1. 1 Health Challenges in the Remote Mountain areas in Nepal in the context of food insecurity and poor health infrastructure Krishna Pahari School of Environmental Management/Pokhara University and Nepal Development Research Institute

2. 2 Outline of presentation Recent diarrhea outbreak in Nepal The Mid and Far Western Mountains – a story of deprivation Food insecurity and malnutrition Basic infrastructure and services Issues of sustainability

3. 3 Diarrhea outbreak of summer 2009 affected 10 districts in the region About 400 deaths more than 100,000 affected Attracted large media attention Also became a big political issue Is it a sudden/unexpected disaster? Or a result of several underlying causes long in the making?

4. 4 Context: Nepals ecological and development regions

5. 5 The Mid and Far Western Region The most impoverished region in Nepal Situation particularly severe in higher hills and mountains in terms of basic infrastructure (roads, communication, health, education, etc) High prevalence of food insecurity and malnutrition Mountain ecosystem increasingly fragile due to growing population pressure Also the region most affected by the past conflict Problem further aggravated due to impacts of climate change Heightened expectations after recent political changes

6. 6 POVERTY MAP based on COST OF BASIC NEEDS (2006) National prevalence 31% Prevalence in Mid and Far Western region higher than in rest of the country These areas largely left out by gains in poverty reduction in 1996-2003

7. 7 Malnutrition Maps Stunting (height-for-age): Measures chronic malnutrition Nepal 50.4 % Mountain and Hills of the Far and Mid-western Dev. Regions have rates as high as 60-70% Wasting (weight-for-height): Measures acute malnutrition Nepal 9.6 % Most common in Terai (high – to very high) Mountain and hills (moderate to low) Underweight (weight-for-age) Reflects chronic and acute malnutrition Nepal 45.2 % Central Terai, Hills and mountains of Mid and Far-west

8. 8 Mid and Far Western Hill/Mountains: also the area most affected by the conflict 1996-2006

9. Local subsistence farming: situation on the ground 3 Irrigated land Mugu, February 2009

10. Winter crop production loss in 2009 due to drought 4 Hill, 25% & Mountain, 40% Bajura, 55% Dolpa, 60% Jumla, 51% Darchula, 55% Terai, 10% With the impact of climate change, droughts and floods/land slides are becoming increasingly common.

11. Impact of the winter drought on household food security * mostly from areas moderately to severely impacted by the drought Households surveyed as part of the assessment* demonstrated the following traits Household level drought impact

12. Access: the Karnali highway – opened 2 yrs ago

13. 13 Access Constraint – modes of transport: either too expensive or too slow

14. 14 Access constraint - topography

15. Situation background – crop and food insecurity 1 The winter crop (wheat and barley) is a critical food source between April to July. Severe lack of rain and snow seriously impaired winter crops across Nepal. The expected poor harvest came on top of: sustained high food prices for over a year; frequent bandhs/strikes; poor summer harvest in some areas of Far- and Mid-West.

16. Situation background – Health and sanitation 1 Very poor health facilities – nearest health post could be as far as 1 or 2 days walk. Most health posts without proper staff (no medical doctor/assistant, lack of basic medicines). Very poor sanitary conditions – open defecation in many areas, even soap could be a luxury! Severe lack of nutritious food due to crop loss by drought Lack of awareness

17. History of epidemic outbreaks 1 Health records show that such outbreaks are not new in those regions though they rarely receive much attention Many times not reported or reported after considerable time due to lack of communications People now have much expectations, communication is improving, media is getting powerful and various groups are active to raise concerns could be one reason for heightened publicity Without significant improvements in basic health facilities, sanitation, food security and nutrition such epidemics are likely to occur in the future!

18. 18 Many people have no option but to depend on food assistance Long term solution should be found

19. Conclusion and issues for discussion Spatial variation in access to services within a country or region – basic infrastructure essential for all people Sustainability of settlements in remote areas: modernization vs. attachment to home land Health system should be considered as a part of broader sustainability – particularly in the context of increased vulnerabilities due to climate change Greater focus should be on adaptation to adverse impacts of climate change in the Himalaya – with implications not only for Nepal for a large population in South Asia: why should the impoverished people in those remote areas suffer from climate change vulnerabilities created by others? ICT could play a vital role in improving access to services including health in remote areas – using emerging new technologies to the benefit of the rural population A good surveillance system based on evidence-based grass root information vital for taking timely actions and saving lives