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MSF - UK : Wednesday September 27, 2006 3:01 PM.

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  • MSF - UK : Wednesday September 27, 2006 3:01 PM.

    MSF - UK : Wednesday September 27, 2006 3:01 PM
    http://www.uk2.msf.org/UKNews/Letter...turgenepal.htm

    Dr Richard Sturge recently returned from the Himalayan foothills of western Nepal. He reflects on the challenges of providing health care in a very remote area with too few staff, erratic drug supplies and ongoing insecurity.


    <table align="left" border="0" width="200"><tbody><tr><td>
    </td> </tr> <tr> <td class="bodytext" height="38">Dr Richard Sturge in Manma, Nepal, 2006
    ? Richard Sturge
    </td> </tr> </tbody></table> For 11 years Nepal has been in the grip of a Maoist insurrection. To the tourist this is barely noticeable. The major urban centres have remained under Government control and trekkers and climbers have free passage through the rural areas - as long as they pay their dues. For the ordinary citizen in the hills and valleys it is a different matter. Maoist rule holds sway, government officials including teachers, police and army have been driven out, administration and development budgets cut to zero and health services, never strong in isolated rural communities, severely curtailed.
    <table align="right" border="0" width="200"> <tbody><tr> <td>
    </td> </tr> <tr> <td class="bodytext" height="29">View of Manma town, Nepal, 2006
    ? Richard Sturge
    </td> </tr> </tbody></table> Kalikot is a District in the Himalayan foothills of western Nepal. It has a population of 115,000 and of the 74 Districts in the country it is the third lowest in terms of the Human Development Index. That means it is poor, very poor, with little opportunity for employment and, following two drought stricken harvests, largely dependent on food aid. That is assuming the food can be distributed and not expropriated either by the military or the Maoists.
    <table align="left" border="0" width="200"> <tbody><tr> <td>
    </td> </tr> <tr> <td class="addresstext" height="26">Manma town, Nepal, 2006
    ? Richard Sturge</td> </tr> </tbody></table> The administrative centre of the district is the tiny one street town of Manma, perched on the top of a mountain and effectively a fortress surrounded by Maoist territory. Its population is swollen by a heavy police and army presence and by people displaced from their villages, mainly government officials, politicians and their relatives. There are no roads in the entire district, only narrow mountain tracks, and hence no wheeled traffic of any sort. The only way in and out of Manma is by helicopter, though even that is uncertain as the helicopters only fly if they can be guaranteed a full payload, industrial disputes are common and weather conditions may be unsuitable for days on end. Those who are prepared to risk the journey can make a two day trek to the nearest roadhead; not as yet an opportunity open to MSF.

    <table align="right" border="0" width="200"> <tbody><tr> <td>
    </td> </tr> <tr> <td class="captionblack" height="38"> Manma helipad, Nepal, 2006
    ? Richard Sturge</td> </tr> </tbody></table> On a spur of the mountain 200 metres below Manma town lies the District Hospital, upgraded in name only from a health centre early last year. Since September 2005 MSF has working to make the upgrade a reality though little was achieved for the first four months because of security problems ? effectively threats from people claiming to be Maoists. However, since February we have achieved a continuous presence and have managed to refurbish and rainproof most of the buildings and start a comprehensive medical service with facilities for emergency surgery. Problems with water supply exacerbated by 2 years of near drought, have been largely overcome, latrines unblocked and waste pits dug out of the rocky soil.

    <table align="left" border="0" width="200"> <tbody><tr> <td>
    </td> </tr> <tr> <td class="captionblack" height="38">Hari, an MSF guard,
    Manma, Nepal, 2006
    ? Richard Sturge
    </td> </tr> </tbody></table> All this with, even by MSF standards, a tiny team. The Nepalese Government, initially at any rate, would only allow visas for 2 ex-pats, both medical, so with our Nepalese colleague we have three doctors, the only ones in the entire District. The rest of the MSF team consists of locally recruited administrators, translators, nurse and health assistant and several auxiliary health workers. We work alongside 20 Ministry of Health staff and here tact and negotiating skills come to the fore. The MOH have no budget for maintenance and little for drugs. Government staff have security of tenure and nearly 3 months holiday a year, largely made up of an enormous number of national holidays averaging one a fortnight! MSF staff have no job security and far fewer holidays but are paid more. Nevertheless, odd grumble apart we work together amicably and maintain an emphasis on partnership.

    <table align="right" border="0" width="200"> <tbody><tr> <td>
    </td> </tr> <tr> <td class="captionblack" height="29">Open air consulation,
    Manma, Nepal, 2006
    ? Richard Sturge </td> </tr> </tbody></table> Apart from providing an all round medical service MSF has concentrated on Reproductive Health Care with early treatment of sexually acquired infections, daily antenatal and postnatal clinics, education in safe delivery, and facilities for intervention where necessary. Although there are no reliable statistics for the prevalence of HIV/AIDS it seems rare, though it has the propensity to increase as worsening poverty means more men migrate for seasonal work in India, where it is more common, and bring it home with them. On the other hand two other disease that need prolonged treatment, TB and leprosy, do pose problems because of difficulties with MOH programmes due to erratic drug supply, difficulties of access to remote hill villages, and lack of staff to ensure compliance with complex treatment regimes. These are areas in which MSF will become increasingly involved as well as extending primary care services to some of the more remote villages up to several days travel away.

    <table align="left" border="0" width="200"> <tbody><tr> <td>
    </td> </tr> <tr> <td class="captionblack" height="32">Manma town, Nepal, 2006
    ? Richard Sturge</td> </tr> </tbody></table> Initially the Government, both nationally and locally, was somewhat suspicious of MSF as they had fallen out with another international NGO the previous year and also doubted our commitment because of the early security induced absences. But they are now convinced and have supported our application for a much needed logistician to speed the development of the project. Conversely the Maoists were always enthusiastic, possibly because they felt that any improvement to the healthcare of the population under their control would reflect favourably on them.
    <table align="right" border="0" width="200"> <tbody><tr> <td>
    </td> </tr> <tr> <td class="captionblack" height="43">Young mother with newborn baby, Manma, Nepal, 2006
    ? Addy Romme </td> </tr> </tbody></table> In April this year Nepal went through the nearest it has ever had to a revolution with three weeks of strikes which brought the country to a standstill and threatened all out civil war, quite apart from cutting our supply chain. Fortunately we had stocked up with food and fuel in readiness for such an eventuality. The strikes and demonstrations ended with the King returning the power, which he had usurped a year earlier, to the Parliament. As a result the Maoists, and then the Government, declared a ceasefire and everybody fervently hopes it will hold. Even if it does 11 years of chaos does not unravel overnight and much remains to be done for a population afflicted by war, food shortage and economic underdevelopment.

    Read more letters home from MSF volunteers in the field.
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