Essay The State of Child and Human Rights in Sonal Singh*, Erik Bøhler, Khagendra Dahal, Edward Mills

epal is one of the poorest lives of most of the rural population. in rural and mountainous regions it countries in the world, with The armed confl ict has eroded the increases to 147 per 1,000 and 201 per Na per capita gross national tenuous gains in key development 1,000, respectively [6]. The maternal product of US$240. Nearly 40% of indicators [4]. mortality rate is one of the highest in the 25 million people living in Nepal The Nepal Demographic and the world at 539 per 100,000 live births do so on less than a dollar a day [1]. Health Survey of 2001 found an infant [5]. In rural Nepal more than 90% of About 90% of the population lives in mortality rate of 64 per 1,000 live birth deliveries are at home. Women rural areas. The high-intensity (more births and a neonatal mortality rate face a one in 24 risk of dying during than 1,000 deaths per year) confl ict of 39 per 1,000 live births [6]. There pregnancy and childbirth, and current between the Communist Party of Nepal are widespread disparities in health levels of insecurity are increasing this (Maoist) rebels and the government services, life expectancies, education, risk further, as the confl ict is hindering forces led by the Royal Nepalese Army and income between urban areas pregnant women from reaching has affected the health, education, and like the capital Kathmandu and the hospitals for delivery [6,7]. other rights of the most vulnerable district headquarters on one side members of society, especially women and the majority rural areas on the Status of Child Health and children [2]. The confl ict, other. The under-5 mortality rate in One out of every 11 children in Nepal which began in 1996, has resulted in urban areas is 93.6 per 1,000, whereas dies before reaching the age of fi ve [6], widespread human rights violations by and almost 70,000 children die yearly both parties as it draws the population from preventable causes. One in two into the confl ict as both soldiers and Box 1. Search Strategy children is stunted or underweight, victims. with little improvement in this situation In this article we examine the In order to identify information since the 1990s [6]. A recent study evidence on the current state of child for our article, we searched Medline, estimated around 30,000 annual health and Google Scholar, POPLINE, World Health (Box 1). We argue that time is running Organization reports, United Nations Development Programme–Nepal reports, out for the children of Nepal, as they Funding: The authors received no specifi c funding face an uncertain future if their health the UN Offi ce for the Coordination of for this article. and human rights concerns are not Humanitarian Affairs (IRINnews) Web site, and Eldis Development Gateway, using Competing Interests: The authors have declared addressed by local governments, non- that no competing interests exist. governmental organizations (NGOs), the terms “Nepal,” “child health,” “human rights,” and “confl ict.” We searched Citation: Singh S, Bøhler E, Dahal K, Mills E (2006) The and the international community in a state of child health and human rights in Nepal. PLoS timely manner. We also suggest possible reports of several non-governmental Med 3(7): e203. DOI: 10.1371/journal.pmed.0030203 solutions to the current problem. organizations including Save the Children, Family Health International, DOI: 10.1371/journal.pmed.0030203 Bleak Indicators and CARE Nepal. We selected articles Copyright: © 2006 Singh et al. This is an open-access article distributed under the terms of the Creative In 1996, before the insurgency began, for inclusion based on their relevance to the topic and their ability to advance Commons Attribution License, which permits Nepal ranked 124 out of the 137 unrestricted use, distribution, and reproduction in countries on the United Nations our understanding of the impact of the any medium, provided the original author and source are credited. Development Programme’s Human confl ict on child health and human rights. Development Index (HDI) [3,4]. This In addition, we identifi ed unpublished Abbreviations: HDI, Human Development Index; NGO, non-governmental organization index, which has a score of 0 to 1, research through contacts with authors and experts in the fi eld. We acknowledge gives a measure of longevity, health, Sonal Singh is in the Masters of Public Health education level, and standard of living. the lack of epidemiological studies Program, Bloomberg School of Public Health, Johns directly linking the confl ict to child Hopkins University, Baltimore, Maryland, United Nepal’s HDI was 0.471 in 1996 [3,4]. States of America, and is at the Department of Although Nepal has since then moved health care in Nepal; documentation Medicine, Wake Forest University Health Sciences, from the rank of “low” to “medium” on crucial aspects of the confl ict was Winston-Salem, North Carolina, United States of often impossible to obtain and we rely America. Erik Bøhler is a member of the United development countries (its HDI score Mission to Nepal, Okhaldhunga Hospital, Eastern in 2005 was 0.526 [5]), this apparent on newspaper articles and eyewitness Nepal. Khagendra Dahal is the International Student Representative, International Physicians for the improvement has not improved the accounts at times. We drew from the collective expertise of the authors (SS, Prevention of Nuclear War, Kathmandu, Nepal. Edward Mills is at the Department of Epidemiology EB, KD) involved in delivering health care and Biostatistics, McMaster University, Hamilton, in Nepal and incorporated suggestions Ontario, Canada. The Essay section contains opinion pieces on topics from international health experts and of broad interest to a general medical audience. * To whom correspondence should be addressed. NGOs active in this fi eld. E-mail: [email protected]

PLoS Medicine | www.plosmedicine.org 0948 July 2006 | Volume 3 | Issue 7 | e203 deaths due to diarrheal diseases in themselves, due to the loss of their the country [8]. In a recent analysis, parents and relatives [16]. Among nearly 66% of schoolchildren in the students, 74% percent in Maoist- northeastern part of Kathmandu Valley affected areas fear that the rebels or were found to have parasitic infections government forces might abduct them and nearly half of them had multiple [17]. There is a general lack of hope, parasitic infections [9]. Only one in especially among the youth. Some four children in Nepal sees a health of them have left the countryside. provider for illnesses [6]. Children are Others have joined the insurgents particularly vulnerable, because they or developed reliance on drugs and are less likely to be taken long distances alcohol [15]. to health centers. DOI: 10.1371/journal.pmed.0030203.g001 Children Lack Food and Education Figure 1. Operations at Okhaldhunga Impact of the Confl ict on the Hospital Being Carried Out without Children face food insecurities due Health Sector Electricity under Torchlight to frequent blockades and cutbacks The Royal Nepalese Army controls (Photo: Erik Bøhler) in local food production caused by the capital, Kathmandu, and the 75 the exodus of merchants from rural district centers in the country, while The confl ict has had a variable areas, lack of access to markets, and many areas surrounding the district impact on coverage of primary-care the displacement of able members centers and rural areas are under posts in rural areas. [10]. In some of some households [18]. This food Maoist control [10]. Families may Maoist-controlled areas, health post insecurity is not evident in Kathmandu, be subjected to harassment if they staff are threatened with reprisals if but is clear in the rural areas. The very attempt to leave or enter the Maoists’ they do not stay at their posts. In other high prevalence of babies who are heartlands. A transport shutdown by areas, staff have fl ed their posts since “low weight for gestational age” means the Maoist rebels in March 2005 held the beginning of the confl ict, both for that newborn children are already at up the supply of vaccines, vitamin A, fear of their lives and because of heavy risk [19]. The situation and de-worming drugs to nearly 3.6 “taxation” of government employees is particularly serious in many parts million Nepalese children. Annually, by the Maoists. The government’s of the midwestern region, which are some 12,000 children in Nepal would directive that health professionals badly affected by the confl ict, with succumb to diseases without these who provide treatment for injuries Humla district having the highest rate essential medicines [10]. without appropriate notifi cation can be of malnourishment in the country [20]. The delivery of health services has prosecuted as supporters of terrorism A recent survey by the NGO Terre des been disrupted in the far western has created a diffi cult scenario for Hommes among internally displaced regions and severely restricted in health workers, who risk incarceration children under three years of age in other parts of the country [11,12]. [13]. In April 2006, several physicians four Village Development Committees Several community health posts have in Kathmandu were detained for taking in a western Terai district found that been destroyed and dozens of health- part in peaceful demonstrations and 59% of children were underweight and care workers have lost their lives. two foreign physicians were deported 15.9% had wasting [21]. According to INSEC (Informal Sector for treating victims of the violence [14]. The confl ict has also deprived Service Center), an independent Although there is no study Nepalese children of education. Prior human rights organization, 40 health establishing a conclusive link between to the confl ict, access to education in posts were destroyed between January the confl ict and mental disorders, a Nepal was extremely limited for girls, 2002 and December 2004 [10]. The recent cross-sectional survey of 290 members of the lower castes, and other Maoists destroyed the electrical supply internally displaced people in Nepal disadvantaged groups [22]. Currently of Okhaldhunga Hospital, a small found high rates of post-traumatic one out of every fi ve children aged six hospital in remote eastern Nepal, in stress disorder (53.4%), anxiety to ten does not attend school [23]. an attempt to harm a nearby army (80.7%), and depression (80.3%) Nearly 700 private schools have closed camp that got its electrical supply [15]. Psychiatrists and mental health down since 1996. Even in districts from the same power plant. As a hospitals have seen an increase in the where schools are open, the continuing result, operations such as caesarean number of patients in recent years series of strikes and blockades has sections were being performed (Okhaldhunga Community Hospital reduced the time children can go to under torchlight (Figure 1). Health Public Health Unit, unpublished data). school [22]. Schools in rural areas education programs conducted by Data from Okhaldhunga Hospital are under-attended by students and the district public health offi ces and in 2004 showed a general downward teachers due to fear, insecurity, and other private organizations are on the trend in attendance, probably due displacement [18]. Schools have been decline due to Maoist and government to transportation problems caused bombed and attacked [18]. Mines have threats. Health-care workers fear a rise by the confl ict, but an increase in been placed in and around schools and in communicable diseases and several consultations for mental disorders playgrounds [22]. Schools have been organizations, including Médecins (Okhaldhunga Community Hospital used as grounds for child recruitment Sans Frontières, have had to scale Public Health Unit, unpublished data). and abduction of teachers, or turned back their activities in rural Nepal as a Within this situation of uncertainty and into barracks and used for political result of the insurgency. confl ict, hundreds of children raise meetings [18].

PLoS Medicine | www.plosmedicine.org 0949 July 2006 | Volume 3 | Issue 7 | e203 HIV/AIDS in Children prosecutions of government offi cials policy changes aimed at making Although the incidence of HIV in or Maoists for their involvement in valuable health services accessible children in Nepal is low, WHO/ disappearances [32]. for the poor, children’s health in this country will not improve. Systematic UNAIDS (World Health Organization/ Recent Progress United Nations Programme on HIV/ capacity building to support the AIDS) estimates that there were 940 In recent years there has been some Female Community Health Volunteers children living with HIV and nearly progress in fi nding indigenous or “Sevikas” is the best hope for 13,000 children orphaned due to solutions to improving the health sustaining the momentum of programs AIDS at the end of 2003 [24]. The of children despite the diffi cult that promote health equity through reality of the situation is unclear, as circumstances. A survey of primary interventions such as family planning, many have been traffi cked to India for health-care services in central Nepal polio prevention, and vitamin A sex work [24,25]. A study by General found that health care for those with supplementation [33]. Improving Pratishthan, an NGO working resources had improved considerably, the quality of services provided at on the prevention of HIV and STDs, but massive privatization had severely existing health centers, rather than postulated that the current confl ict limited access for the poor [33]. increasing the number of centers, is an may have pushed a large number of Improvements in maternal literacy have effective way to improve child health young girls from rural villages to urban also been shown to improve health in Nepal [37]. In the regions most areas in search of food, shelter, and behavior in Nepal [34]. The vitamin A affected by the confl ict, the health security who later end up involved in program was successfully implemented situation should be monitored by prostitution for subsistence [26]. This in the remotest districts of Nepal with using sentinel site surveys (surveys of may fuel the spread of HIV among community participation. A recent representative sites to collect health young girls. cluster randomized trial assessed the related information using UN teams of use of simple interventions, such as experts) and participatory appraisal (a Children and Human Rights participation in women’s groups at the process which invites people to explore Since the end of the cease-fi re in community level and monthly women’s the issues that affect them to fi nd 2003, there has been a steady increase group meetings with female facilitators realistic and feasible solutions to their in human rights violations against to identify local perinatal problems problems). Such monitoring requires Nepalese children by both parties to and strategies to address them. The commitments by both Maoist and the confl ict. The National Human trial showed a reduction in neonatal government authorities to allow survey Rights Commission estimates that mortality rates from 36.9 per 1,000 to teams to assess the current health and more than 500 children have been 26.2 per 1,000 [35]. Women in the human rights situation and respect killed in the confl ict [27]. Although intervention clusters were more likely demographic and health surveys. it is extremely diffi cult to assess the to have antenatal care, institutional In order to sustain child complete extent of child soldiering delivery, trained birth attendance, and development, it is imperative that in Nepal, the use of child soldiers is hygienic care than were controls. both parties halt all violations against common by both parties to the confl ict The recently released Millennium children in Nepal and uphold [28,29]. Girls are raped and subjected Development Goals Report is international humanitarian law and to other forms of sexual violence by optimistic that Nepal will meet the human rights [38]. Both parties have both Maoists and government forces; goals of: halving the proportion of to refrain from drawing children into survivors of gender-based violence people living below the national the violence and should view children often remain silent due to a lack of line; reducing the under-5 as “the zone of peace” and schools and protection [18]. mortality rate by two-thirds; achieving health posts as “weapon-free zones.” Nepal holds the dubious gender equality; improving maternal The agreement between the Nepalese distinction for the highest number of health; and ensuring environmental government and the UN Human Rights “disappearances” in 2004. Children sustainability by 2015 [36]. But in the Commission to set up an international under age 18 have “disappeared” current political and developmental monitoring mechanism to protect and have been arbitrarily detained by climate, it seems unlikely that the child human rights is a step forward [39]. government forces [18]. According health goals will be met. The goals of Both parties should invite international to INSEC, nearly 3,000 people were achieving universal primary education observers such as the United Nations killed and about 26,000 people were and reversing the spread of HIV/AIDS to instigate, conduct, and monitor a abducted in Nepal in 2004 [30]. While are also unlikely to be realized [36]. peace process [40]. There is also an accurate estimates are hard to come urgent need to implement a human by, Child Workers in Nepal, a local The Road Ahead rights accord which abides by the NGO, estimates that in 10 years of In a country as diverse as Nepal, no Geneva Conventions and commits both the insurgency 27,323 children have single solution can address the current the government and Maoists to respect been abducted, while the state security problems facing child health. Sparsely clear human rights standards and forces have arrested 229 children populated mountains with Tibetan accept human rights monitoring [40]. [31]. From January to August 2005 the language and nomadic traditions The should insurgents are said to have abducted pose different challenges than the conduct independent, impartial, public 11,802 children while the security densely populated Terai regions, investigations into atrocities against forces have arrested 17 children which have similarities to India. Unless children and allocate the necessary [31]. There have been hardly any the government starts introducing funds to ensure that young people have

PLoS Medicine | www.plosmedicine.org 0950 July 2006 | Volume 3 | Issue 7 | e203 access to adequate health care and 3. United Nations Development Programme 19. Bøhler E, Adhikari N (2004) Birth weight (2004) Nepal human development report and early growth of premature infants in education [18]. Immediate emergency 2004. Empowerment and . Kathmandu, Nepal. J Inst Med 26: 7–9. support should be provided to children Available: http:⁄⁄www.undp.org.np/ 20. Integrated Regional Information Networks affected by the confl ict by the state, publication/html/nhdr2004/index.php. [IRIN] (2005) Nepal: Focus on malnutrition. Accessed 22 May 2006. Available: http:⁄⁄www.irinnews.org/report. government organizations, and 4. United Nations Development Programme asp?ReportID=47631&SelectRegion= NGOs, and efforts should be made to [UNDP] (2004) Human development Asia&SelectCountry=NEPAL. Accessed rehabilitate child survivors [38]. Non- indicators. In: Human development report 2 October 2005. 2004: cultural liberty in today’s diverse world. 21. Terre des homes Nepal (2005) Nutritional governmental organizations and civil New York: UNDP. Available: http:⁄⁄hdr.undp. status of the children victims of the armed society must strive to enforce existing org/docs/statistics/indices/hdi_2004.pdf. confl ict in Nepal. A survey report among IDP Accessed 2 October 2005. children in Banke district. Lalitpur (Nepal): legislation protecting children and 5. United Nations Development Programme Terre des homes Nepal. Available: http:⁄⁄www. also address the issues of child soldiers, (2005) Country fact sheets—Nepal. In: un.org.np/uploads/reports/TDH/2005/ child labor, and traffi cking in children Human development report 2005. Available: Nutritional-status-of-Children-tdh.pdf. Accessed http:⁄⁄hdr.undp.org/statistics/data/ 26 February 2006. affected by the confl ict [41]. country_fact_sheets/cty_fs_NPL.html. 22. Save the Children, Children’s Environments The king of Nepal reinstated Accessed 2 October 2005. Research Group, UNICEF (2003) What’s the the parliament in April 2006 after 6. Nepal Ministry of Health (2002) Nepal difference? An ECD Impact Study from Nepal. Demographic and Health Survey 2001. Kathmandu: Save the Children. Available: nationwide protests [42]. The Kathmandu: Family Health Division, Ministry http:⁄⁄www.unicef.org/media/fi les/ Maoist rebels have signed a code of of Health, and New Era; Calverton: ORC Nepal_2003_ECD_Impact_Studty.pdf. Macro. Accessed 24 May 2006. conduct with the representatives of 7. United Nations Population Fund [UNFPA] (5 23. UNICEF (1 April 2005) UNICEF appeals the government, raising hopes for a April 2005) UNFPA urges adversaries to respect for fear to be banished from Nepal’s peaceful solution to the confl ict in human rights in Nepal. Confl ict blocks life- classrooms. Available: http:⁄⁄wwwnotes. saving health services to women [press release]. reliefweb.int/w/rwb.nsf/0/ Nepal. Available: http:⁄⁄www.unfpa.org/news/news. 00804D8D95F9291F85256FD6006388B0? The international community, cfm?ID=602&Language=1. Accessed 22 May OpenDocument. Accessed 2 October 2005. which provides 60% of Nepal’s 2006. 24. YouandAIDS.org (2006) Nepal at a glance. 8. Pokhrel D, Viraraghavan T (2004) Diarrhoeal Colombo (Sri Lanka): United Nations development budget, has a larger diseases in Nepal vis-à-vis water supply and Development Programme. Available: role to play in protecting the rights of sanitation status. J Water Health 2: 71–81. http:⁄⁄www.youandaids.org/ 9. Sharma BK, Rai SK, Rai DR, Choudhury Asia%20Pacifi c%20at%20a%20Glance/Nepal. children. The work of the international DR (2004) Prevalence of intestinal parasitic Accessed 26 February 2006. community has become more critical infestation in schoolchildren in the 25. Singh S, Mills E, Honeyman S, Suvedi BK, Pant as the freedom of the media has been northeastern part of Kathmandu Valley, Nepal. NP (2005) HIV in Nepal: Is the violent confl ict Southeast Asian J Trop Med Public Health 35: fuelling the epidemic? PLoS Med 2: e216. DOI: curtailed by the promulgation of an 501–505. 10.1371/journal.pmed.0020216 ordinance that ensures the state’s 10. Integrated Regional Information Networks 26. (18 May 2004) Flesh trade on the rise due to direct control over the private and [IRIN] (28 February 2005) Nepal: Focus on increase in violence. The Kathmandu Post. the impact of the confl ict on rural health. 27. Nepalnews.com (2005) 500 children killed free media. Another law to restrict the Available: http:⁄⁄www.irinnews.org/report. in confl ict: NHRC. Available: http:⁄⁄www. independent work of the NGOs may asp?ReportID=45810&SelectRegion= nepalnews.com/archive/2005/nov/nov21/ Asia&SelectCountry=NEPAL. Accessed news03.php. Accessed 26 February 2006. handicap the actions of organizations 22 May 2006. 28. Singh S (2004) Post-traumatic stress in former involved in health and human 11. United Nations Children’s Fund [UNICEF] Ugandan child soldiers. Lancet 363: 1648. rights issues [43]. The international (7 March 2005) Thousands more could die 29. National Human Rights Commission Nepal (26 due to transport shutdown in Nepal, UNICEF October 2005) Child rights report [Nepalese]. community needs to raise its voice warns. New York: UN News Centre. Available: Kathmandu: National Human Rights against the atrocities levied against http:⁄⁄www0.un.org/apps/news/ Commission Nepal. Available: http:⁄⁄www. children by both confl icting parties. It story.asp?NewsID=13554&Cr=Nepal&Cr1=. nhrcnepal.org/publication/doc/reports/ Accessed 22 May 2006. Child_Rights_Report_np.pdf. Accessed 22 needs to provide enough resources to 12. Singh S (2004) Impact of long-term political November 2005. meet the basic needs of the children confl ict on population health in Nepal. CMAJ 30. Informal Sector Service Centre [INSEC] (9 171: 1499–1501. April 2006) Nepal Human rights yearbook and support developmental programs, 13. Sharma GK, Osti B, Sharma B (2002) 2006. Kathmandu: INSEC. Available: but ensure that foreign support does Physicians persecuted for ethical practice in http:⁄⁄www.omct.org/pdf/omct/2006/ not fund military exercises or increase Nepal. Lancet 359: 1519. hr_yearbook_06.pdf. Accessed 26 May 2006. 14. Singh S, Arya N, Mills E, Holtz T, Westberg 31. Child Workers in Nepal Concerned Centre child health violations, in order to G (2006) Free medical doctors and students [CWIN] (2005) Children in armed confl ict. prevent the children of Nepal from detained in Nepal. Lancet 367: 1730. Available: http:⁄⁄www.cwin.org.np/ becoming another “lost generation.” 15. Thapa SB, Hauff E (2005) Psychological press_room/factsheet/fact_cic.htm. distress among displaced persons during Accessed 26 February 2006. an armed confl ict in Nepal. Soc Psychiatry 32. US Department of State (2004) Country Acknowledgments Psychiatr Epidemiol 40: 672–679. reports on human rights practices—Nepal. We thank Anthony Costello, Luke Mullany, 16. Poudel K (6 December 2002) Children in Available: http:⁄⁄www.state.gov/g/drl/rls/ confl ict: Dangers of changing behaviour. hrrpt/2004/41742.htm. Accessed 3 November Masamine Jimba, and KC Poudel for their Kathmandu: Nepalnews.com. Available: 2005. valuable comments. http:⁄⁄www.nepalnews.com.np/contents/ 33. Taylor HG, Khadka R, Taylor CE (1999) englishweekly/spotlight/2002/nov/nov29/ Health equity in Nepal: A half-century of References coverstory.htm. Accessed 2 October 2005. development in the Kali Gandaki Valley, 1. United Nations Development Programme 17. Child Rights Information Network [CRIN] western region. Baltimore: Johns Hopkins (2003) Human development indicators 2003: (2005) Impact of armed confl ict on children University School of Hygiene and Public Nepal. In: Human Development Report 2003. in Nepal. Available: http:⁄⁄www.crin.org/ Health. Available: http:⁄⁄www.future.org/ New York: Oxford University Press. Available: resources/infoDetail.asp?ID=4584&fl ag=report. downloads/Health_Equity_in_Nepal.pdf. http:⁄⁄hdr.undp.org/reports/global/2003/ Accessed 2 October 2005. Accessed 2 October 2005. pdf/hdr03_HDI.pdf. Accessed 22 May 2006. 18. Watchlist on Children and Armed Confl ict 34. LeVine RA, LeVine SE, Rowe ML, Schnell- 2. Informal Sector Service Centre [INSEC] (2005) (2005) Caught in the middle: Mounting Anzola B (2004). Maternal literacy and health No. of children killed by state and Maoists in violations against children in Nepal’s armed behavior: A Nepalese case study. Soc Sci Med connection with “People’s War” (13 Feb, 1996 – confl ict. New York: Women’s Commission 58: 863–877. 30 Nov, 2005). Kathmandu: INSEC. Available: for Refugee Women and Children. Available: 35. Manandhar DS, Osrin D, Shrestha BP, Mesko N, http:⁄⁄www.inseconline.org/hrvdata/ http:⁄⁄www.watchlist.org/reports/nepal.report. Morrison J, et al. (2004) Effect of a participatory child_data.php. Accessed 2 October 2005. php. Accessed 2 October 2005. intervention with women’s groups on birth

PLoS Medicine | www.plosmedicine.org 0951 July 2006 | Volume 3 | Issue 7 | e203 outcomes in Nepal: Cluster randomized 38. Child Workers in Nepal Concerned Centre Everest. Int J Equity Health 4: 9. Available: controlled trial. Lancet 364: 970–979. [CWIN] (2004) CWIN Nepal—Annual report http:⁄⁄www.equityhealthj.com/content/4/1/9. 36. United Nations Development Programme 2004. Kathmandu: CWIN. Available: http:⁄⁄www. Accesssed 22 November 2005. (2005) Nepal Millennium Development Goals: cwin.org.np/resources/reports/cwin_report04. 41. Sherchan U (2001) Mountain children of Progress report 2005. Kathmandu: HMG Nepal PDF. Accessed 24 November 2005. Nepal: A lost generation? Presented at the National Planning Commission. Available: 39. United Nations (12 April 2005) Secretary- World Mountain Symposium, Interlaken, http:⁄⁄www.undp.org.np/publication/html/ General welcomes agreement to set up UN Switzerland, October 2001. mdg2005/mdg2005.php. Accessed 2 October human rights offi ce in Nepal. New York: UN 42. Pandey K (2006) Protests and bombing disrupt 2005. News Centre. Available: http:⁄⁄www.un.org/ health care in Nepal. BMJ 332: 1052. 37. Acharya LB, Cleland J (2000) Maternal and apps/news/story.asp?NewsID=13949&Cr= 43. Whiting A (2005) Crisis profi le: What’s going child health services in rural Nepal: Does access nepal&Cr1. Accessed 2 October 2005. on in Nepal? Available: http:⁄⁄www.alertnet. or quality matter more? Health Policy Plan 15: 40. Singh S, Dahal K, Mills E (2005) Nepal’s org/thefacts/reliefresources/111997404550. 223–229. war on human rights: A summit higher than htm. Accessed 26 February 2006.

PLoS Medicine | www.plosmedicine.org 0952 July 2006 | Volume 3 | Issue 7 | e203