalis in absolute poverty has decreased <a href="http://nepalitimes.com/regular-columns/guest-editorial/schooling-and-nutrition-poverty-in-nepal,1098" data-saferedirecturl="https://www.google.com/url?q=http://nepalitimes.com/regular-columns/guest-editorial/schooling-and-nutrition-poverty-in-nepal,1098&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNE5Rfegg0JNVXKpiotepEHWK3ctxQ">from 59.3% in 2006 to about 20% </a>today, there are large parts of the country with such grinding poverty that it forces families to ignore serious ailments because they cannot afford travelling to a hospital.At Bayalpata, we treat <a href="https://archive.nepalitimes.com/article/nation/aim-for-fewer-patients-in-achham-possible-hospital,2022" data-saferedirecturl="https://www.google.com/url?q=https://archive.nepalitimes.com/article/nation/aim-for-fewer-patients-in-achham-possible-hospital,2022&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNF4N287SaVbb8sNES0Lwkx4OhGavg">patients who have walked or have been carried for days</a> because they either do not have access to medical care, or cannot afford it. Having a sick person drives even some better off families into poverty, and men have to migrate to earn enough to pay off loans they took for treatment. For Nepal, the real pandemic is poverty.A 42-year-old woman was admitted to <a href="https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/this-is-how-to-upgrade-nepals-rural-health/&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNHxwuUmg6vrBxCxISbf1HiE37jNoA">Bayalpata Hospital</a> last week after fracturing both bones on her left leg after a fall while travelling to a school where her daughter was about to give her secondary school examination. The tests were postponed at the last moment because of COVID-19.A 14-year-old boy was admitted with a fractured femur after falling from a tree. Despite the lockdown fodder and firewood must still be collected, the maize needs to be planted, livestock have to be tended.Bayalpata Hospital has set up an emergency department and fever clinic as per government directives. We have trained healthcare workers to deal with coronavirus patients. But all we are encountering so far are the chronic poverty-related diseases that have always been endemic in western Nepal.<a href="https://www.nepalitimes.com/latest/enlisting-female-health-volunteers-to-fight-covid-19/" target="_blank" rel="noopener">Enlisting female health volunteers to fight COVID-19</a>, Ramu Sapkota and Mukesh PokhrelThe <a href="https://www.thelancet.com/action/showPdf?pii=S2214-109X%2818%2930386-3" data-saferedirecturl="https://www.google.com/url?q=https://www.thelancet.com/action/showPdf?pii%3DS2214-109X%252818%252930386-3&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNHN3iLt2G4_SkTyvig6g1vEBfPv5g">Lancet Global Health Commission</a> says 8 million people every year die around the world  from treatable conditions in low and middle income countries. Yet, that does not qualify as a global pandemic.<a href="https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/who-will-save-nepals-poor-new-mothers/&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNFDYqLJvteBaRIZP72Pq6sigwjSkg">More than 1,200 women die</a> in childbirth every year in Nepal, that is three fatalities evry single day. <a href="https://www.nepalitimes.com/banner/tb/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/tb/&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNHYW7_isIE72BQ49VZGoyQMHD2gSw">Tuberculosis</a> kills 6,000 people in Nepal every year. There were 2,736 fatalities in <a href="https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNFBa59bECywSEyR8IEj4-iHamayEA">road traffic accidents</a> in Nepal last year. All of these deaths were in one way other linked to deprivation and inequities.Every day at Bayalpata Hospital we manage cases of children who are <a href="http://archive.nepalitimes.com/regular-columns/guest-editorial/schooling-and-nutrition-poverty-in-nepal,1098" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/regular-columns/guest-editorial/schooling-and-nutrition-poverty-in-nepal,1098&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNENzTMpW5lgmR02wVhfwM6ibW_H_w">stunted or wasted due to malnutrition</a>, exposing them to opportunisitic infections. Some of their families are too poor to provide enough food. There are also cases of fractures, neglected infections like abcess and bone infections every day – mainly among children because parents are forced to be busy at work in the farm, or had gone abroad to earn.COVID-19 is a dangerous, easily spread viral infection. Yet, when the pandemic does  spread to western Nepal it will just be another disease burden on top of the pyramid of poverty we have to deal with here every day.<a href="https://www.nepalitimes.com/here-now/environmental-destruction-is-a-medical-emergency/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/environmental-destruction-is-a-medical-emergency/&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNHCbDoFCPznSW29oc0wSkBzQEDm4w">Bikash Gauchan</a> is the Healthcare Director for <a href="https://www.theatlantic.com/sponsored/cathay-pacific-2016/a-new-way-to-care-for-nepals-poorest/894/" data-saferedirecturl="https://www.google.com/url?q=https://www.theatlantic.com/sponsored/cathay-pacific-2016/a-new-way-to-care-for-nepals-poorest/894/&amp;source=gmail&amp;ust=1585722723480000&amp;usg=AFQjCNGT68-k6h4a6jXvhDF3yPCKSdhXyA">Nyaya Health Nepal</a> in Achham based at Bayalpata Hospital.

Poverty – the real pandemic

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/6365179b9c7e80680e02c286jpeg.jpg" alt="" width="1400" height="905"/><figcaption>IN GOOD HANDS: Community Health Worker Bhajan Kunwar checks patient Namsara Tamrakar at her home in Chandika village of Achham. Pics: Marty Logan and Srawan Shrestha</figcaption></figure>Rounding a steep curve on the road to the district capital of Mangalsen a startling set of modular structures comes into view. The modern buildings look out of place in this scenic, but underserved, region of western Nepal.The construction is part of a $4 million expansion of <a href="http://archive.nepalitimes.com/news.php?id=17650#.WreWXNRua70">Bayalpata Hospital</a>, a unique medical facility that is a model for public-private partnership to improve medical care in Nepal’s remote interior.Inside the ward, orthopaedic surgeon Mandeep Pathak is examining an elderly man with a swollen knee. Clearly visible on an x-ray monitor is a short pin inserted by a general practitioner a few weeks ago, after the patient fell and broke his kneecap.https://www.youtube.com/watch?v=SuWvlDGasEAIn the same room with the surgeon today is Community Medical Assistant (CMA) Khagendra Pant, who is wrapping plaster around the arm of a small boy. Thanks to training at the hospital, Pant was able to diagnose the boy’s injury as a clean fracture that did not require an operation.Such training means Bayalpata now has to refer just 10-20% of orthopaedic cases to hospitals in Dhangadi and Nepalganj, compared to nearly 70% two years ago.“I am proud to say that all the basic trauma care can now be done by general practitioners. Plus they can diagnose cases and decide which need to be referred to outside centres,” says Pathak.Training is integral to Bayalpata’s mission, says Director of Medical Education <a href="http://archive.nepalitimes.com/regular-columns/GUEST-COLUMN/Saving-one-mother-at-a-time,816">Bikash Gauchan</a>: his hospital has continuing medical education for clinicians, and on the job training for future nurses and other staff. General practitioners from various centres learn rural surgery at Bayalpata while mid-level staff come to improve their clinical knowledge.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/6365179e9c7e80680e02c287jpeg.jpg" alt="" width="1400" height="650"><figcaption> </figcaption></figure>For some <a href="http://archive.nepalitimes.com/article/nation/aim-for-fewer-patients-in-achham-possible-hospital,2022">patients who travel many days</a> to reach Bayalpata, access to basic surgery here means avoiding an expensive trip to the city. People whose limbs were fractured as long as three years ago delayed treatment until surgery was available at the hospital because they couldn’t afford the trip to a city hospital.Treatment at Bayalpata and at another hospital in Dolakha run by the non-profit Possible, is <a href="http://archive.nepalitimes.com/article/nation/Nation-free-for-all-healthcare,491#.UbrA4ueLA1s">free</a>. The group believes healthcare is a fundamental human right protected by Nepal’s Constitution, and should have no cost at point of delivery.Possible is funded by donations and Nepal government grants, which will grow as its hospitals attain clinical targets, such as the percentage of women who give birth in a facility with a trained clinician. Operating expenses last year were $4.8 million, of which 9% came from the government.Arrivals are registered in the hospital’s Electronic Health Record (EHR), which puts patients’ information at the fingertips of clinicians throughout the hospital, and eliminates bulky paper records.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/636517a19c7e80680e02c288jpeg.jpg" alt="" width="1400" height="823"><figcaption> </figcaption></figure>One patient already on the EHR is Namsara Tamrakar. Sitting cross-legged on a raised, wooden platform outside her home in Chandika village (left), the elderly woman shows visiting hospital staff that she knows how to use her inhaler, but it is empty.Three years ago, a doctor at Bayalpata diagnosed her with chronic obstructive pulmonary disease and prescribed medicine via inhaler. Now Community Health Worker Bhajan Kunwar (see box, left) visits regularly to follow up. Like others, Tamrakar’s house has a small blue metal tag on an outside wall with a unique household ID. The houses are also geo-tagged.Kunwar’s visit is guided by CommCare, a software developed by Dimagi and customised by Possible that includes counselling information and checklists for each patient. Plans are to integrate CommCare with the EHR so that field followups are immediately reflected in the hospital’s system. Eventually, Bayalpata’s EHR will be linked to a national data system.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221104141144/636517a49c7e80680e02c289jpeg.jpg" alt="" width="1400" height="1024"><figcaption> </figcaption></figure>Kunwar takes Tamrakar’s blood pressure: 120 by 80. The woman is happy to hear the news and to see Kunwar again: “She comes, does a check-up, and tells me what sickness I have, and if it is getting better or worse. She insists I go to Bayalpata for a follow-up.”The hospital's <a href="http://archive.nepalitimes.com/article/nation/Nation-Crowdfund-globally-act-locally,490">community health program</a> focuses on maternal and child health as well as non-communicable diseases such as hypertension, diabetes and respiratory ailments. Possible employs 56 community health workers looking after more than 80,000 people in Achham and Dolakha. It is planning to more than quadruple that number next year.Bayalpata Hospital started in 2009, when the group <a href="http://archive.nepalitimes.com/article/nation/Crowding-it-out,1003">Nyaya Health</a> (now Possible) took over an abandoned government facility. Then it had five beds and treated up to 12,000 patients a year. Last year, Possible saw 86,000 patients at Bayalpata: the goal is to treat 150,000 people annually after the new wards, emergency room, administration building, a dormitory and remaining small houses for on-call staff are added.“Our integrated, hospital-to-home approach will be a model for Nepal, and beyond,” explains Gauchan, “and we will be proving that in a resource-limited setting, health care expansion, providing universal health coverage to people is possible.”But is the Bayalpata model really replicable? Skeptics say that two hospitals could have been built for the cost of the new buildings, which feature rammed earth technology, solar energy and rainwater collection, and that only substantial donor support made the expansion possible.Gauchan admits that the initial investment may seem high but says it will be more cost-effective in the long run.He adds: “The existing infrastructure for rural health care is way less than the minimum needed to address the emerging burden of non-communicable diseases and road accidents as well as infectious diseases. That is why we are investing in a very robust infrastructure.”<h2>Community spirit</h2>In 2011, Bhajan Kunwar (pictured above) was living an “Ok” life with her husband Purna and children in Bhageswor village of Achham when her sister-in-law Shavitra asked for a favour.Shavitra had been hearing rumours that her husband, who was working in India, was having an affair or had even remarried. Would Purna take her to India to find out? Purna agreed, and brother and sister set off with a friend. En route, Purna received a phone call from Shavitra’s husband warning them not to come, or there would be trouble.They continued anyway, and after crossing the border got on a train. That night, a group of men, perhaps including police, boarded the train and took Purna away. He later called Shavitra’s husband to say he had been kidnapped and would be killed unless help came quickly.Police found Purna’s body the next morning, on the roadside in Ahmednagar, east of Mumbai. It looked like he had been run over, but Bhajan believes he was murdered.Widowed at 25 and with two small children, Bhajan spent the mourning period worrying about how she would afford to send the children to school, and if her mother-in-law and community would accept her becoming the breadwinner for her husband’s four younger brothers and sisters and their families. (Her father-in-law had died earlier).That month, Bayalpata Hospital had a vacancy for a community health worker for the area. Bhajan was hired and six years later, still visits on foot the more than 700 households in her catchment area, checking that patients are taking their medicines, and much more (see main article).“This hospital made me strong,” she tells us. "Before I didn’t know anyone in my village and I didn’t know so many things.” Now with a college certificate, Bhajan advises young women to get educated before they get married. “I tell them ‘if I can do it, you can do it too’. I believe in myself and don’t care what others say about me. If you are true and honest, no harm will come to you.”Bhajan says she will never forget her husband. “But I have to live for my children, and control my mind and my heart. If I am strong, they can have a regular life. The hospital is now my husband, I cannot imagine leaving it.”Marty Logan in Achham<h2>Operating remotely</h2>When nine-year-old Samir Tamang was bitten by a dog on his way to school in Rayale village of Kavre last week, he had to take a two-and-a-half hour long bus ride to Kathmandu with his grandfather Suk Bahadur Tamang, for a rabies vaccination at Teku Hospital.Samir missed school and his grandfather, who works as a driver in Kathmandu, had to ask for leave from his employers.“We are relatively close to the capital, but imagine what it must be like for people living in remote parts of Nepal where there are no roads,” says Suk Bahadur.Indeed, despite the spread of basic health care in Nepal, emergency treatment and procedures like mending broken bones or caesarean sections are not yet available in rural areas. This means families have to sell property or borrow from moneylenders to be able to afford treatment in the cities. Studies have shown that many Nepali families are driven to poverty if relatives are referred to private hospitals.Unmet surgical needs in remote districts remain a major public health issue in Nepal, according to a recent study in 39 remote area hospitals commissioned by the Nick Simons Institute (NSI).One day this week, an informal survey of patients at the government-run Bir and Teaching Hospitals in Kathmandu showed that a majority of the patients were from remote districts, some as far away as Piuthan and Jajarkot.The NSI study shows that except for caesarean sections in Dolakha, Lamjung and Panchthar, very few government hospitals elsewhere were able to do simple operations of the abdominal cavity, or even mend broken bones.Nepal’s surgery rate falls well below the Lancet Commission target of 5,000 operations per 100,000 population. If the goal is to have a surgical facility within two-hour travel distance for patients, at present only a third of the population can reach an orthopaedic surgeon, and only 22% have access to abdominal surgery.However, the survey reaffirms that the presence of a medical general practitioner (MDGPs who can perform caesarean sections and other relatively simple surgical procedures) can change this. District hospitals with resident MDGPs can eliminate the need for patients to make expensive and extended trips to the cities for treatment.The minimum personnel at a district hospital should include an MDGP, obstretrics doctor, anaesthesia assistant, staff nurse and biomedical technician. However, Nepal’s density of hospitals with such staffing is very low (0.4-3.1 per 100,000) as against the Lancet Commission target of 20 per 100,000 population.“In the long run we need specialists but placing three of them in each district hospital will take a long time. For the next 5-10 years, MDGPs will be the answer to solve surgical problems throughout the country,” explains Anil Shrestha, NSI’s Executive Director.The study recommends an MDGP-led generalist surgical team with proper staff, drugs and equipment to upgrade emergency surgical care in all district hospitals.Adds Shrestha: “The government has to strengthen strategically located district hospitals and make them functional to take care of surgical needs throughout the year. It is entirely possible to do.”Sonia Awale in KavreRead also:<a href="https://www.nepalitimes.com/editorial/poor-health/">Poor health</a>, Editorial <a href="http://archive.nepalitimes.com/news.php?id=17650#.Wrydky5ubIV">Resurrection Accham</a>,  Paavan Mathema<a href="http://archive.nepalitimes.com/article/nation/aim-for-fewer-patients-in-achham-possible-hospital,2022">Boy walked eight days to treat broken arm</a>,  Tsering Dolker Gurung<a href="http://archive.nepalitimes.com/article/nation/Nation-free-for-all-healthcare,491#.UbrA4ueLA1s">Free-for-all health</a>,  Duncan Maru and Roshan Bista

Marty Logan

State of the art rural hospital

Architecture can be a powerful agent of change, shaping not just spaces but the way people live, connect, and experience the world.&nbsp; For Nepal, which is <a href="https://nepalitimes.com/banner/natures-fragile-gift-to-nepal">gifted by nature</a> and rich in <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/ambassador-fund-cultural-preservation-nepal,2092">cultural heritage</a>, &nbsp;reviving rural architecture with modern amenities could hold the key to more <a href="https://nepalitimes.com/here-now/what-sustainable-tourism-means-in-practice">sustainable tourism </a>that benefits local people more. “<a href="https://nepalitimes.com/banner/bayalpata-hospital-in-nepal-wins-global-design-award">Design and architecture</a> are amazing tools to create a unique experience for visitors,” says Spanish architect Tomeu Esteva of Esteva i Esteva Architecture Studio. “Difficult destinations have beautiful hotels with design and comfort.” Esteva was in Kathmandu with his colleagues at an event organised by the Spanish Honorary Consulate at Dwarika’s Hotel last week to showcase buildings which Nepali architects can adapt with local material and design inputs.&nbsp; Rural architecture holds a unique significance: it is more than a shelter and must reflect <a href="https://nepalitimes.com/here-now/inking-an-idenity">local identity, culture</a> and <a href="https://nepalitimes.com/here-now/saving-humla-from-heritage-loss">heritage</a>. An area’s natural and cultural harmony can be upset by <a href="https://nepalitimes.com/here-now/protecting-protected-areas-from-infrastructure?fbclid=IwAR1wK0MDFlFST_2EYb3f54LS4-fPt6rYfLG1DJ1JaQsU3w8-ezyXIxGOqzk">poorly planned development</a>, speakers at the event said, but the environment can be improved and revitalised by well-integrated structures.&nbsp; Another Spanish architect, Belen Moneo, has designed hotels at elevations of 3,700m in her home country Spain that supply natural spring water spas. “<a href="https://nepalitimes.com/banner/lost-in-reconstruction">Creativity in construction</a> must be encouraged. Rural architecture always shows possibilities of what we can do better,” Moneo explains, adding that designs must enhance <a href="https://nepalitimes.com/opinion/the-healing-power-of-nature">the beauty of nature</a> and give a natural feel at a time when steel, glass and cement dominate <a href="https://nepalitimes.com/here-now/rebuilding-kathmandu-after-the-1934-quake">urban design</a>.&nbsp; This is why the <a href="https://nepalitimes.com/here-now/weaving-nature-into-craft">use of natural products</a> such as bamboo, local timber, straw and rammed earth are in demand from customers who want a fresh eco-friendly look encouraged in construction of rural architectural structures. The demand for boutique hotels has increased world over, with &nbsp;more and more tourists favouring aesthetics, experience and comfort over price. While creativity is an important part of <a href="https://nepalitimes.com/here-now/architecture-for-mountains">construction and architecture</a>, incentives to build and use <a href="https://archive.nepalitimes.com/article/nation/Building,370">rural construction materials</a> still remain minimal, and Moneo emphasises the significance of design and execution.&nbsp; Esteva helped design the Vana Retreat in Dehradun that kept the natural environment in focus, with the structure giving an elaborate aesthetic experience to visitors. Another example is Hotel Las Mercedes in the Dominican Republic which was designed and constructed by Moneo and the company she co-founded Moneo Brock, respecting and revaluing the traditional architecture of the area. Hotels providing such experience could attract tourists and revenue. The Spanish ambassador to Nepal Juan Antonio March Pujol said, “The role of architecture and architects in developing tourism is crucial, not only in urban areas but rural settings as well.”&nbsp; The concept of rural boutique hotels gained traction in Spain during the 1990s, particularly in regions like Majorca with economic and environmental sustainability as the main focus. In Nepal <a href="https://nepalitimes.com/opinion/12-full-opinion/guiding-nepal-s-tourism-industry">the tourism industry</a> directly employs about 1 million people, and makes up about 8% of the country’s GDP. In Nepal, the stone homes of <a href="https://nepalitimes.com/news/reviving-himalayan-vulture-and-culture">Mustang and Manang</a>, bamboo and mud structures of <a href="https://nepalitimes.com/here-now/the-tarai-s-shrinking-forests">the Tarai</a>, and the Kathmandu Valley’s terra cotta tile skylines, graceful temples, and tranquil bahal courtyards are all examples of <a href="https://nepalitimes.com/here-now/nepal-s-traditional-seismic-resistant-designs">Nepal’s traditional architecture</a>.&nbsp; Nepali architect Sarosh Pradhan has been working for the past eight years on the Brakka Village project in Manang Valley north of <a href="https://nepalitimes.com/banner/municipalities-want-to-manage-annapurna">the Annapurnas</a>. Other examples of this kind of rural architecture for high-end tourism are the Shinta Mani Hotel in Mustang and Khumbu Lodge below <a href="https://nepalitimes.com/news/mt-everest-pvt-ltd">Mt Everest</a>. Says Pradhan, “There are places in Nepal that radiate purity and embrace simplicity. Creating projects in such settings require deep reflection and thoughtful planning.”  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250421030444_a07a23f6b60fa89c0f35b9dc1aaf19937da4881e6bfb2e1858f3c27dff91729f.jpg" data-media-id="editor_19" data-image-id="20250421030444_a07a23f6b60fa89c0f35b9dc1aaf19937da4881e6bfb2e1858f3c27dff91729f" data-rendition-name="original" width="4608" height="2184" loading="lazy" alt="A new architecture for Nepal's tourism"> </figure>  Rural architecture is not easy, and sometimes more expensive. Inflation, energy efficiency, <a href="https://nepalitimes.com/here-now/those-who-stay">the climate crisis</a>, and <a href="https://nepalitimes.com/banner/cost-of-living-in-a-big-city">increased costs of living</a> pose obstacles to sustainable rural architecture. Read also: <a href="https://nepalitimes.com/here-now/forgotten-international-starchitects-in-nepal">Forgotten international starchitects in Nepal</a>, Anne Feenstra and Varun S Bapu Esteva says faith and trust between client and architect is necessary for any project to be successful. He adds that architects must practice being humble, the process of designing always involves learning and not imposing their ideas on clients. Nepal is uniquely positioned for the growth of <a href="https://nepalitimes.com/banner/hiking-up-the-benefits-of-tourism">rural tourism</a> because of its stunning countryside as well as its internationally renowned traditions in holistic wellness. Creating infrastructure that is small, thoughtfully planned and that respects both tradition and contemporary hospitality standards is crucial. “Projects in Nepal can be made cost effective by using materials from houses that have been brought down,” says Esteva. “Pilot projects involving <a href="https://nepalitimes.com/banner/local-government-by-the-people-for-the-people-of-the-people">local people </a>and simple designing also helps the process.” <a href="https://nepalitimes.com/banner/vacant-homes-become-homestays-in-nepal">The growth of homestays in Nepal</a> is a step in the right direction, but they are still a bit too rustic for the international traveller who also wants comfort and is willing to pay extra for it. Upgrading the facilities in homestays and ensuring that the <a href="https://nepalitimes.com/here-now/an-archive-of-nepali-heritage">architectural heritage</a> of the locality is preserved using locally sourced building material could allow owners to charge more. Says Sangita Shrestha of Dwarika’s Hotel, “Our effort is to build upon rural architecture by empowering local communities and using what is available locally. We can fine tune and encourage indigenous design and training.” The vision goes beyond just boosting the economy, it is about building a future where tourism helps villages grow in a healthy and lasting way. Instead of using up resources, it gives back to the land and the people. It supports local communities by<a href="https://nepalitimes.com/opinion/staying-in-nepal-to-create-jobs"> creating jobs</a>, improving infrastructure, and protecting natural beauty. When done right, tourism can be a tool for <a href="https://nepalitimes.com/editorial/progress-and-or-preservation">preserving culture and nature</a>, not harming them. Architects must therefore see their work as more than just designing buildings, they also need to care deeply about people and places, especially in rural areas that can benefit the most.&nbsp; With global interest in sustainable and off-the-beaten-path travel increasing, Nepal stands at the cusp of a <a href="https://nepalitimes.com/news/missing-out-on-nepal-s-tourism-potential">tourism transformation</a> that values community-driven, eco-conscious hospitality. A mix of modern ideas and traditional knowledge could transform rural tourism in Nepal. Says Shrestha, “Young architects should spend time with <a href="https://nepalitimes.com/latest/the-unsung-heroes-of-conservation">local and indigenous communities</a>, listen to their stories, and learn from their <a href="https://nepalitimes.com/banner/life-and-livelihood-in-remote-nepal">ways of living</a>. These communities have deep knowledge about the land, materials, and climate. If this wisdom is used in new designs, it can help create tourism spaces that truly benefit everyone.” &nbsp;

A new architecture for Nepal's tourism

Extract from an addendum to Nepal's Two Wars, Chapter 2 in the updated edition of Essays on Nepal: Past and Present by Sam Cowan, a retired British Army general with a long association with the Gurkhas. The book was first published in 2018, and republished earlier this month by FinePrint exclusively on Amazon. The addendum details a one-to-one conversation the author had in the <a href="https://archive.nepalitimes.com/news.php?id=8884">Royal Palace </a>with the <a href="https://archive.nepalitimes.com/news.php?id=8371">King Gyanendra</a> in November 2002 just after he had taken his initial steps on the road that ultimately led to <a href="https://archive.nepalitimes.com/news.php?id=14681">the abolition of the monarchy</a> in Nepal in 2008. In the early evening of September 16, 2002, in my role as Colonel Commandant of the Brigade of Gurkhas, I had my second and last official audience with King Gyanendra to give him an update on the Brigade’s activities over the previous 12 months. I had some 6 or 7 such audiences with <a href="https://nepalitimes.com/here-now/preserving-king-birendra-s-family-home">King Birendra</a>.&nbsp; These were official affairs with the British ambassador of the day present, along with key <a href="https://archive.nepalitimes.com/news.php?id=12233">palace officials</a> and a representative from Nepal's Foreign Ministry. The two monarchs were very different in character and temperament, but both treated me with the utmost civility and made the audiences as relaxed and easy for me as possible.&nbsp; It is, however, worth recording that when the official business had been covered, King Birendra, with a twinkle in his eye, often ended by asking, “Now General, what’s the gossip in London?” The second audience with <a href="https://archive.nepalitimes.com/news.php?id=8026">King Gyanendra </a>was my last official act in uniform. We came back to Kathmandu in the first week of November (after treks) to stay for a few nights with our Defence Attaché before heading back to the UK. Waiting for me was a message from the Palace saying that King Gyanendra would like to meet me informally: <a href="https://archive.nepalitimes.com/news.php?id=6933">no uniform</a> and no ambassador.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250421080420_f9046f9882d4481781d14f2b64f18c7fbbea62562e1d74e3465de6d01fb43750.jpg" data-media-id="editor_7" data-image-id="20250421080420_f9046f9882d4481781d14f2b64f18c7fbbea62562e1d74e3465de6d01fb43750" data-rendition-name="original" width="1750" height="2406" loading="lazy" alt="Gyanendra crowned page 1"> <figcaption>Nepali Times Special Edition of 6-14 June 2001 with enthronement of Gyanendra. </figcaption> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250421080424_21333d6ae21828eb47fe3f849438d215fe2804460d47bb2896ef4aee4e895ad2.jpg" data-media-id="editor_8" data-image-id="20250421080424_21333d6ae21828eb47fe3f849438d215fe2804460d47bb2896ef4aee4e895ad2" data-rendition-name="original" width="1500" height="1857" loading="lazy" alt="Royal massacre"> <figcaption>Nepali Times 22-29 June 2001 covering the royal massacre after which Gyanendra became king. </figcaption> </figure>  Although I had no idea what the purpose of the meeting might be, events in Kathmandu since I last saw the king put me on edge. On October 4, 2002, Gyanendra had dismissed Prime Minister Sher Bahadur Deuba, allegedly for failing to hold <a href="https://nepalitimes.com/news/what-goes-on-in-nepal-s-elections">elections</a>. He had put in place a new prime minister and a cabinet personally selected by him. When I heard the news on my travels, the people I met were generally supportive of the king’s actions. There was a general view that something had to be done, the country was going nowhere, and the king deserved his chance, not least to solve<a href="https://nepalitimes.com/latest/14-years-after-conflict-no-closure-in-nepal"> the Maoist </a>problem. Back in Kathmandu, views were not so sanguine. The chosen prime minister, Lokendra Bahadur Chand, was a relic from <a href="https://nepalitimes.com/here-now/mob-movement-and-mayhem">the Panchayat period</a> whose party had failed to win a single seat in the last elections held in 1999. Some of the chosen cabinet ministers had, to put it mildly, dubious reputations, and others had no record of proven competence in any field. There was a fear that the king’s real motive in dismissing <a href="https://nepalitimes.com/editorial/deubas-denouement">Deuba</a> was to start to reverse the democratic gains made since 1990. I informed <a href="https://nepalitimes.com/news/nepal-britain-mark-centenary-of-1923-treaty">the British ambassador</a> about the invitation. He was strongly against accepting it, which was probably the clinching reason for my decision to do the polite thing and accept it. On the evening of November 7, 2002, I presented myself at the royal palace, alone and in civilian attire.&nbsp; As in the past, the Military Secretary, Major General Vivek Shah, met and escorted me into the presence of the monarch. This time, however, he was politely asked to leave the room and shut the door behind him. King Gyanendra greeted me warmly and invited me to sit down.&nbsp; Read also:<a href="https://nepalitimes.com/news/the-ghost-of-monarchy-returns-to-haunt-nepal"> The ghost of monarchy returns to haunt Nepal</a>, Shristi Karki  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250421080424_e382af945d0ad2a04ae41fabe5393f793dd10f54cb1220f111c7c9e7423eb558.jpg" data-media-id="editor_15" data-image-id="20250421080424_e382af945d0ad2a04ae41fabe5393f793dd10f54cb1220f111c7c9e7423eb558" data-rendition-name="original" width="1000" height="993" loading="lazy" alt="Gyanendra coup"> <figcaption>Nepali Times 4-10 February 2005 after king Gyanendra's coup imposed media censorship. anendra became king. </figcaption> </figure>  I had wondered, and to be truthful, had worried, not just about the purpose of the meeting, but about how the conversation might start and develop. I reduced my resolve to two points: be polite but speak candidly. The latter resolve was quickly put to the test with the king’s opening words: “Sam, [in previous meetings it had been ‘General’, you walk the highways and byways of this land more than most, tell me what the common man is thinking?” &nbsp;“Your Majesty, I have no idea what they are thinking, but they are waiting.” “Waiting?” “Yes, Your Majesty, they are waiting to see whether what you did some weeks ago in appointing your own prime minister and cabinet ministers is going to make any difference to their lives or whether it is just going to be more Kathmandu hot air.” “Everything is going to be difficult and is going to take time, a lot of time.” “Your Majesty, time is the one thing you don’t have. You must act quickly and decisively to take advantage of the opportunity you have created. Everyone knows that you have appointed these new ministers. Why don’t you get them in here one by one and tell them that they have three months to deliver a programme in their area of responsibility that is going to make a difference to people’s lives? Most will fail to do so. Sack them! It will be a powerful signal of your strong intent to deliver real change.” I can express the opening of our conversation in this way because just about every word is still etched in my mind. The king’s response to my last quoted words was to challenge me to give an example of something that could be delivered quickly. I can give a verbatim record of what I said in response to this unexpected challenge: “Health posts, Your Majesty, there is no shortage of them throughout the country as building them has been one of the sources of local corruption, but very few have any medicine to issue at present or have skilled people to assess and meet medical needs. Your Majesty, children are dying for lack of a few pills. Given the right priority, over a period, say of six months, every health post could be fully stocked with medicine and manned with trained people. This is something I could help to lead for you as I know it would have strong international backing. At last, people would know that you mean business.” As I warmed to the theme, I could see no sign of the king having any enthusiasm for the idea, and I quickly disengaged as it dawned on me, as it had clearly dawned on the king, that the reason for the deficiencies in health posts was to prevent any Maoist combatant from gaining access to any <a href="https://nepalitimes.com/opinion/tech-away/nepal-s-health-tech-industry-is-here-to-stay">medical support</a>, and if this meant people suffering, so be it. The subject of the Maoist insurgency inevitably came up, and I took the opportunity to elaborate on what is written in the final four paragraphs of the article above. I advised King Gyanendra that, self-evidently, since there were three parties in the conflict—him, the Maoists, and the political parties—it was imperative that he form an alliance with one of them, preferably the political parties; otherwise, he would find himself isolated, as the other two parties would inevitably, at some stage, form their own alliance. However, it quickly became apparent that the king’s mind was on a totally different track. On the Maoists, he told me that he had channels open to them, but he was scathing about the political party leaders. He made it clear that they would be waiting for a very long time before he gave any power back to them, and that is a polite way of expressing the actual words he used, but “crawling through the door” is a phrase which has stuck in my mind.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250421080424_5403455ff6168f0d202a96cb53edea69136d74d59b989cfcc7cc4a1d57672cb5.jpg" data-media-id="editor_17" data-image-id="20250421080424_5403455ff6168f0d202a96cb53edea69136d74d59b989cfcc7cc4a1d57672cb5" data-rendition-name="original" width="2000" height="1317" loading="lazy" alt="fall of monarchy"> <figcaption>Nepali Times 28 April-3 May 2005 with cover image by Ajay Joshi of jubilant protesters after street demonstrations sidelined king Gyanendra, paving the way for a ceasfire and restoration of democracy. </figcaption> </figure>  As the conversation developed, it became ever clearer that King Gyanendra had decided to go in alone, relying on the misleading assurances he was constantly receiving from <a href="https://archive.nepalitimes.com/news.php?id=14954">the army</a>, and no doubt his close advisers, that the Maoists could and would be quickly defeated militarily, and taken out of the equation. This would obviate the need for him to do any deal with the political parties.&nbsp; Thus, the way would be clear for him to establish a version of his father’s Panchayat system, under a constitution that would be granted to the people by him, their sovereign, as his father and brother had done in 1962 and 1990. As in those constitutions, ultimate power would have remained in the sovereign’s hands. This proposed direction of travel was very clear from what the king said to me. In sum, King Gyanendra was motivated by a desire to emulate his immediate predecessors by granting his people a constitution that would restore his father’s Panchayat system in a modern form and give him a central role in decision-making. What was particularly dispiriting was that beyond this single objective he had no plan worthy of the name, nor demonstrably did he have the people with the skills to implement an appropriate plan even if one had existed. Crucially and depressingly, there was little or no indication from the king that he realised that such a course of action could put Nepal’s monarchy into serious jeopardy, as indeed proved to be the case. <h2>King Twice</h2>  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250420110436_315d519fe3d68d2406ebe1480fed54720fbf21b8907a4da5cde751fdc623d445.jpg" data-media-id="editor_19" data-image-id="20250420110436_315d519fe3d68d2406ebe1480fed54720fbf21b8907a4da5cde751fdc623d445" data-rendition-name="original" width="1302" height="632" loading="lazy" alt="“Tell me what the common man is thinking!”"> </figure>  <a href="https://archive.nepalitimes.com/news.php?id=8371">Gyanendra Bir Bikram Shah has been king twice</a>. In 1950 he was enthroned briefly as a child king (left, above) by the Rana Prime Minister Mohan Shumsher when his grandfather, King Tribhuvan, fled to exile in India. In 2001 he was crowned king again after the massacre in the royal palace in which his brother King Birendra and nine other members of his family were killed by Crown Prince Dipendra.&nbsp; During his second reign, Gyanendra gradually asserted power by sacking Prime Minister Sher Bahadur Deuba in 2002, and then taking full control after the 1 February 2005 coup. He was sidelined after the ceasefire in April 2006, and became a commoner after the Constituent Assembly finally <a href="https://archive.nepalitimes.com/article/from-nepali-press/Ftnp-abolishing,624">abolished the monarchy in 2008</a>. In the past year, Gyanendra has tried to exploit public dissatisfaction with the political parties to restore the monarchy.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250421080432_26ef4a4b0e3cee9fdc6794446702efe16550d293904b4f6dd46fe35d4d10c788.jpg" data-media-id="editor_22" data-image-id="20250421080432_26ef4a4b0e3cee9fdc6794446702efe16550d293904b4f6dd46fe35d4d10c788" data-rendition-name="original" width="1136" height="702" loading="lazy" alt="Essays on Nepal by Sam Cowen"> </figure>

“Tell me what the common man is thinking!”

“It's Kathmandu.” Just as the family was sitting down for one of its extended lunches, that jubilant cry was from François Driard’s grandfather announcing the next posting for his diplomat parents.&nbsp; Driard (pictured) was 18 in the summer of 1996,<a href="https://nepalitimes.com/opinion/suburban-tales/chasing-a-nomad"> a bit of a hippie</a> already, and his life was about to change forever with the magical word “<a href="https://nepalitimes.com/banner/time-capsule-of-kathmandu">Kathmandu</a>”. “I was awed with that information from my grandfather, nothing else mattered … In France <a href="https://nepalitimes.com/here-now/tales-of-courage-and-suffering-cx95f89e">in the 1990s</a>, Kathmandu had a mythical aura,” Driard recalls. He came to Kathmandu for Christmas that year to visit his stepfather, the French Ambassador Michel Lummaux. It was to be the first of many visits during school holidays, before he decided to permanently settle down in Nepal. “Kathmandu, and Nepal, were very different then, it was magical, I liked the nature, the people, civilisation, temples, trees,” says Driard, who explored the country sitting on the top of buses. “Visitors talk about the crazy <a href="https://nepalitimes.com/banner/cost-of-living-in-a-big-city">urbanisation</a>, traffic jams today, and all that is true. But Kathmandu has not <a href="https://nepalitimes.com/here-now/loss-of-soul-and-soil">lost its soul</a>.” After his stepfather’s tenure in Nepal ended, Driard worked as a business reporter for international publications but decided he did not want to be anyone’s employee anymore. In 2007 he landed in Kathmandu with €20,000 in savings to invest.&nbsp; He knew a few crucial things about himself: he liked food and nature, which is very much tied up with his upbringing--full of lively conversations during lunch and dinner at the family table between <a href="https://nepalitimes.com/here-now/nepals-yak-cheese-is-on-world-map">abundant cheese, wine and cigars</a>. So he decided it would be cheese, and registered Himalayan French Cheese and went to the French Alps for a month to learn how to make Tomme de Savoie. “<a href="https://nepalitimes.com/banner/the-story-of-langtang-cheese">Cheese making is such an ancient craft </a>and so I thought I won’t need much money or studying which I hated and indeed, if you have a tamako bhado and fire you are set,” explains Driard. But Nepal’s temperature and humidity were not ideal, even at higher altitudes. The first customers for his cheese were the Hyatt Regency and Nina and Hager. But he needed to create a market for cheese in a country which only knew hard churpi in the north and soft paneer in the south. He started selling his cheeses at the Summit Hotel weekend market, expanding to his own 1905 Farmer’s Market which later moved to Le Sherpa in Maharajganj, where it is now, and also a market at Labim Mall in Pulchok. He had cow dairies in Nuwakot and Dhulikhel, and finally a yak cheese unit at 3,379m in Ramechhap. It was the yak blue cheese from here that went on to win a Gold Medal in France, putting Nepal’s French cheese on the world map. “People come and try our cheese at the market, they ask questions. There is a lot of education to be done about cheese,” adds Driard, who also has three cheese shops in the Valley. Driard now makes 25 types of cheese. The products are being noticed and every year he has French students coming to Nepal to learn the art of yak cheese making. “In France, one family or company makes one kind of cheese for generations. In that I’m very unique as a cheese artisan,” he says. “The students come in to learn but I tell them to also teach us something too, add another cheese to my collection.” Read also: <a href="https://nepalitimes.com/here-now/langtang-after-10-years">Langtang after 10 years</a>, Sonia Awale Being a foodie, Driard is now also dabbling in meat with his own charcuterie at Meatini with bacon, ham, sausage and pâtés. All of this is now served at his Emilio’s Pizza, a leafy hideaway in Lazimpat. His South Side in Moksh is probably the smallest wine bar in the world. “I call the process sublime,” says Driard of his ventures, which have grown organically. “You need the same temperature and humidity of 12°C and 80% for cheese, meat and wine.” Emilio’s speciality is the eight-cheese pizza (which has eight types of cheeses), and a pizza with bhutan topping (not the country but fried intestines and organs Nepali-style). He has opened a small branch at Courtyard in Pokhara.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250426070456_bacae302c040dc18eeecdeafda72ddf06a6d2cec138ea9be7e45fe94cdf8b5b3.jpg" data-media-id="editor_8" data-image-id="20250426070456_bacae302c040dc18eeecdeafda72ddf06a6d2cec138ea9be7e45fe94cdf8b5b3" data-rendition-name="original" width="1500" height="1125" loading="lazy" alt="8 cheese pizza"> <figcaption>Eight-cheese pizza</figcaption> </figure>  With two artisanal cheese units, two farmers’ markets, a <a href="https://nepalitimes.com/here-now/the-meat-of-the-story">meat processing unit</a>, a bakery, and wine bar he now envisions a vineyard so he can add Nepali wine to his repertoire. Another future plan is to start up an agri-tourism business where customers can drink, eat and work in peace. In the past 20 years in Nepal, Driard has not always succeeded in his ventures but this hasn’t curbed his enthusiasm. He is learning as he goes, and like an old wine, Nepal is growing on him. Its slowness suits his French art de vivre with eating slowly outdoors, having conversation, importing less.&nbsp; “I have proven that with even a little money you can do a lot of things in Nepal,” adds Driard. “In the West, they easily invest half a million euros on a cheese factory, I invested 10 times less.”&nbsp;

Fromage, vin et charcuterie Népalais

Bhuthan भुठान starts with Bishnu Bahadur KC played by <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/dhuwa-smoke-telefilm,2671">Hari Bansha Acharya</a> on a call, requesting to speak to the visa officer. By this point, he had <a href="https://nepalitimes.com/here-now/nepal-should-now-allow-visa-on-arrival">applied for a visa </a>to Bhutan 10 times, but was denied each time. KC was a <a href="https://nepalitimes.com/here-now/nepal-s-women-excel-in-sports-in-2024-z9ramyct">national football player </a>in Bhutan in 1988 before he and other Nepali-speaking Lhotsampa people were forced out of the country in the 1990s as part of the Druk regime’s ‘One Nation One People’ campaign. Over 100,000 Bhutanese Nepalis were forced out, driven across India and dumped in Nepal where they lived in seven<a href="https://nepalitimes.com/here-now/elderly-left-in-bhutan-refugee-camp"> refugee camps</a> supervised by the United Nations and other charities until they were resettled in the United States, Australia, New Zealand and some European countries starting in 2007. In the fictional movie with the satirical English title The World’s Happiest Man, KC has resettled in the state of Ohio in the US but wishes to visit his home country once before he dies. Between flashbacks, we learn KC has died without having fulfilled his wish. &nbsp; The drama then focuses on KC’s two families from two marriages as they debate whether to cremate him as per <a href="https://archive.nepalitimes.com/article/from-nepali-press/muslim-hindu,2996">Hindu rites </a>or give him a Christian burial. A mediator played by Hollywood actor Bruce Dern urges them to take a firm decision before it is too long.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250430140420_b398a08091b866da2b0b8f6c1e6e26781609749aba896bfd2c68a10a519295c3.jpg" data-media-id="editor_5" data-image-id="20250430140420_b398a08091b866da2b0b8f6c1e6e26781609749aba896bfd2c68a10a519295c3" data-rendition-name="original" width="945" height="945" loading="lazy" alt="Bhutan, the movie"> </figure>  There are drawn out scenes of KC being baptised and when he is confronted by his first wife from Darjeeling played by Anuradha Majumdar, he says he changed his religion in the hope that he will be <a href="https://nepalitimes.com/opinion/comment/bhutan-s-refugees-between-hope-and-despair">allowed back in Bhutan</a>.&nbsp; We find out KC has a second wife, a Christian Nepali played by Puja Chand. Dayahang Rai as the younger son doesn’t have much screen time to flex his acting chops. &nbsp; Acharya competently portrays a man that is equal parts haunted by the memories of and longing for his home country. KC’s pain and loss is acute when he is teaching football to Gungun but between mid-scene, he freezes, perhaps lost in memories of being in Bhutan’s national team. &nbsp; In another scene, KC recalls his mother singing a lullaby in Dzongkha. He also has a box filled with medals, photographs and a football which he deflates with a knife in a powerful depiction of his <a href="https://nepalitimes.com/here-now/searching-for-a-homeland-away-from-home?fb_comment_id=1506516030025634">complicated emotions about his homeland</a>. KC keeps checking his mailbox in the hopes that his <a href="https://archive.nepalitimes.com/news.php?id=4977">visa application</a> has been accepted. He says in Nepali: “If a tree that has already struck roots in one place is shifted to another, it will not survive.”  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20250430140420_4a9c27410326489576c04dedf40016bda3825e8f9663317f54fbfec4cbda6d34.jpg" data-media-id="editor_9" data-image-id="20250430140420_4a9c27410326489576c04dedf40016bda3825e8f9663317f54fbfec4cbda6d34" data-rendition-name="original" width="1422" height="2048" loading="lazy" alt="Bhutan, the movie"> </figure>  Dern’s character says that the <a href="https://nepalitimes.com/opinion/comment/nepal-s-transitional-justice-and-the-west-s-recalibration">western world</a> has become “lonely in pursuit of happiness”, another reference to Bhutan’s obsession with its Gross National Happiness index. Scenes shift quickly throughout making the story difficult to follow at times. The use of symbolism is a trite overdone. Nonetheless, भुठान is a nuanced depiction of raw pain and agony of losing one’s homeland. But one cannot help but leave the theatre feeling deflated. KC dies without having visited <a href="https://nepalitimes.com/here-now/small-bhutan-dreams-big">Bhutan</a>, but perhaps he does in his afterlife. It is up to the audience to create its own ending to this sad story of exile. भुठान Mad Monkey Films, 2025 Directed by Binod Paudel 102 minutes In cinemas in Nepal

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