Food and nutrition insecurity is a persisting public health threat in developing countries and at the same time a complex field to study. Food security is all about the basic human rights of food, care and health.
The ‘Asia Enigma’ or, food scarcity and malnutrition amidst plenty, is a problem in South Asia, from which women and children suffer the most. Nepal, at the World Food Summit in 1996, aimed to reduce the number of undernourished people by 50% by the year 2015. The food security situation is improving but one third of the households in the mountains experience inadequate food consumption compared to the rest of Nepal.
Nepal is currently the third poorest country in Asia after India and Bangladesh;Humla, a post-conflict area that was heavily affected by the Maoist insurgency and where the Nepal Trust has been working for over 20 years throughout the conflict, is one of the poorest districts in Nepal and thus in the world. Combined with its harsh climate and the fact that only 1-2% of the land is arable, Humla is a highly food insecure area which relies on food assistance and subsidies (mainly rice) from the Nepalese government and its development partners. Today the consequences of the conflict can still be felt and combined with the food security situation it complicates the health situation and living circumstances of the people of Humla.
In addition, Humla faces many problems in the area of health, which is mirrored in the high rates of infectious diseases, nutritional disorders and maternal and perinatal diseases. It has a relatively high fertility rate compared to the rest of Nepal (6.2 vs. 2.7 respectively). High fertility is often linked to maternal mortality in the prenatal and postnatal stage, but especially during childbirth. Reasons are low access to good quality care before, during and after pregnancy and the fact that only 2% of the births are attended by a skilled nurse. Women are normally expected to give birth outside the home often in outbuildings or cowsheds
Moreover, many women continue to keep working during pregnancy and lactation which increases the chance of serious health problems. Maternal mortality is closely linked to malnutrition, also considering that the period of pregnancy and lactation requires more nutritious food. Risks of malnutrition for girls and women prevent them from reaching their full growth potential, and they will, thus, be deprived for the rest of their lives.
Nutritionally stunted mothers have a higher risk of giving birth to low weight babies and statistics from the Nepal Demographic and Health Survey show that over one third of the women of reproductive age in Humla were anaemic and more than 20% were underweight. 60% of children under five years old were stunted, 15% severely underweight, and 53% anaemic. In addition, under-five mortality rates are extraordinarily high, with over 40% of the children dying before they they reach the age of five.
Women in general are often being disfavored in terms of food allocation, especially in their reproductive years, when their social status is low. Combined with the pressure to marry and work hard, female adolescents and menstruating, pregnant and lactating women are often the ones that are most disadvantaged.
As part of our health strategy to focus on these high-risk groups in Humla (especially women and children) the Nepal Trust has currently started to build a chain of birthing centers, linked to our already established health posts, with the aim to tackle these high infant mortality rates and maternal mortality rates and to decrease the number of women that take themselves into cow sheds to give birth to their babies.
As good nutrition is, amongst other factors, the basis for maternal health child, and infant feeding and caring practices are the basis for good child health. So it is important to take this into account in order optimize the functioning of these birthing clinics, primary health care services and food security programs. As detailed information is often lacking about the health and nutritional status of women and their children and also to gain better insight into problems women face before, during and after childbirth, we are currently conducting a detailed study to address these issues.
Donya Madjdian, a masters student in Health and Society, from the department of Sociology of Consumption and Households at Wageningen University and Research Centre in the Netherlands is currently doing her research internship at the Nepal Trust whereby her main assignment is to conduct a comprehensive study related to Gender, Family and Intra-household Allocation of Food patterns in Humla as part of her masters course.
The overall goal of this study is to gain insights into the relationship between intra-household allocation of food including feeding practices of infants, and the under nutrition of women of reproductive age and infants in two villages in Humla, in order to optimize the functioning of birthing clinics and food and nutrition security programmes, with the ultimate aim to improve the health and nutritional status of Humli women of reproductive age and their children.
Donya has spent several months in Humla, and is currently working on her final report. In Humla Donya was assisted by Yeshi Lama, a female student who is currently studying in Kathmandu and who hails from Bargaun village in Humla, where we are currently constructing our first birthing center, for translating interviews and to be introduced to the communities. Donya and Yeshi travelled to various villages to gather valuable information and stayed at home-stays (developed by the Nepal Trust as part of our tourism development program) throughout their stay, which provided Donya a great insight into the daily lives of local families and to learn more about their culture and traditions.
Below are some words from Donya on what inspired her to come to Humla;
“During my studies I learned to see health from a holistic point of view taking into account different perspectives. We learned to study the often-complex interactions between the social and physical environment of individuals and communities that might influence health behaviour and lifestyles. Gradually, I found out that I would love to work at the interface of global health and development cooperation. In addition, I spent a considerable part of my studies on food and nutrition security as food and health are inseparable. South Asia and preferable Nepal is strongly appealing to me, on the one hand due to its incredible contrasts in nature and culture, its rich history and beautiful people and on the other hand the fact that it is one of the least developed countries in terms of human development.From September to December 2014 I will hopefully join The Nepal Trust, a registered Scottish charity and (I)NGO in Nepal, for my research internship after which I expect to graduate from the M.Sc. Health and Society at Wageningen University. Nepal Trust's values and development philosophy are very much after my own heart as they are actually the values on which my study program is based, for instance the participatory, bottom-up approach. Although I certainly understand that I will have to go to one of the most remote areas in Nepal and that life in Humla is extremely challenging, doing a research internship at Nepal Trust would be a great opportunity for me to learn more about doing field research in the field of food and nutrition security, the working environment of a grassroots NGO, and to put my gained knowledge into practice thereby contributing to Nepal Trust's successful activities and helping to improve the life of the people of Humla. As Nepal Trust already does since 1993, I am dedicated to work with health, community development and hope in the Hidden Himalaya’s and I am looking forward for making the most out of this opportunity”.
Donya has had a great time in Humla so far and, without saying, we are looking forward to Donya completing her study, which will help us to gain more insight into these complex issues that will improve our service delivery. We will be happy to keep you updated on her progression.
Meanwhile all at the Nepal Trust would like to thank all of our supporters and volunteers for their help and donations. Please let your friends and relatives know about our work and encourage them to donate or help. Enjoy the festive season coming up and hope that 2015 will be be healthier and happy for all.
The Nepal Trust has recruited a new Health Manager to oversee our work in Humla, the most remote and impoverished district in Nepal. Gorkha Bandari has recently graduated as a health professional and, very importantly, he comes from the village of Thehe in Humla. Thehe is the largest Hindu village in Humla and very poor but driven by aspirations for improvement. The Nepal Trust, in collaboration with Dutch donors, is constructing a new community school which will raise educational standards and life chances for the students.
One of Gorkha's first tasks was to familiarise himself with the NT clinics many days walk apart. He had also to supervise the distribution of fresh medicines to each of the clinics. The following is Gorkha's own report:
'Despite the start of the monsoon and the currently severe floods that take place throughout the country the Nepal Trust was able to send a big shipment of much needed medicines into Humla for distribution at the clinics. Local contributions obtained through patient treatment fees have also contributed to local transportation costs related to the medicine distribution.In the first 6 months of 2014 Nepal Trust clinics treated 4,867 adults, 345 children below 5 years and provided family planning services to 1,008 people, totaling 6,220 patients up to the month of July 2014.A field trip took place in which the NT health manager visited various clinics to discuss the programme and the running of the Clinics and Birthing Centres with both NT staff and the respective health committees.Bargaun and Sarkegad birthing centers are near completion and also the refurbishment works at the Sarkegad clinic has started. As soon as this is finished, we are able to stock the new centres and provide medical equipment, such as delivery beds, operational equipment and the like. The Little Doctor Programs in Simikot, Bargaun and Yalbang are ongoing and already have proven successful as students are eager to learn about healthcare, first aid and healthy lifestyle issues.'
New developments move ahead steadily in keeping with the remote, and very relaxed, way of life in the Hidden Himalayas. The lack of roads and other essentials of 'modern life' in this very mountainous region can make working there difficult but rewarding. Local people are hard working and very enthusiastic about the positive change that is slowly happening and bringing new hope to this beautiful but remote corner of the world. They contribute in many ways through their own resources and labour and also in decision making and sourcing funding from government agencies. The Nepal Trust is there to help facilitate this self-help approach and support the local communities to achieve their goals.
The new Birthing Centres are progressing well. Bargaun has started recruitment of specialist staff and is virtually up and running. The Sarkegad building is now complete, with the help of a Community Assistance Grant, and internal work is underway. The adjoining Government Health Clinic, originally built by the Nepal Trust, is now receiving urgent remedial work necessary as the result of years of neglect through a debilitating civil war centered in this particular area. Funding for the Yari Birthing Centre is almost there and work will be starting shortly.
Our 2014 Little Doctor Health Education programmes are now fully subscribed and funded. Thank you to all who have contributed to support this innovative and very worthwhile project.
It is, perhaps, appropriate to look back and think about why the Nepal Trust is here trying to make a difference. Twenty years ago a young mother from Humla approached two British doctors and asked them to please come and establish a health clinic in her home district of Humla where there was nothing functioning. Within two years a brand new clinic was operating a service and attracting patients from two to three days walk away - such was the need! From there we have established a chain of clinics and services covering most of this remote and impoverished district changing lives and bringing hope.
The following are extracts from 'A Personal View' written by a young British doctor who spent a month working in one of the more remote clinics over 15 years ago.
'Its been an experience of a lifetime. I have, like on all journeys, gained so much personally but I think I have also given much too. I feel like I have been part of something very rare, part of a tradition and way of life that is in danger of disappearing for ever.
The people I worked with are very special. Their way of life is very hard and unromantic but, from my perspective, it was very romantic, peaceful and spiritual.. However, I did gain some understanding of their perspective as I lived at the clinic on my own. This meant cooking, collecting firewood, cleaning, clinic teaching,washing - all without modern tools, light, electricity, etc. It was hard work and yet I was lucky that my work did not involve 8 hours of back breaking work in the fields! Suddenly you understand why the women who come to the clinic laugh at you when you tell them they must wash themselves and their children every day!
Life takes on a whole new perspective and I don't think I will ever be the same again. I think I will struggle with the demanding 'Western' patients who have driven 5 minutes down the road and demand to be seen right away. In Humla I saw people who had walked for two days with severe Rheumatic Heart Failure and still sat patiently waiting to be seen.
Medicine in remote areas: no resources, no means of evacuation, no money, no time, no understanding. Very difficult! I know so little of a HUGE problem. I can only give my brief experience and perspective to others; my opinions and ideas almost worthless in such a big complex of problems.But, I feel I did some positive small changes during my time at the clinic. I feel, at least, that I left behind three Health Workers who were a little more knowledgeable, motivated and informed. I think that my time at the clinic improved its reputation, increased the people's trust in the clinic and trust in Western health workes and the Nepal Trust.'
Fifteen years has seen many changes, still no roads but mobile phones in places! Many volunteer doctors and health professionals have contributed over the years and many share similar sentiments. Things are improving. Our integrated approach has seen significant improvements to lives and societies. Children survive the early dangerous years and health knowledge has been widely disseminated through our child health education programmes. The clinic in the report above is vey successful and run in collaboration with another specialist NGO to ensure resources are used efficiently and meet all essential needs.
However, it's a long haul and not a simple in-out operation!
Thank you for all your support. Please spread the word.
Life is indeed hard for women in Humla. Particularly in the Hindu communities, woman are responsible for much of the hard labour as well as having to raise and support children. Officially banned in law the ancient practice of chaupadi is still widely practiced particularly in the more remote villages. Menstruating women and those in child labour are banned from the home to cowsheds and outhouses because they are considered impure and will bring misfortune such as crop failure, illness and death to the family. It is thought that if they touch men or anything in the house, cook or use public water tanks or wells the community will be punished by the gods.
Slowly these perceptions are changing through education and the Nepal Trust is helping to promote the change through its chain of health clinics and its child education programme. Our Little Doctors programme trains over 60 young students annually in basic health care and young girls now understand that the changes to their bodies is a perfectly natural function that should not be hidden away but helped.
The Trust is also building three Birthing Centres where mothers can give birth in a safe environment. Each centre is linked to an existing Health Clinic so that resources can be used to best effect. The first Centre at Bargaun village is nearing completion and will support a number of surrounding Hindu and Budhhist villages including the largest Hindu village in Humla. The second Centre at Sarkegad is well on the way to completion helped by a Community Assistance Grant. Sarkegad is the economic centre of south Humla and developing rapidly. Our third Centre at Yari will start construction later in the year. Funding is almost in place supported mainly by Rotary International.
Our clinics were very busy during 2013 and over 9000 patients were seen and received treatment. Poor hygiene and dirty water were responsible for a lot of intestinal problems and skin diseases. Smoky homes and damp conditions led to a variety of respitory disorders and conditions like conjunctivitis. Pneumonia and intestinal problems were particularly bad amongst the under 5 year olds and is a major cause of the very high infant mortality rate in this region. Family planning advice and support was given in nearly 4000 cases.
In this report you will see a link to a film on YouTube, 'Journey to the Sky', made by Rotarians from Durango in Colorado. We have said previously that our work is carried out in a very integrated way. We have built many hydro and solar energy schemes over the years to provide clean energy and lighting to homes that previously were lit by polluting oil lamps. This alone has had a beneficial impact on reducing respitory disorders. This film is about a group of Rotarians who travelled to Humla to install solar lamps in a number of homes and villages. They also became involved with one of our Little Doctors courses and saw for themselves how important and valuable this type of health education is.
Thank you for all your support and I hope you can continue to do so or pass on the good news to family and friends.
Our UK chairman, Dr Mike Love, has recently returned from a voluntary three week trip to our project sites in Humla. It was a gruelling trip over high passes and mountain trails to reach some of the villages. He is able to report a satisfactory outcome and genuine progress being made. The new on-site health manager, Ratna Lamichanne, is introducing new methods and training to improve health care delivery. Our cooperation with another Ngo, ISIS, has seen significant improvements at the health clinics in Kermi and Yalbang both in the service delivery and infrastructure. This type of collaboration has positive benefits and avoids duplication and wasted resources in such a remote and difficult area. New staff, particularly female, have been or will be recruited which will give more confidence to female patients who find it difficult to be examined by a man in their very conservative society. A small laboratory is now available in the Yalbang clinic for the analysis of blood and urine samples - another first for the district.
Change is happening rapidly and increasing expectations. Limited roads are beginning to appear from the Tibet side, sometimes hand built by the villagers themselves. Mobile phones can be used over about 75% of the area so contact and keeping in touch is a lot easier. However, for the majority life is how it has been for the last thousand years but with small improvements happening year-on- year.
Our first Birthing centre at Bargaun village is on course for completion in the spring of 2014. This is another district first. Bargaun is working in collaboration with our nearby clinic at Torpa village which will improve efficiency and delivery. About three hours walk down the mountain is the largest, and poorest, Hindu village in Humla, Thehe. We are now in discussion with the village leaders to develop a collaborative health care delivery policy involving Thehe, Torpa and Bargaun. Work has started on a new Birthing Centre in south Humla in the village of Sarkegad attached to our existing clinic. Some initial funds have been secured for this vital project and it is hoped to complete by 2015. The new Birthing Clinic at Yari village in north Humla is at the advanced planning stage and the majority of the funding has already been secured. As always, the community have to contribute up to 10% in kind. This ensures a sense of ownership and future care.
Our three Little Doctor programmes in Simikot, Yalbang and Bargaun have been completed and 66 young students successfully graduated. We urgently need funding for next years programme.
As reported before our other activities are fully integrated with the health programme to help nurture and promote healthier lifestyles. An example of this is our Renewable Energy programme that has developed numerous hydro and solar energy schemes all of which significantly reduce the need for kerosene and wood and leads to a reduction in respitory diseases. Earlier this year eight members of the Rotary Club of Durango Daybreak in Colorado trekked, in horrendous monsoon conditions and under the direction of the Nepal Trust, to deliver and fit 165 solar lamps to homes and small businesses on the Great Himalayan Trail in Humla. These are homes that would otherwise not be connected to another electricity supply and will help them to develop their businesses for trekkers and tourists and improve the local economy. While in Humla they were also able to participate in one of our Little Doctor programmes. They have now produced a fantastic film about their trip http://www.youtube.com/watch?v=4EOTfz-7lBM 'Journey to the Sky'. It is well worth watching to get some idea of the difficulties of working in such a remote area.
If you would like to trek with the Nepal Trust do get in contact. Our Treks 2 Build have been running since 1994 and will provide you with the experience of a lifetime and you will also put something back in to these deprived communities.
Finally, to all our supporters and friends around the world, from everyone at the Nepal Trust, we would like to wish you a very happy Christmas and festive season with your family and friends. We hope that 2014 brings you joy and new hope and that the people of the Hidden Himalayas will continue to see improvements to their hard lives. It is a privilege to work for them when they also share their lives, and what little they have, with us.
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