It was a rainy night in August, 50 years ago, in our ancestral village of Balara near the Indian border. Because of the monsoon, our village was surrounded by flood waters.&nbsp; I vividly remember my grandmother Sharada Devi picking me up, and putting me to sleep on the bed. Waking up the next morning, I learnt that she had been bitten by a snake, and a porter had carried her in a bamboo basket across the Bagmati to a shaman. She died on the way. That bereavement at a young age left a wound that is still fresh. Even after half-a-century, the trauma of snakes has not left me. Many thousands of Nepalis die every year because of lack of timely treatment for snake bites. The Tarai presents an ideal habitat for venomous snakes, and during the monsoon they come out of their flooded hideouts to enter homes and fields. The monsoon is also when there are more farmers out and about for planting, exposing them to the danger. Snake bite has been such a clear and present danger to life in Nepal’s southern borderlands that during the many festivals this season, stories are told of people who have survived snake bites because of their devotion.&nbsp; There are Maithili folk songs that pray for the welfare of snakes, but also plead for divine protection from snake bites at night, so they can wake up alive in the morning.&nbsp; The traditional occupation of the Natuwa people is of snake charmers. They used to travel from village to village blowing on a flute-like instrument, making a captive cobra sway and dance.&nbsp; The Natuwa can be Hindu or Muslim, and are also called upon when a venomous snake is found inside the house. Some earned the reputation for being quacks because of their ineffective and fake treatment of snakebites. Mobarak Miya (below) lives near Simara, and shows a round wooden box in which he used to keep his dancing cobra.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240926110956_e1c94271600b547e21183c3502b51993e37a1aa404b16b3cbff89124d360c149.jpg" data-media-id="editor_0" data-image-id="20240926110956_e1c94271600b547e21183c3502b51993e37a1aa404b16b3cbff89124d360c149" data-rendition-name="original" width="1204" height="1600" loading="lazy" alt="The snake bite emergency"> </figure>  “Nowadays snakes are a protected species and the law does not allow us to keep them, but we had a charmed life as snake charmers,” recalls Miya, who now does day jobs to earn a living. For a hazard that claims thousands of lives every year in Nepal, there are no reliable estimates of fatalities from snake bites. Awareness is lacking about distinguishing between venomous and non-venomous snakes, or what to do if bitten. Snake bites are treatable, but health posts lack adequate anti-venom vials. About 10 people every year are killed by tiger or wildlife attacks, but those get much more media attention than the estimated 40,000 snake bite cases a year in Nepal and the 3,000 fatalities that result from them. &nbsp;&nbsp; As with everything else, it is the marginalised communities which are most exposed to the risk. Tarai Dalits, who spend more time outdoors in the fields and live in flimsy mud and thatch houses, suffer disproportionately.&nbsp; With federalism, rural municipalities should be taking a more proactive approach to supplying antidotes to their health posts and spreading awareness. But this is not happening. Statistics from existing health posts that administer antivenom show that many victims are from across the border in India. This proves that northern Bihar also suffers from the same risk and lacks treatment. The role of local FM radio in spreading awareness has transboundary importance because these stations have a considerable listenership in India.&nbsp; Tarai families are more exposed to the risk because most of Nepal’s venomous species are found in the plains. But in addition, unsafe housing, flooding, paddy plantation and harvest, grazing livestock, open defecation, and sleeping on the floor are added risk factors. Researchers at BPKIHS in Dharan showed in a pilot in four Tarai villages that a Motorcycle Volunteer Program to rush snake bite victims to health posts saved lives. There used to be about 500 snake bites per 100,000 population with a 10% fatality rate in the sites, but after the experiment, only 0.5% of the 315 cases were fatal. &nbsp; Snakes kill and maim the poorest Nepalis, which may be why the state is not so bothered, and there is a direct correlation with unsafe housing, lack of education, and quality health services.&nbsp; The snake bite emergency is as serious as ever. It could be that agriculture, pesticide use, urbanisation, infrastructure has forced snakes out of their habitat. Climate breakdown, heat stress, and floods could be making human-snake contact more probable. &nbsp;&nbsp; Whatever the cause, I lost my grandmother and many Tarai households lose family members every year. Nepal has had multiple governments in the past three decades, and two elections under the federal system that were supposed to provide accountable local governance.&nbsp; But the menace of snake bites remains an emergency. &nbsp; Chandrakishore is a Birganj-based commentator who writes this monthly column Borderlines for Nepali Times.

Chandra Kishore

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The snake bite emergency

There is nothing quite so green as a green pit viper, so distinctively designed as a banded krait or so exquisitely patterned as the scales on the hood of a spectacled cobra. Despite the chilling beauty of these ancient creatures, for centuries <a href="https://nepalitimes.com/banner/hisss">snakebites have caused thousands of deaths and continue to do so</a>. Living in the wild jungles of Chitwan and Bardia, we rarely saw any snakes except during the monsoon off-season when they were flooded out of their homes, so mishaps were minimal. Alerted by the vibrations of our stomping footsteps, keeping well out of the way is every snake’s preferred option. But for us any close encounter triggers an instinctive frisson recoil, no doubt inherited from ancestors and honed by deep-rooted survival mechanisms.&nbsp; In Nepal we have a specially complex relationship with our serpent brethren. They are heralded in mythology, revered as powerful protective deities, valued for medicinal properties and feared as potentially lethal. They are diligently worshipped during Nag Panchami and their venom compounded into lifesaving drugs. But <a href="https://nepalitimes.com/news/snakes-on-plains">snakes are generally destroyed at any opportunity</a>, even though most species are harmless and make valuable contributions to Nepal’s natural ecosystems. Of the 89 varieties found in Nepal, only 21 species are venomous. These harmful species of vipers, cobras and kraits annually kill mainly farmers, children and villagers from rural communities in the lowland Tarai, and particularly during the hot wet summer months. In Nepal, an estimated 40,000 persons are bitten and more than 3,000 die from snakebites every year, not all of them officially reported. Worldwide, WHO estimate 5.4 million people are bitten with 1.8 to 2.7 million cases of envenoming each year. The tragedy is that these fatalities are preventable and caused by a lack of understanding by those afflicted, often the poorest of the poor. Thousands of lives can be saved by spreading awareness about the venomous snake species in Nepal, how accidents can be prevented and the immediate steps to take when someone is bitten. Chief of the GoN’s Epidemiology and Disease Control Division, Hemantha Chandra Ojha is a softly spoken man with a lush moustache and an infectious passion for his subject. He explains that despite a network of snakebite treatment centres supplied with antivenom, “Over three quarters of victims die before they reach help by not acting fast enough, being delayed by jhankris, lacking transport or having to travel too far.” It was this confluence of avoidable catastrophes that first caught the attention of my colleagues at the Rotary Club of Kathmandu Mid-Town. Our member Isabella Khadka seized the opportunity to really make a difference. She has tirelessly cajoled, rallied, fundraised and inspired by leading the Rotary Snakebite Prevention Project in a four-year crusade 2022-2026 to reverse this lack of knowledge, and address this desperately neglected and preventable public health issue. “We aim to eliminate the myths,” says Khadka. “We are using high tech social media and communication solutions country-wide to tackle an age-old problem. No one should die of snakebite in Nepal.”&nbsp; Less than two years since inception, the Rotary initiative has already reached over 25 million listeners with radio spots on 41 local FM stations, Radio Nepal and Kantipur FM discussion programmes, outreach meetings, local champions, and orientation sessions for teachers, health workers and journalists. The range of knowledge products feature vibrant Maithili artwork using five colour-coded languages (Nepali, Pashimi Tharu, Awadhi, Bhojpuri and Maithili), and include posters, social media, Facebook, YouTube action clips, training videos and the bilingual website <a href="http://www.snakebitenepal.org/" target="_blank">www.snakebitenepal.org</a>.&nbsp;  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240304070344_0dd9db2fb801ec6bf5891de08e94194972349d4e3b3737ffadd8e6623f0703ec.png" data-media-id="editor_3" data-image-id="20240304070344_0dd9db2fb801ec6bf5891de08e94194972349d4e3b3737ffadd8e6623f0703ec" data-rendition-name="original" width="1606" height="648" loading="lazy" alt="Snakebite prevention in Nepal"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240304070344_983e90e685e5dc0a2b621a5bfd169f08548c2cbd6c9ebd82ae7c5efea0064d09.png" data-media-id="editor_4" data-image-id="20240304070344_983e90e685e5dc0a2b621a5bfd169f08548c2cbd6c9ebd82ae7c5efea0064d09" data-rendition-name="original" width="1604" height="650" loading="lazy" alt="Snakebite prevention in Nepal"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240304070344_4054bb5a149d64b31ba629cc657a63310d3cb39b22b25fa527757e7cd90751c9.png" data-media-id="editor_5" data-image-id="20240304070344_4054bb5a149d64b31ba629cc657a63310d3cb39b22b25fa527757e7cd90751c9" data-rendition-name="original" width="1605" height="650" loading="lazy" alt="Snakebite prevention in Nepal"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240304070344_bf593d7aa91969e1dd8a6ef3390af2be49a0c4b9a94c9f08daa09c1442307c71.png" data-media-id="editor_6" data-image-id="20240304070344_bf593d7aa91969e1dd8a6ef3390af2be49a0c4b9a94c9f08daa09c1442307c71" data-rendition-name="original" width="1579" height="650" loading="lazy" alt="Snakebite prevention in Nepal"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240304070344_f2ac3217fd3e6aec4521f8d998b56cdf9e5cb26a23593e7c2d4db58f1af013ff.png" data-media-id="editor_7" data-image-id="20240304070344_f2ac3217fd3e6aec4521f8d998b56cdf9e5cb26a23593e7c2d4db58f1af013ff" data-rendition-name="original" width="1602" height="650" loading="lazy" alt="Snakebite prevention in Nepal"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240304070344_09029f12f168063624a452899762e4c0394947be752f7120e5b6bea73b4881b6.png" data-media-id="editor_8" data-image-id="20240304070344_09029f12f168063624a452899762e4c0394947be752f7120e5b6bea73b4881b6" data-rendition-name="original" width="1603" height="650" loading="lazy" alt="Snakebite prevention in Nepal"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240304070344_1a41528fcf31a07b9f70f123695f970e4510e03142a5d64376c257c1099067c3.png" data-media-id="editor_9" data-image-id="20240304070344_1a41528fcf31a07b9f70f123695f970e4510e03142a5d64376c257c1099067c3" data-rendition-name="original" width="1595" height="650" loading="lazy" alt="Snakebite prevention in Nepal"> </figure>  Khadka has assembled a strong team to prepare the Rotary campaign, secure an international grant, and co-opt partners that include the BP Koirala Institute of Health Sciences in Dharan and Snakebite Research Centre with Prof Sanjib Kumar Sharma, Epidemiology and Disease Control Division, National Health Education Information and Communication Centre, World Health Organisation and WWF Nepal, amongst others. The implementers are Digital Broadcast Initiative Equal Access. In 2019 a major High Level Meeting and Workshop on Snakebite was inaugurated by President Bidya Devi Bhandari in Kathmandu to seek consensus on best practice methods to tackle this issue for Nepal. Experienced global practitioners from Oxford, Frankfurt, Melbourne and India, as well as Nepal’s many expert herpetologists, endorsed the need for increased public awareness.&nbsp; Since then, collaboration has been secured from government, embassies, development agencies and NGOs as well as medical institutions, civil society and local communities. Awareness events have been conducted throughout Nepal and abroad, and most recently on 22 February 2024 in the Armed Police Headquarters in Kathmandu to update diplomats and donors. Ongoing training is given in all seven Provinces to health workers on the management of <a href="https://nepalitimes.com/here-now/snakebite-is-treatable-no-one-need-die-from-it">anti-snake venom</a> and the improvement of snakebite treatment centres. The key messages being communicated in the national awareness campaign are not complicated. They resonate from my jungle days even though I was thankful never having to cope with a snakebite emergency. Reading this might save your life, or someone else’s.&nbsp; PREVENTION STRATEGIES - Keep your surroundings clean – snakes hide in tall grass, rubbish and firewood - Snakes are attracted to food storage – and hidden rodents - Beware while walking around at night - use a torch and tap the ground in front of you - Beware while working outdoors (e.g. in fields) - use a long stick to tap the ground - Stay away from areas where snakes might hide - Sleep under a mosquito net to help deter snakes – and avoid sleeping on the ground - Snakes are an important part of the natural environment. FIRST-AID&nbsp; - Help snakebite victims stay calm - don’t panic or move the bitten part - Do not feed the victim anything&nbsp; - Quickly transport victim to health care facility - on a motorcycle between driver &amp; pillion rider&nbsp; - Don’t play with or touch dead snakes – take a photo to show health workers - Use tables on the website to locate closest antivenom treatment center - Don’t have transportation? Use website to find a health worker to advise over phone.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240304070344_f34f8698f65a7b59ee3dda2646aa211da04d47858e4ef286087c1d753455bfc8.png" data-media-id="editor_11" data-image-id="20240304070344_f34f8698f65a7b59ee3dda2646aa211da04d47858e4ef286087c1d753455bfc8" data-rendition-name="original" width="1590" height="650" loading="lazy" alt="Snakebite prevention in Nepal"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240304070344_e0b67381546333a6b31ad40ad597b307a2884de3108b51e49414343cb110f58f.png" data-media-id="editor_12" data-image-id="20240304070344_e0b67381546333a6b31ad40ad597b307a2884de3108b51e49414343cb110f58f" data-rendition-name="original" width="1619" height="650" loading="lazy" alt="Snakebite prevention in Nepal"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240304070344_f095ea2254df8687ad13fe2139917a2b261994db791aea4d7dc3666ac6eaee9b.png" data-media-id="editor_13" data-image-id="20240304070344_f095ea2254df8687ad13fe2139917a2b261994db791aea4d7dc3666ac6eaee9b" data-rendition-name="original" width="1599" height="650" loading="lazy" alt="Snakebite prevention in Nepal"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240304070344_c1d7f6fb9ded5cc8d94c137f781c765e49aecd1bf9f34daeca302d7371fd72af.png" data-media-id="editor_14" data-image-id="20240304070344_c1d7f6fb9ded5cc8d94c137f781c765e49aecd1bf9f34daeca302d7371fd72af" data-rendition-name="original" width="1623" height="650" loading="lazy" alt="Snakebite prevention in Nepal"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240304070348_50708a81dca5486a7070fe8d21b5758fa5a0b47cc9a70b2171b1f752769fc370.png" data-media-id="editor_15" data-image-id="20240304070348_50708a81dca5486a7070fe8d21b5758fa5a0b47cc9a70b2171b1f752769fc370" data-rendition-name="original" width="1600" height="650" loading="lazy" alt="Snakebite prevention in Nepal"> </figure>   <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20240304070348_fb39503983562f902373e3a6ae612b3ae26baeba1faa72d3d832bede16329f2f.png" data-media-id="editor_16" data-image-id="20240304070348_fb39503983562f902373e3a6ae612b3ae26baeba1faa72d3d832bede16329f2f" data-rendition-name="original" width="1694" height="699" loading="lazy" alt="Snakebite prevention in Nepal"> </figure>  &nbsp;

Lisa Choegyal

A crusade to prevent snakebite casualties

https://www.youtube.com/watch?v=Q3Cvph_7Sjc&amp;feature=youtu.beLike every monsoon, this year has also seen a spike in snakebite deaths across the country. In the Tarai, emergency wards are crowded with patients as doctors try to cope. At least 15 people have died so far in Saptari, Sarlahi, Morang and Rautahat, districts that were also hardest hit by <a href="https://www.nepalitimes.com/editorial/flood-of-recrimination/" target="_blank" rel="noopener noreferrer">floods</a> last month.There are at least 40,000 cases of snakebite every year in Nepal, with some 3,000 fatalities in the Tarai alone. But a recent epidemiological study found the death rate from <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/Buzz-a%20pound-of-prevention,575" target="_blank" rel="noopener noreferrer">snakebite</a> has come down from 18.7% 20 years ago to 6.62%, largely because of awareness and anti-venom treatment.Read also: <a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/here-now/snakebite-is-treatable-no-one-need-die-from-it/" target="_blank" rel="noopener noreferrer">"Snakebite is treatable, no one need die from it."</a>Globally, 5.5 million snakebites occur every year, with up to 138,000 deaths. Another 400,000 people require amputations and suffer severe injuries. Bangladesh, India, Nepal, Pakistan and Sri Lanka together account for 70% of global snakebite mortality. But it was not until 2017 that the World Health Organisation (WHO) recognised snakebite as a neglected tropical disease, and came up with a roadmap to reduce risk.In Nepal too, snakebite never received the attention it deserved. It is not communicable or infectious, is rare and tropical and affects the poorest people.“Snakebite is a severely neglected public health burden in Nepal. There is so much we don’t know about snakes and their venoms, and there are signs it is going to get worse with climate change,” warned Sher Bahadur Pun of Sukraraj Tropical and Infectious Diseases Hospital in Kathmandu. (See box) <figure><img width="1400" height="939" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a52599c7e80680e0522ecjpeg.jpg" alt=""/><figcaption>Photo: AMERICAN CHEMICAL SOCIETY</figcaption></figure>High Level Meeting and Workshop on Snakebite in Nepal on 2-3 August in Kathmandu, is the first international conference on snakebite in the country. Taking part are 20 of the world's foremost  authorities on snakebite including David Warrell of Oxford, David Williams, head of the Global Snakebite Initiative (see interview, page 7), Ulrich Kuch of Goethe University in Frankfurt, and Priyanka Kadam from India, and 50 Nepali scientists are taking part.Nepal is aiming to be one of 11 member countries on WHO’s roadmap for snakebites, and is trying to muster serious commitment from the government for research and treatment.“We hope to sensitise policymakers and the public about the hidden burden of this neglected tropical disease,” said Sanjib K Sharma, a doctor at the BP Koirala Institute for Health Science in Dharan, one of the conference organisers. “We also want to start working on developing anti-venoms in Nepal instead of depending on imports.”Of the four types of anti-venom imported for the 21 types of poisonous snakes in Nepal, one doesn’t work and three others are not reliable. In fact, 80% of people here who are administered anti-venom suffer from reactions, 12% of which are fatal. Activists in India are now lobbying to stop the export of anti-venom because of unmet domestic need.Anti-venom is produced by injecting donor animals such as horses and sheep with venom, and then extracting the antigen from the blood. But the procedure is expensive – a vial of anti-venom costs up to $2,200. Since snakebite requires between 20-25 vials to neutralise the venom, the pharmacy bill alone would total $30,000 per patient. Global production is limited, and most snake bites can only be cured with anti-venom from that particular species.WHO’s target is to halve the numbers of deaths and disability from snakebite by 2030, and the Wellcome Trust and UK Department for International Development (Dfid) have announced £80 million and £9 million respectively for the development of a universal anti-venom. However, clinical trials will take decades.Nepal’s challenge is at ground level. Awareness about preventing snakebite is still low, people prefer to visit traditional healers if bitten, and many patients get to anti-venom centres too late. Even so, snakebite fatalities fell from 10.5% to 0.5% after motorcycle volunteers were deployed in a pilot project in 2013. (see box)Diana Barr of the Australian Venom Research Institute at the University of Melbourne says Nepal and Bangladesh are best equipped to take the WHO strategy forward. “You’ve got some of the key things, like local expertise, your health ministry is pushing for change, and there is support from outside organisations,” she told Nepali Times. “Nepal can easily implement the WHO strategy and get dramatic results in a couple of years.”Experts attending the Kathmandu conference this weekend believe the WHO target of halving snakebite deaths is doable. All it needs is effective treatment, trained nurses and doctors who deliver that treatment, educating the community to take simple precautions, and come to hospitals sooner if bitten.Said Sharma of BPKIHS: “The universal vaccine is the holy grail for snakebite treatment, but until then we have to work on anti-venom epidemiology within the country and educate people about snakebites.” <h2>Motorcycle volunteers to the rescue</h2> <figure><img width="1250" height="1068" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a525c9c7e80680e0522edjpeg.jpg" alt=""><figcaption> TWO-WHEELS GOOD: Snakebite victim held firmly between motorcycle volunteer driver and relative and being rushed to hospital. The fatality rate fell by ten times in this pilot project in the Eastern Tarai. Pic: SANJIB K SHARMA</figcaption></figure>One of the major barriers to snakebite treatment is the delay in getting victims to a health centre with anti-venom. In many cases, patients die on the way due to an inefficient transportation system.In 2004, a group from BPKHS in Dharan, in collaboration with the University of Geneva, tested a Motorcycle Volunteer Program in four villages in the eastern Tarai with a high incidence of snakebites. The pilot project mobilised motorcycle volunteers in all four villages, which had a total population 62,000. They helped transport snakebite victims to a specialised treatment centre in Damak that had anti-venom and staff trained in snakebite management. The motorcycles combined with community health education sharply reduced the mortality rate from snakebite.Before the experiment, there were 502 bites/100,000 population with a case fatality rate of 10.5%. After the intervention, the incidence decreased to 315 bites/100,000 and the fatality rate fell to 0.5%.‘Simple educational messages and promotion of immediate and rapid transport of victims to a treatment centre decreased the mortality rate and incidence of snake bite in southeastern Nepal,’ stated a study published in The American Society of Tropical Medicine and Hygiene in 2013. It recommended that the test be replicated elsewhere. <h2>Snakes and Ladders</h2> <a style="background-color: #ffffff; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/between-existence-and-extinction-in-nepal/" target="_blank" rel="noopener noreferrer">As global temperatures go up, so do snakes, insects and plants</a>. Not only are venomous snakes now found at altitudes where they were not present before, experts say even their venom may be getting more poisonous.Kathmandu Valley used to experience snake bites, but they were never fatal. Now, there are cobra sightings on the Valley rim, and even in Langtang National Park. And last year, a patient admitted for snakebite at Sukraraj Hospital in Teku died while undergoing treatment.Poisonous snakes may have come up hitchhiking on cargo trucks carrying logs from the Tarai, but health experts say there is evidence climate change may be allowing venomous snakes, and other tropical wildlife, to move to higher areas of the Himalaya.“Elsewhere we are starting to see the <a href="https://www.nepalitimes.com/editorial/climate-damage/" target="_blank" rel="noopener noreferrer">movement of various species with the warming of the earth</a>, so the case of snakes should be no different,” explains Sher Bahadur Pun of Sukraraj Topical and Infectious Disease Hospital in Kathmandu, which has seen a rise in the number of patients from the Valley and surrounding districts with severe snakebites.Pun adds that more research needs to be done to find the exact correlation between venomous snakes and climate change.In addition, snakebites that were previously poisonous only in the immediate tissue surrounding a bite can now be more venomous or even fatal. <a href="https://www.nepalitimes.com/opinion/turning-on-the-heat/" target="_blank" rel="noopener noreferrer">A warmer climate</a> appears to affect the physiology of the venom glands and the chemical composition of snakes' secretions.“When people got bitten by snakes in the past, they only developed swelling, but now I see cases where victims are bleeding from bites by the same type of snake,” says Sanjib K Sharma of the Department of Internal Medicine at BPKHS in Dharan. Read also: <a href="http://archive.nepalitimes.com/news.php?id=17330#.XULEUvIzbIU" target="_blank" rel="noopener noreferrer">Snakebite!</a>, Buddha Basnyat<a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/Buzz-a%20pound-of-prevention,575" target="_blank" rel="noopener noreferrer">An ounce of venom</a>, Buddha Basnyat<a href="https://www.nepalitimes.com/?p=30821&amp;preview=true" target="_blank" rel="noopener noreferrer">Snakebite is treatable,</a> Nepali Times <h2>Know Your Snakes</h2> Snakes look similar but their colour, scales, eyes and head shape can be useful in distinguishing dangerous species from harmless ones. Some snakes found in Nepal:Green Snakes (Orthriophis hodgsonii) have a few large scales on the top of the head and round pupils. These snakes are non-venomous and harmless. Cat-eyed Green Snakes (Boiga cyanea) have no pit organ between nostril and eye, which distinguishes them from venomous pit vipers.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a525f9c7e80680e0522eejpeg.jpg" alt="" width="1000" height="492"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a52619c7e80680e0522efjpeg.jpg" alt="" width="1000" height="667">Green Pit Viper (Trimeresurus septentrionalis) are the only venomous species of green snakes in Nepal. They have a pit organ between the eye and the nostril, which is an infrared detector used to find prey in the dark. Bites are painful but not fatal.Russel Viper (Daboia russelii) is one of the most dangerous snakes in Nepal, found in the Tarai only. Its head is covered by numerous small symmetrical, oval scales, it has a long tail and long venom fangs that fold back into its mouth.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a52649c7e80680e0522f0jpeg.jpg" alt="" width="1000" height="581"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a52669c7e80680e0522f1jpeg.jpg" alt="" width="1000" height="739">Tibet Pit Viper (Trimeresurus tibetanus) can be found in oak and rhododendron forests on Phulchoki, Helambu and in Tibet, up to 3,200m. Bites can be painful, but not dangerous.Himalayan Pit Viper (Gloydius himalayanus) has a few large scales on the top of its head, like some non-venomous viper lookalikes. But it has a pit organ and a dark stripe from eye to mouth. Found at 1,600-3,000m in the mountains, it is active in the daytime hunting rodents. Bites can be painful but not fatal. Has been found in Mustang.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a52699c7e80680e0522f2jpeg.jpg" alt="" width="1000" height="605"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a526b9c7e80680e0522f3jpeg.jpg" alt="" width="800" height="851">Cobra and King Cobra are common and dangerous causes of snake bite envenoming in Nepal. Most bite at dawn, injecting a large quantity of venom that leads to paralysis of the peripheral nervous system, and then death by asphyxia. Raises forebody, displays extended neck skin hood and hisses when disturbed. Found in the Tarai and up to 3,500m.Python (Python molurus) have no venom but kill prey by constriction. They can bite if disturbed. Found mainly in the Tarai and low valleys.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a526e9c7e80680e0522f4jpeg.jpg" alt="" width="1000" height="798"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a52709c7e80680e0522f5jpeg.jpg" alt="" width="1000" height="545">Common Krait (Bungarus caeruleus), Greater Black Krait (Bungarus niger), Lesser Black Krait (Bungarus lividus) and Wall’s Krait (Bungarus walli) are the most common and dangerous causes of snake envenoming in Nepal. They differ from all other snakes in having one row of hexagonal scales along the middle of their back from neck to tail, which are much larger than other scales. Active at night, some victims do not know they have been bitten while asleep. Respiratory paralysis can kill even after 12 hours. Found up to 1,450m.Himalayan Krait (Bungarus bungaroides) found at higher altitudes, their bites cause death due to asphyxia. Banded Krait (Bungarus fasciatus) are also highly venomous and found in the Tarai.Cat Snake (Boiga trigonata) look like most Kraits but differ in having laterally compressed bodies, unlike Kraits, which have rounded or triangular cross-sections. Mildly venomous.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a52729c7e80680e0522f6jpeg.jpg" alt="" width="1000" height="470"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a52759c7e80680e0522f7jpeg.jpg" alt="" width="1000" height="426">Kukri Snake (Oligodon arnensis) differs from Russell Pit Viper in having pupils that are round, large scales on top of the head and no pit organ. Unlike Kraits, it has scales on the back that are all of similar size and shape.Common Wolf Snake (Lycodon aulicus) is a small snake that often enters homes at night to hunt geckos and mice. Unlike more dangerous Kraits, it has scales of the same size all over its body, and is harmless.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a52779c7e80680e0522f8jpeg.jpg" alt="" width="1000" height="646"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a52799c7e80680e0522f9jpeg.jpg" alt="" width="1000" height="553">Coral Snake (Calliophis beddomei) are rare and found up to 2,200m. If cornered, it responds by flattening its body and lifting and curling its tail. Bites are rare, sometimes fatal.Tawny Cat Snake (Boiga ochracea) are widely distributed in the Tarai and mid-hills. They are often reddish brown and active at night, but unlike Kraits are not venomous.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a527b9c7e80680e0522fajpeg.jpg" alt="" width="1000" height="518"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a527d9c7e80680e0522fbjpeg.jpg" alt="" width="1000" height="558">Water Snake are common in paddy fields and ponds, but are not venomous. The Striped Keelback (Amphiesma stolatum) is active by day and rarely bite. It has prominent and distinct spots and stripes on the body.Adapted from: Venomous Snakes of Nepal: A Photographic Guide by SK Sharma, DP Pandey, KB Shah, F Tillack, F Chappius, CL Thapa, E Alirol and U KuchBP Koirala Institute of Health Sciences, 2013 ISBN number : 978-9937-2-6003-9<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a52809c7e80680e0522fcjpeg.jpg" alt="" width="800" height="1037"> <img width="2500" height="1890" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a52829c7e80680e0522fdjpeg.jpg" alt="">IF A SNAKE BITESReassure victims, lay them down sidewaysIdentify snake if possibleImmobilise bitten limb with splintDo not cut, use tourniquets, ice on wound Wash wound with soapTransport victim quickly to a health centre with anti-venomSymptomsEnvenoming due to cobra and krait bites lead to neuromuscular paralysis with the following effects: Inability to open the eyes on looking upInability to open the mouthInability to protrude the tongue from the mouthInability to swallowParalysis of the muscles of the hands and feetDifficulty breathing

HISSS

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221108131156/636a52509c7e80680e0522e9jpeg.jpg" alt="" width="1400" height="787"/><figcaption>Pic: DIANA BARR</figcaption></figure>David Williams grew up in rural Australia among all kinds of creepy crawlies. He kept lizards and snakes as pets, even venomous ones. He has been bitten six times, but that has not put him off research into finding a cheaper and more effective anti-venom to treat bites.Williams now heads the Global Snakebite Initiative and has been helping in <a href="http://archive.nepalitimes.com/news.php?id=17330#.XULEUvIzbIU" target="_blank" rel="noopener">snakebite</a> management in Cambodia and Papua New Guinea. He is in Kathmandu for the first international conference on snakebite in Nepal this weekend, and spoke to Nepali Times.Read also: <a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/?p=30833&amp;preview=true" target="_blank" rel="noopener">HISS</a>, Sonia AwaleNepali Times: Why hold a snakebite conference in Kathmandu?   David Williams: One of the main reasons the conference is being held here is that Nepal has got a lot of expertise, doctors who are very interested in research and want to fix the problem and initiatives like the motorcycle volunteers. There are many diseases that have no cure or treatment, but snakebite is something that is eminently treatable, nobody should have to die from it. So with a reasonably modest amount of investment by health ministries and supporting organisations, we can solve the problem of snakebite. Nepal has all the elements necessary to tackle its snakebite epidemic, and save lives.What are the main challenges?There is a solution to <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/Buzz-a%20pound-of-prevention,575" target="_blank" rel="noopener">snakebite problems</a>, but it is largely a matter of investment. Production of anti-venom requires putting the money into establishing manufacturing facilities, having a proper quality control and a regulatory agency that is able to provide oversight of manufacturing. The same goes for collecting venom. So it is a matter of commitment, and spending the money to do it in the right way. The things that hospitals need to have in order to effectively treat snakebite patients are often the same types of medical consumables that are needed for a lot of other diseases. So if you have a strong health care system that is functioning well with the right drugs and treatment, then we are likely to achieve better outcomes.But are these <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/tips-for-surviving-snakebites,1471" target="_blank" rel="noopener">interventions</a> possible in Nepal? It is a lot easier and cheaper to prevent snakebite than to deal with consequences, so community education and awareness for behavioural change is probably the most important aspect. Another is having sufficient stock of effective anti-venoms. Countries have to ensure that reliable supply, and one way to go about is to ask for World Health Organization (WHO) assistance. The good thing is that there has been some strong research in this area with which Nepal should be able to take an initiative to be able to make anti-venom within the country and not rely so much on India. It is especially important to have addition supply of anti-venom this time of the year, when snakebite becomes an epidemic.The WHO wants to halve snakebite deaths by 2030. Is this realistic? It is fairly easy to achieve and there is good evidence to back this up. In Ghana it was found that if you introduce effective treatment, train nurses and doctors who deliver the treatment, and educate the community to come to the hospital sooner, fatalities can be reduced by as much as 80% in a very short period. It took Ghana only 18 months. So I think having 12 years from now to <a href="http://archive.nepalitimes.com/news.php?id=19557#.XULEV_IzbIU" target="_blank" rel="noopener">cut the fatality</a> and disability by 50% is quite a reasonable target. At core it is about effective treatment, health workers who know how to give treatment and communities that prioritise getting that treatment.Is climate change pushing venomous snakes up the mountains? If the world keeps warming, yes. As the weather warms up here in Nepal with climate change, you will start finding venomous snakes in areas where they were never found before because it was too cold. Another aspect that can contribute is changes in the habitat. For example, with deforestation you create open habitats that a lot of venomous snakes, such as the cobras and the Russell vipers, actually find more conducive to their lifestyle.Read also:<a href="http://archive.nepalitimes.com/news.php?id=17330#.XULEUvIzbIU" target="_blank" rel="noopener">Snakebite!</a>, Buddha Basnyat<a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/Buzz-a%20pound-of-prevention,575" target="_blank" rel="noopener">An ounce of venom</a>, Buddha Basnyat<a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/tips-for-surviving-snakebites,1471" target="_blank" rel="noopener">Snakebite Survival,</a> Buddha Basnyat

“Snakebite is treatable,  no one need die from it.”

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

New year revolutions

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

What is invisible is more dangerous

82 in २०८२

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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