Essay The State of Child Health and Human Rights in Nepal 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 human rights in Nepal 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 malnutrition 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.