ORIGINAL RESEARCH The Intersection between Armed Conflict and the Health Service System in the Rolpa District of Nepal: 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 India. 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 Nepalese Civil War (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 Asia 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 Amnesty International. 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