July 12, 2006
Nepal: Finding a Way to Work Independently in a Fragmented Country

The ceasefire between Nepal's royal government and the Maoist rebels still holds, but for how long? Despite a return to calm and the hope of a lasting peace, the Nepalese people still have only limited access to medical care. Doctors Without Borders/Médecins Sans Frontières (MSF) has managed to find a way to work independently in isolated mountainous regions that have been divided by the conflict, which has lasted for more than 10 years. Marie-Pierre Allié, MD, who has participated in many MSF field assignments and is now a member of the board of directors for the organization's office France, has returned from a two-week trip to Nepal and provides an update.

Has calm really been restored in Nepal?

In Nepal, the steep topography and 10 years of conflict limit the populations' access to medical care, especially in the rural mountain areas. Photo © William Martin / MSF

The current situation is completely different from what it was before last April's anti-royal demonstrations, led by the opposition and Maoist rebels. The demonstrations finally brought back a semblance of democracy, with the restoration of parliament. Thanks to a bilateral ceasefire agreement, the attacks and violence against every target that represented authority—like the police or military installations—have ended, as have confrontations on the outskirts of the cities. People described restrictions on movement, curfews that became effective very early in the evening, and a strong sense of insecurity. It's completely different today. They are very relieved by the country's return to calm, but still have doubts about the future and a long-term settlement to the conflict.

In this relatively peaceful context, can we still justify MSF's programs?

In the Rukum district, MSF works in government-controlled areas (as here, in the Salle hospital), but also in zones under Maoist control. Photo © William Martin / MSF

Nepal is a very poor country. The conflict aside, access to medical care is very limited. Medical care is not free, but the population, which is 90 percent rural, is poor and people cannot always afford treatment. There is also a real problem reaching health centers from the high mountain areas, where travel is long and arduous. It can take several hours on foot to reach a health center, which may lack supplies, medications, and even qualified health-care providers. Airplanes are the only way to transfer the most urgent cases from a health center to a hospital, but flights are sometimes cancelled, especially during monsoons.

Last, the population's ability to travel depends on the goodwill of the Maoists who, from one day to the next, may appear in an area and set up a "bandah," a blockade that prevents civilians from traveling for an indeterminate period.

In that context, MSF's presence offers access to free care, particularly via our mobile clinics.

How has MSF managed to retain its independence in this fragmented country?

After long and difficult negotiations, we finally managed to work in the Maoist zone. We are the only humanitarian organization working with parties on both sides of the conflict. Today, we can reach populations in the isolated mountain villages. In the Rukum district, where we have been working since 2003, we have two health centers open in the Maoist zone and are working throughout the district hospital located in the government zone. All treatment offered by MSF is, of course, free.

It has not been easy to provide this assistance. It took a major communications effort that involved introducing our activities so that they would be recognized and understood as independent, neutral humanitarian efforts.

What are the major health problems the teams have encountered in this region?

Our teams treat common illnesses like childhood diarrhea and respiratory infections. We also treat many patients with fractures and sprains due to the country's rough terrain and those with skin problems resulting from hygiene.

In the Maoist-controlled zone, MSF built and opened a health center in Rukumkot. Photo © William Martin / MSF

But to my mind, one of the key issues in these regions is women's health. Their lives are very harsh. They work in the fields and carry loads that are much too heavy. We monitor many pregnancies and women sometimes require a cesarean section. Now they often give birth in their village and in an emergency like that, or for a serious fracture, they have to be transferred to a hospital, which is not always possible. Fortunately, we have not yet experienced any major issues. However, to reduce the risk of fatal complications, we are trying to find a way to be able to operate on site.

© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)