ORIGINAL RESEARCH The Intersection between Armed Conflict and the Health Service System in the of : An Ethnographic Description

Sachin Ghimire

"Terror warfare attacks not just the body, not even formation campaigns discouraged people from just the body politic, it attacks core definitions of traveling and accessing health care. Other negative humanity." (Nordstrom, 1998) effects of the war included disruption of the supply of medicines, vaccination programs, family Abstract planning services and DOT programs. Our research demonstrated many instances in which Background: In the Nepalese district of Rolpa, international humanitarian principles and basic local political battles, national level power human rights were violated by both sides. conflicts, and bureaucratic crises led to a chronic Finally, the ongoing crisis of primary health care state of social exclusion and a continuous has led many people to seek health care outside of disregard for the people’s health. These historical their local communities, traveling as far away as problems were aggravated by the Nepal Civil . War. Conclusions: The health service system is an Research Question: This paper examines the way integral part of the political system and should be in which the Nepal Civil War affected the people's supported by the political structure. This was not health, the health service system and the social the case in Rolpa either before, during, or after the well-being of the population both during and after civil war . the conflict. Keywords: exclusion, conflict, health service Metodology: Ethnographic survey (85 subjects) system, cross fire, health and illness, post conflict and direct observations. situation, Nepal. Results: During the civil war in Rolpa, both sides in the conflict fought for control of the health Background services system. Forced “donations”, forced Rolpa is a hill district in mid-western Nepal. It involvement in medical care (to benefit the belligerents), and the contradictions of performing is bordered by the districts of Dang to the south, dual roles simply to stay alive discouraged health Puthyan to the east, Salyan to the west, and workers from remaining in the war-affected Rukum to the North. The indigenous Kham region. Health centers were damaged and Magar ethnic group is predominant in Rolpa; other destroyed at a time when all work on developing groups include Brahmin, Keshtriyas, and the so- the health services infrastructure was halted. called untouchable caste groups. Rolpa was the Frequent security checks, fear of ambushes and birthplace of the (1995-2006), landmines, potential cross fire, and disin- popularly known as “Maoist Movement of Nepal.” Rolpa’s long history of social exclusion is Sachin Ghimire, Research Scholar, Center for Social reflected in extremely low standards of living and Medicine and Community Health, Jawaharlal Nehru a lack of basic infrastructure. These conditions University. Email: Submitted: 5/11/09 Revised: 8/2/2009; Accepted: 8/15/2009 led the population to resort to violence in pursuit Conflict of Interest: None declared. of their aspirations for a better life. Peer-reviewed: Yes The “People’s War” initiated by the Com-

Social Medicine (www.socialmedicine.info)- 139 - Volume 4, Number 3, September 2009 munist Party of Nepal (CPN, Maoist) was an Literature Review armed insurrection. To suppress it, the Nepalese The intersection between conflict and health is state launched various counter-insurgency an emerging field of study. Research on armed “Operations” against the Maoists. The South conflicts suggests that this “man made” disaster is Forum for Human Rights (SAFHR) reported in destructive not only of human lives, but also of 2000 that military operations, such as Kilo Sierra human civilization. It has become evident that 2 launched in 1998, had resulted in extra-judicial armed conflict destroys the health and life of killings, disappearances, arbitrary arrests, rape, individuals, damages health service systems, and torture. Supporting the SAFHR allegations, prevents health care delivery and outreach Thapa and Sijapati, writing in 2003, noted that the programs, and leads to violations of medical killing of Maoists supporters and other civilians neutrality. Each of these problems has been escalated to unprecedented heights in 1998. Kilo documented in the Nepal Civil War: Sierra 2 operations during this period were spread Damage to the Health Care System: Singh out across all the "Maoist affected" regions of the noted that "[the civil] war in Nepal had led to country in contrast to the earlier Operation Romeo widespread destruction of limited infrastructure which had concentrated on a particular area in the and had adversely impacted access to health-care western hills. These kind of inhuman actions were services and personnel, affecting family planning, reported by different Nepali human rights maternal and child health programs, and organizations and . immunization services throughout the country. The decade long civil war ended in 2006 with Likewise, attacks had damaged many health the signing of a comprehensive peace accord facilities, and staffs were often reluctant or unable between the Nepalese government and “insurgent” to travel in rural areas. Many women were CPN(Maoist). Currently, the Community Party of reported to have died during childbirth because Nepal (Unified Marxist Leninist or UML) heads a they could not reach emergency obstetric care." coalition government and the UCPN (Maoist)1 is (Singh 2005) Similarly, Ghimire and Pun in the opposition. highlight the disturbances in the health services Nepal has not only one of the world’s worst system during the war, noting that "40 health posts health service systems but also some of the were completely destroyed between January, world’s worst health indicators; it is ranked as the 2002, and December, 2004, and tens of others 12th poorest country in the world. As noted by were rendered unusable. Some of these health Collins, “Its notoriously unstable politics and posts were attached to the offices of the village mountainous terrain hinder development."(Collins development committee, which were the Maoists’ 2006) Life expectancy at birth is 62 years for favourite targets.” (Ghimire and Pun, 2006) Like- males and 63 years for females. The prevalence wise, Thapa and Sijapati write, "the ministry of of malnutrition in children under five reaches Finance's Economic Survey, 2001/ 02 reported 48%. This is associated with a under five- that not a single hospital, health post, or health mortality rate is 76/1000. Maternal mortality ratio centre was added during the review period. The per 100,000 live births in 2004 was 740. HIV numbers of primary health centers only rose by 20 prevalence is reported to be 0.5%. (WDR 2007). while the number of sub health posts actually went As noted by the author (Ghimire 2008) the down from 3171 to 3161." (Thapa and Sijapati, Nepalese State is clearly not fulfilling its 2003:145) Potter commented that "though the responsibilities to ensure citizens the right to conflict severely worsened the government health health and the satisfaction of other basic human care system, it is important to note that it was not needs. a well-functioning system prior to the conflict either. It will likely suffer most of the same 1 The UCPN is allied with another left front, the United inadequacies in the future that it did ten years Liberation Front.

Social Medicine (www.socialmedicine.info)- 140 - Volume 4, Number 3, September 2009 ago." (Potter 2007) delivering prompt medical treatment to all those Disruption of Health Care Services: injured in the fighting. Stevenson argues that International humanitarian principles make it clear while the government agreed in principle that that health workers should be allowed to fulfill "necessary [medical] treatment be given at the their duties even in conflict zones. But, in the earliest possible opportunity to anybody who context of the civil war, many health workers were approaches a health center after being injured and tortured, abducted and killed, creating a climate of that the patient must be treated immediately fear among health personnel. Stevenson has without inquiring where and how he or she was documented a series of challenges for medical wounded or fell sick", this was often disregarded personnel attempting to care for wounded and in practice. (Stevenson 2002) traumatized patients. These included the cross- Damage to Individuals: Mental health is an fire between government force and Maoist important dimension in the study of conflict and militants, as well as threats and abuses from both health. Dahal’s study of internally displaced war sides of the conflict. (Stevenson 2002) Potter widows documented how "increasing work writes, "one of the chief causes of project delays burdens as a result of difficult economic situations was Maoist-announced bandhs (transportation further underpins their psychosocial health closures/strikes), where roads and highways could problems." Dahal’s study insightfully explored the be shut down at any time, sometimes for hours, multiple dimensions of the physical and mental sometimes weeks. Those who refused to adhere to health for this group of war victims. (Dahal 2007) the closures risked facing consequences, ranging Internal displacement can have profoundly from verbal warnings to explosive devices on negative impacts on both physical health and highways. As a result, many staff could not travel mental wellbeing. Singh and his colleagues note to and from field sites as easily, supplies were not that "currently, ordinary civilians constitute a always delivered on time and project-related large proportion of those displaced: the displaced trainings were occasionally postponed." (Potter now include the affluent landowners, government 2007) officials and teachers who are threatened by the Violations of Medical Neutrality: Stevenson Maoists as well as the poorer civilians who have writes that during the civil war Maoist insurgents fled violence and insecurity, including young men arrested by Nepalese army were often tortured to and women who have fled their villages for fear of the point of death; physicians were then forced to forced recruitment and harassment by the Maoists produce false reports documenting that death had and intimidation by the security forces. A recent occurred as a result of crossfire. Moreover, a cross-sectional survey among 290 internally "directive from the Nepal Ministry of Health was displaced people in Nepal found high rates of issued that instructed all doctors to immediately post-traumatic stress disorder (53.4 per cent), provide information to security officials about anxiety (80.7 per cent) and depression (80.3 per individuals seeking treatment for wounds linked to cent)". (Singh et. al 2007) the conflict; mainly bullet wounds and injuries Post-conflict Period: In post-conflict Nepal, caused by explosions. Doctors who disobey this reconstruction and repatriation have assumed directive are considered supporters of terrorists important dimensions. Collins writes "a according to the Terrorist and Disruptive has now been declared and a source close to the Ordinance 2001 and liable to arrest and Maoists assures The Lancet that they guarantee the imprisonment." (Stevenson 2002) This directive safety of health workers and of internally was severely criticized. displaced people who wish to return home." The International Red Cross also criticized the (Collins 2006) However, displaced persons are Nepalese government for applying a double still reluctant to return to their homes and many standard in the provision of health care by not commitments of peace accord remain unfulfilled.

Social Medicine (www.socialmedicine.info)- 141 - Volume 4, Number 3, September 2009 Research Question goals or to express their hostility." (Bartos and This research was undertaken to explore the Wehr 2002:13) Therefore, "the definition of interconnection between the Nepal Civil War, the conflict offered here implies that conflict behavior Rolpa health services system, and the health of the can occur not only because the parties have Rolpa population. Specifically, this research incompatible goals because they feel hostility explores the crucial role of conflict in the toward each other." According to these authors, suffering of people and in accessing health care. such incompatibility of goals consists of incompa- It also examines changes that have occurred in the tibility of roles, incompatibility of values, and post-war health service system. contested resources. These kinds of incompatibility of roles and values arise from Methodology whole-part differentiation, task specialization, Data collection: Data was collected during a separation and difference in size and technology. month-long ethnographic survey in Rolpa in Bartos and Wehr note that resources are December 2008. The author conducted in depth contested when there is a sense of injustice, interviews using a survey guideline as well as illegitimate power, and different level of absolute direct participant observation. In all 85 and relative deprivation. Violence (or the threat of respondents were interviewed. Of this group, 40 violence) is one of the major means of contesting were patients visiting health centers (purposive resource allocation. (Bartos and Wehr, 2002:29) sampling). Twelve respondents were individuals “[F]rom the health perspective violence is seen affected or wounded in the conflict (snowball as any act of verbal or physical force or life sampling). Fifteen health care professionals, three threatening deprivation directed at an individual members of the PLA (People's Liberation Army), that causes physical or psychological harm, seven Maoists, and eight civil society members humiliations and that perpetuates subord- were interviewed. ination."(Sinha, 1997). Incompatibility of goals or Ethical Issues: Prior to undertaking this values that are expressed though violence will research, the author clarified the interest and impact on human health. Ill health is, thus, an purpose of the study. In order to protect unavoidable consequence of armed hostility. respondents from additional harm, the researcher "Violence is a cause of ‘non health’ and death.” protected their anonymity by not taking (Sinha 1997) Violence is negative energy for photographs or recording names or identifying human lives. information. In this paper any individuals named For the purposes of this research, the terms have been assigned pseudonyms. violence, conflict, and war are used inter- Theoretical perspective: A critical perspective changeably. “Conflict" in this study represents the in ethnography is necessary to understand the civil war that was existed in Nepal during 1995- political and economic relations and other social 2006. Moreover, "Civil War", "People's dimensions in a setting of armed conflict. Critical Movement", "Maoist Movement", "Revolution" ethnography is necessary for studies of resource all denote aspects of the armed conflict in Nepal contestation, conflicts of interests, and exercise of during this period. In this war, there were two power over suppressed and oppressed groups. opponents: the government Special Forces (SF) Pains, sufferings, tragedies and social frag- and the Maoists. “Health service system” is mentation cannot be isolated from their social defined as the health resources of the Nepal state. context in any study of human beings.. The incompatible goals of these two parties Conceptual Framework: "Conflict can became very detrimental for people's health as originate either in goal incompatibility or in well as the health service system, part of the hostility, and that it involves a unique type of state’s resources. behavior against each other to attain incompatible

Social Medicine (www.socialmedicine.info)- 142 - Volume 4, Number 3, September 2009 Health workers caught in cross fire. such kind of ideological and emotional solidarity During the civil war, government health staffs eventually meant trying to develop values had to play dual roles. Both sides in the fighting compatible with both fighting opponents. It could considered the government health system as a be fatal for health workers to favor either side and “state resource” to be contested. Health workers yet it was difficult for health workers to maintain were compelled to act like government supporters absolute neutrality. in front of the Special Forces (SF) while simultaneously agreeing to the demands of the Targeting the Health Services System People’s Liberation Army (PLA). During the Civil War it was impossible to Health workers in Rolpa who failed in this dual carry out any improvements in the Ropla health role often suffered violence. Typical incidents services system. Moreover, there were severe described by informants are as follows: Maoist disruptions in existing services such as vaccine insurgents beat up the Community Medical distribution and the organization of the vasectomy Assistant (CMA) of the Ranghsi sub-Health Post camp. (SHP). In Serum, the office assistant of the SHP, The disruption of the vaccination campaign D. B. Rokka, was kidnapped and killed by the provides one example of the situation in the Special Forces. The Village Health Worker conflict zones. Informants from remote areas such (VHW) of was tortured and beaten up by as and Kureli stated clearly that the Special Forces and subsequently suffered from there was no immunization program during the post-traumatic stress disorder. The VHW of Jaya civil war. This is consistent with observations Maa Kachala was severely tortured in police made by international organizations.2 Curiously, custody. At the Thawang Health Post, the assistant reports from the District Board of Immunization was severely beaten up by the Special Forces and document very high vaccination rates during the the health post blasted using a rocket launcher. same period. It appears that the government The Special Forces accused the health post of provided incorrect statistical data which performing "incompatible roles" by providing exaggerated the extent of vaccine coverage. treatment to Maoists. On the day of polio Because of the hostility between fighting vaccination, L. Rokka, a Female Health Volunteer opponents, the vaccination program was severely (FHV) was abducted by the army and accused of affected and the government was compelled to providing treatment to the Maoists. report false statistical data demonstrating high These actions are in violation of the principles rates of coverage. Both fighting opponents had of the International Red Cross which sets out the hindered the health delivery system in their obligation of warring parties to “respect and demonstration of incompatible goals. protect medical and religious personnel, medical units and means of transport." (DFID et. al. Contesting government health resources 2003:18) In Rolpa health workers were tortured, Control over government health resources was killed, and displaced from their regular jobs. a highly problematic area for medical personnel Regular army operations, danger of potential during the civil war. As an insurgent force, the combat, and fear of ambushes were additional Maoists were committed to maximum utilization factors that discouraged health workers from of government resources. When they felt it was visiting district headquarters to collect medical needed, the Maoists forcibly took medicines from and surgical materials. Some low-level health the health services system. Health personnel found workers were able to develop the proper it generally necessary to share up to 50 percent of ideological and emotional solidarity with the Royal Nepalese Army (RNA) and the PLA, and 2 "Health programmes have been dislocated and in the they decided to stay in the villages. Developing most affected districts like Rolpa there has been a break in the immunization program.” (SAHFR 2000)

Social Medicine (www.socialmedicine.info)- 143 - Volume 4, Number 3, September 2009 medical supplies (including items such as Donation by Terror condoms and acetaminophen) with the Maoists in The Maoists forced all government workers order to avoid the suspicion of holding (including health care personnel) to make incompatible roles and values. This “sharing” “voluntary” contributions from their salaries. occurred because government control over the These contributions took various forms. There villages was often weak. At times Maoists would was a yearly special donation amounting to a take medicines needed for their wounded even month’s salary; school teachers were required to when this broke prior verbal agreements with donate two month’s salary. An additional five government medical personnel. To raise any kind percent of salary went to support the Maoist of reservation during this “resource sharing” insurgents.Elderly people were also supposed to meant placing oneself at maximum risk for donate 5% of their pension. Though presented as physical torture or death. voluntary, in reality this was a "do or die" It was compulsory for health post and sub situation for the employees. Workers who refused health post personnel to assist in the construction to make the donation were considered to of the Martyr’s highway3 by providing medicines, demonstrate “incompatible values” and were dressing kits, and other needed supplies. Of note, threatened, tortured, or killed. Many villagers allopathic medical workers were not the only ones were not in a condition to disobey. To avoid these forced to support the Maoists. The staff of a levies many, including a large number of health homeopathic hospital was under similar pressure workers, chose to flee the villages for the relative and was forced to supply the People’s Liberation safety of the larger towns. Ironically, workers who Army (PLA) with first aid kits. remained at their post faced suspicions from the The Government was clearly aware that the government of being Maoist sympathizers. Maoists were using their resources and attempted There is some evidence that in towns to stop this. One technique was to limit the flow of controlled by the Maoists health services medical supplies to the health posts and sub health improved in certain respects. Maoists increased posts. Supply of medication to the SHP had to be the supply of medicines in order to attend to the approved by the District Police from a list of health needs of their own combatants. The PLA supplies vetted by medical personnel.4 As a also forced health care personnel to remain in the result, health personnel in Rolpa generally agreed villages. that very few medicines reached the health centers The irregular supply of health workers during the civil war.5 (commonly called “doctors” in local dialects), long term absenteeism, lack of health facilities,

3 and lack of medicines in the government health The Martyr’s Higway was a two lane road that services system discouraged people from visiting connected many remote villages of Rolpa. Maoists named the road as a tribute to all "great" martyrs during government facilities. Poor people turned to the civil war. shamanism, faith healing, and locally available 4 In Rolpa, "VDCs like Jinabang, Rank, Iribang, herbs. Ramkot, Jangkot, Vhabang, Korcabang, were While the distrust of the health system started prohibited to send medicines. Excluding those place if during the civil war, it has continued to the present there was demand of medicines from other places, it was necessary to take recommendation from District day. police office."(Aryal 2005.) “In district police office, there was a team of medical persons; it used to provide suggestion to police force about the control of medicines those may be useful for Maoists." coordination and negotiation with the security forces. 5 "Health personnel were particularly vulnerable when Sometimes, they seize drugs, dressings, and bandages" transporting drugs and medical supplies. In areas (DFID et. al. 2003). In Rolpa "local administration has affected by the conflict, the transportation of ordered not to distribute hard antibiotics and medicines medication involves delays and requires lengthy those could be useful for Maoists."(Aryal 2005)

Social Medicine (www.socialmedicine.info)- 144 - Volume 4, Number 3, September 2009 Post conflict situation. The police station of Kotgaon and the police The end of the civil war found the people of station of Powang operate from the cafeteria of Rolpa with an inefficient health service system the district health office and health post building characterized by lack of infrastructure, shortage of respectively. The practice of carrying patients in staff, dysfunctional administration, and poorly “Doko’ (a bamboo basket) from home to health maintained equipment. By comparison to the centers continues. The cost of this service varies conflict period the condition of health services according to distance from home to hospital, system in Rolpa is comparatively functional, but running from two to three thousand Nepalese the overall standard of health services has seen no rupees (30 to 40 USD). However, the government change at all. Shortage of health professionals, has announced plans to provide around one untimely supply of vaccines, lack of medicines, thousand Nepalese rupees (approximately 12.7 poor supervision and monitoring, and a dilapi- USD) as an incentive to support safe motherhood dated infrastructure are all common problems at for hill districts. the present time. Since the government health service system The Nepalese government has recently has not been able to provide satisfactory services launched a Free Health Service at the SHP, HP at the primary care level, people are forced to and PHC levels. The system is supposed to make long journeys to access health services guarantee free registration, free services, and free either at the District Hospital or even outside of medicines. However, the Government has not Rolpa. People visit Dang, , Nepalgung taken into account that, without giving special even bordering areas of India such as Luckhnow priority to strengthening the health service system, and Delhi. This is a form of additional social it is not possible to launch a special program that suffering that patients have to bear. Similarly, the provides universal coverage of health services. In influx of patients from non-functional primary Rolpa today, the health service system completely facilities represents a burden on tertiary care fails to fulfill even its most basic functions. centers. If tertiary centers are overwhelmed by The deplorable state of the health services in patients with simple ailments such as headache Rolpa was evident during field work. Some and stomach ache, they cannot perform their role examples are described here: as referral centers. The District Hospital lacks a cafeteria or Major political parties in Nepal, including the waiting space for visitors. Male and female (NC), CPN(UML), and UCPN patients share the same latrine whose condition (Maoists), have incorporated population-wide can only be described as sickening. Patients primary health care into their election manifestos. suffering from nausea, vomiting, and other gastro- But in reality, none of the Nepalese governments intetinal diseases could literally not breathe inside have made significant efforts to improve the the latrine. condition of the Rolpa health service system. In Thawang, a village regarded as the strong hold Rolpa, the primary health care system remains in of the Maoists, has received little support in its crisis and the health service system is grossly attempts to build a health post. The contractors inadequate. Once someone gets sick, the family is who had been hired to build the post seemed more forced to spend large amounts of money accessing interested in quick profits and left the community health services outside the district. The deplorable with a poorly designed, poorly built, and poorly state of the public health system creates a chronic functioning facility. At the time this research was situation of medical dependency. being carried out, the facility was not in use. On the day of the BCG vaccination campaign, Conclusions mothers had to bring their babies to a temporary In Rolpa both sides in the conflict fought for health post run out of a small house. control of the health services system. Forced

Social Medicine (www.socialmedicine.info)- 145 - Volume 4, Number 3, September 2009 donations and forced involvement in medical care level of dissatisfaction at the micro level. This (to benefit the belligerents) were only two of the crisis could be seen as a structural determinant of many reasons that health workers felt insecure in ill health. The solution lies in a structural the conflict zone. The contradictions of transformation affecting the local political performing dual roles simply to stay alive in the structures where the majority of the people war zone finally discouraged health workers from struggle to maintain healthy lives. Such a trans- remaining in the war-affected region. Absen- formation should address questions of teeism among medical personnel had a significant accessibility, the rational distribution of basic adverse impact on people's health. Health centers health and education facilities, and should were damaged and destroyed at a time when all guarantee the inhabitants of Rolpa sanitation, work on developing the health services food, housing, and employment. infrastructure had been halted. Many poor people were obliged to rely on Shamanism, faith healing, References and irrational medical practices. Frequent security checks, fear of ambushes and landmines, potential Aryal, K. (2005), 'Aushadhiko Avhavma Mardaichan Rolpaliharu', in Gautam, B., Bhattarai, A.(eds) cross fire, and disinformation campaigns Swashthya, Samaj ra Rajniti, Kathmandu: Martin discouraged people from travelling and accessing Chautari. health care. Other negative effects of the war included disruption in the supply of medicines, Bartos, Otomar J. and Wehr, Paul (2002), Using vaccination programs, family planning services, Conflict Theory. USA: Cambridge University Press. and DOT programs. Especially hard hit were Bhatt, Shafquat M. (2006) Conflcit in Jammu in tuberculosis patients who had to visit the health Kashmir and its implications for health: An exploratory centers to follow DOTS and whose mobility was study, Unpublished M. Phil Thesis. Jawaharlal Nehru highly disturbed because of the war. Our research University demonstrated many instances in which inter- Collins, S. (2006), 'Assessing the health implications of national humanitarian principles and basic human Nepal’s ceasefire', The Lancet. Vol: 368 September 9 rights were violated by both sides in the civil war. Finally, the ongoing crisis of primary health care Dahal, K. B. (2007). Health Embedded in Social has led many people to seek health care outside of Context: Internally Displaced War Widows in Nepal. The Journal of Finish Anthropological Society 32 their local communities. (1),pp 63-70. The difficulties of the health care system in Rolpa did not originate with the civil war. Rolpa Department for International Development, Swiss has faced a long history of exclusion, Development Cooperation, German technical characterized by a shortsighted government, a Organizarion (2003), Conflict and health in Nepal. Action for peace building. 6th March , 2003 , dysfunctional bureaucracy, and low levels of DFID/DHSP, SDC/RHDP, GTZ/HSSP .Country awareness by the population. Geography has not Office, Nepal. facilitated development in this hilly district accessible primarily via steep, narrow trails. To Department for International Development (2004), these problems were added the burdens of the civil Service delivery in difficult environments: the case of Nepal, Asia Policy Division Nepal country office war. Tragically, the harm done by the civil war Jeremy Armon, Chris Berry, Debi Duncan with lives on in post conflict Rolpa where conditions Rebecca Calder, Susan Clapham, Mark Harvey seems little different from the time of active conflict. Ghimire, S. (2008), 'HIV and AIDS in Broadsheet The armed conflict in Rolpa has aggravated Dailies', Media Addhyan, Journal. Vol. 3, pp. 99-129, .Kathmandu, Nepal. pre-existing low levels of awareness, poor living standards, lack of basic facilities, and a continuous Ghimire, L. V. Pun, M. (2006), 'Health effects of

Social Medicine (www.socialmedicine.info)- 146 - Volume 4, Number 3, September 2009 Maoist insurgency in Nepal,' The Lancet, Vol 368, Survival, 23:2, 103 - 110 Issue 9546, page 1494, 28 Oct. Sinha, R. (1997) Violence and health: An exploratory Nordstrom, C. (1998),'Terror Warfare and the Medicine study. Unpublished M.Phil. Thesis, Jawaharlal Nehru of Peace, The Embodiment of Violence', Source: University. Medical Anthropology Quarterly, New Series, Vol. 12, No. 1, pp. 103-121 Forum for Human Rights (2000), People's War in Nepal, Vol 1, issue 3, July, Lalitpur, SAFHR Potter, Katherine .J (2007), Mitigating the Maoists Office. conflict: The impact of civil war on health promotion Ngos in Nepal. Unpublished Master thesis. University Stevenson, Philip C. (2002) 'High-risk Medical Care in of Washington. War-Torn Nepal'. The Lancet; 359:1495,UK

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Social Medicine (www.socialmedicine.info)- 147 - Volume 4, Number 3, September 2009