Simikot: Diarrhoea claims 10, 400 infected.

Every year, about this time we see small headlines like this in the Kathmandu press. We are told of a litany of problems, from a lack of the simplest medicines and broken governmental promises and absent staff at public health posts.

Diarrhoea is so easily treated with rehydration solutions and if very severe, a short course of antibiotics, even if this does nothing to change the conditions of poverty under which such a common and simple disease becomes so much more dangerous.

But in these remote areas, even this basic right is denied, particularly to the more marginal. This combination of bureaucratic lethargy and extreme poverty is a deadly mix, leading to suffering and misery that we can barely comprehend. These issues are not new-anyone who visits or works in the more remote areas will have witnessed them and we've been reading about them for many years. What is new is how the current conflict might be feeding these problems.

The state in many of these more remote areas functions inadequately in fulfilling its responsibility to provide public services. It had great difficulties in the past, prior to the conflict. But as funds are diverted from much needed health provision into the military machine (one aspect of the state machinery that is not 'failing') frequently veiled as quasi-developmental ventures, there are even less resources to deal with these issues.

Government health posts in these areas are frequently under or un-staffed. In some areas of the mid hills we witness the concomitant growth of small private pharmacies and clinics, frequently unregistered and staffed by either those working in the government system or increasingly by those amongst the literally thousands of health workers trained in the mushrooming private technical training colleges. Maoists may insist that government health workers remain in their posts and that staff do not close early to go to their private clinics. They certainly want to encourage the influx of resources, including health care related ones, into the areas they control.

Last year I spoke to a young man who was training to be a health assistant. From the far west, his family was investing money in his education, and like many others, he was attending one of the newly opened technical training colleges in Kathmandu. On returning to his village in the western hills for a holiday, he was incarcerated by the Maoists for several days. Eventually he was released and told that he would be allowed back to work in the area when he qualified. And was that his intention? He stated that he would rather wait until things "returned to normal".

One impact of the conflict is how it has inadvertently fed the proliferation of private institutions catering to this increased need as more and more health workers wait out the conflict and stay in urban areas.

Yet some health workers will make it back to these areas to open a small pharmacy or run a clinic. I was told last year by a representative of a drug company how a drug distributor in the west had been arrested by security forces. He was supplying drugs to unregistered pharmacists and the logic of the security forces was that he was therefore supplying drugs tothe Maoists.

This illustrates the increased surveillance that the army now has over health related institutions and workers. But this blanket desire to want to cut off the supply chains to the Maoists, not just in health resources but with food, clothing and other goods that most would consider as basic human needs, will affect the poor and marginal the most.
It is not the Maoists (who, ethically, have as much right to treatment as anyone else) who are dying of diarrhoea in these remote areas of Nepal but those who for years have been living an increasingly insecure existence further destabilised by the conflict. Does the conflation of state and military now feel that all the people in these areas are to be punished for the unfolding political situation around them?

Certain areas of Nepal are in a precarious balance with chronic and acute food shortages exacerbating infectious diseases. The army's current security agenda, made worse by Maoist handling of workers, will almost certainly make these health related problems worse.

In future we are likely to read many more devastating articles chronicling death from what to us seem like such minor ailments.

Ian Harper currently lectures in medical anthropology at the University of Edinburgh.