Thursday, December 18, 2008

Some hardtalk with Nicola Notaro, European Commission, DG Environmental

During a lecture on “The EU and the future of International Climate Protection” organised by the Institute for European Studies at the VUB I took my chance to go into a hot debate with Nicola Notaro. Notaro is an important architect of the recently approved EU climate and energypackage and came here to talk on it's implications for the EU leaderships' role in international climate negotiations.

Q: “I have first a remark and then a question. You mentionned the positive signal the EU package has given to the negotiations in Poznan but I was also there and I only heared disappointment with IPCC scientists, with developping countries and even outrage among environmental NGOs. It did not give the long hoped boost everybody was waiting for, resulting in a lack of progress in Poznan.

But my question is this. With the current EU package the door stands open for 66% external emission reductions, which means the EU will only have to reduce with another 4% it's domestic emissions from here to 2020. In your presentation you mentionned an interesting principle from the EU. According to the EU treaty article 174 the EU subscribes to the principle of “rectification at source”. Is this principle compatible with 66% outsourcing of rectification?”

A: “The 66% is only an option, it is the maximum possible and of course we hope that countries will try to reduce domestically as much as possible. You have to understand that these outsourced reductions are also real reductions. What the rectification at source concerns: you have a point but maybe decreasing polution at the source of polution, even outside the EU, is still compatible with that principle?”

Q: “It is interesting that you mention that these outsourced reductions are real because in fact they are not. Many studies show that 30 to 50% are non additional reductions. On the 1st of October 2008, 76% of the projects were already build at the time it was decided that they will receive a CDM credit. Recent research in India has shown that not one single banker who lends money to a project developper considers possible CDM income in the future. Now, the EU knows all these problems and they tried hard in Poznan to change the verification by bringing it under UN supervision, because now the verificators are paid by the project developpers. But China refused and the system stayed as it is: defunctional.

But my second question is related to the adaptation fund, considered as the only breakthrough in Poznan. You also highlighted that finaly developping countries have received access to this fund but in fact it is an empty box. Only 1% of the needed money is in there and the EU blocked efforts to increase the amount of money inside. You said yourself that they did so because they think an extra tax on the reduction of emissions would give the wrong incentive and it would be better to tax emissions and use that money for the fund. I totally agree with that but then please explain me why did the EU not adopt the proposal from ENVI to earmark 50% of the auctionning of emissions for mitigation and adaptation in developping countries? That would have been a tax on polution no? Why doesn't the EU practice what it preaches?”

A: On the CDM: we are fighting on 2 fronts at the same time and I don't see a problem with that. The EU package will start in 2012 and we hope that by then the problems with the CDM will be solved. Concerning your question on the earmarking of revenues from the auctioning of emissions: I agree it is not enough yet, it should be 50% but I think that option is still there and it is up to member states to decide how they will use this money. I think that now at least 20% will be used for mitigation and adaptation in Developing Countries, that is at least something.

Q: “A final question, since you are from Italy. Which exceptions did Italy get, on what objective grounds did they get them and why Italy and not other countries?”

A: As I'm not a representative from Italy you will have to ask that question to the Italian Embassy.

What I learned from his presentation is that the EU wants to sell it's package as the world's most progressive, accomplished with remarkable speed and despite the economic crisis. That is all true and we should be happy for these reasons, but does that also mean that the package is able to realise it's goals, is just and sufficient to prevent catastrophic climate change, (NO)taro?

Tuesday, June 10, 2008

The aid industry in Nepal

The aid industry in Nepal
BIG BUGDETS, BIG PROBLEMS


“Foreign aid has not made any significant contribution to reducing poverty in Nepal”, according to a prominent Nepalese politician. Two months later, Maoists win the elections and immediately announce that from now on foreign aid will have to be approved by the people first. Is Nepal being screwed by the aid industry? Has it helped to bring Maoists to power?

Nepal is the poorest country in Asia with an income of less then a dollar a day. According to the United Nations Development Program, poverty in Nepal increased in the last three decades, mostly in rural areas. People in Kathmandu now earn five times more then those in rural areas. The poorest 40% of the population have become worse off, while the richest 10% have become richer. Only a third of the students leave school with a qualification, most of them studied in private schools.

Since 1991, Nepal has been the largest receiver of foreign aid in the whole of South Asia. Over 80% percent of the education budget comes from foreign donors. The share of foreign aid in the national development budget has increased from 50% in the nineties to 70% today. Loans have increased faster then grants.

As a condition for getting loans, Nepal has fulfilled the wishes of financial institutions such as the World Bank to open markets, privatize crucial public institutes and limit domestic borrowing. However, several studies have shown that privatization in Nepal has increased the gap between poor and rich. It didn’t help the economy either.

The aid sector is not geared for introspection. They usually blame corruption and the civil war (1996-2006) for obstructing their plans to develop Nepal. Certainly Maoist insurgents destroyed infrastructures and projects, but foreign aid seems to have done a lot of damage as well, including increasing corruption in the country. According to the anti-corruption agency, nearly one billion US dollar donated for nearly 5000 projects donated by various organisations are not open for accounting by the government.

Flashy health camps with western doctors are actually killing uneducated villagers from a remote district. An illegal and dangerous dam has huge profits for foreigners while causing massive floods and social upheaval. The water mafia gets loans for projects that destroy previous projects, whose own loans are not even paid back. The list is endless, but the tolerance of Nepalese people is not. In every single project discussed in this article the Maoists won by a landslide, often on the promise to end the dictates of foreign donors. In remote West Nepal, a Maoist who threatened to kill anyone coming near to the planned construction site of a dam got his democratic mandate.


A sick system
Despite massive foreign aid, most Nepalese still never see a doctor in their life. The health care system is totally inadequate to meet the people’s needs. In remote rural Myagdi district, we interviewed a hundred people on the standards of health care in their area. There is only one doctor in the area but most of them never visited him. Asked why they said he only came once a week, from his private clinic in Pokhara city. He always told the free government medicines had run out, but he could sell us some better but expensive medicines from his private clinic. This story was repeated in several other rural areas of Nepal. Neglect has been replaced by a mirage of health care interventions. These include the establishment of rural health posts catered by uncaring, corrupt doctors, or no trained personnel at all.

In Humla, a remote, impoverished district in the North-West of Nepal, the Scottish NGO Nepal Trust has come up with an original solution. They fly in a team of European doctors and conduct short health camps, accompanied by a media circus of cameramen and photographers. In their rush to treat thousands of patients in a few days, the camp becomes a fiasco. While they claim to have treated 8000 people, what really happened was that, according to several reliable witnesses, 2000 people queued up on average 4 times. Uneducated patients were seen to return on the next day, complaining they didn’t feel any better after swallowing all the medicines, which were meant to last for two weeks. According to the witnesses, who prefer to stay anonymous, at least three people died shortly after one of the health camps ended. Kids were playing with used needles dumped in a nearby open pit. Local traditional doctors were neglected.

Babita Lama co-founded the Nepal Trust but stepped out in 2002, feeling disgusted about the rude way the Scottish management was treating the staff and locals. Today she feels as if her ‘baby’ is sick. “They didn’t do any research on what local people really need. There is an acute lack of awareness among the people on how to use medicines and a complete lack of follow up after the health camps. The camps resemble a medical circus”, she complained. According to insiders, health camps obscure the real political and economic origins of sickness. They’re like a band-aid on a festering wound.

Nobody gives a dam
The picture of foreign aid doesn’t get any better if you look at big projects, usually foisted upon Nepal by big financial institutions. This large majority of aid money (77%) should bring development on a big scale. The Asian Development Bank (ADB) says: “Nepal needs to harness its vast hydroelectric power potential in a socially and environmentally sustainable way.” Nepal indeed has the second biggest hydropower potential in the world and yet it faces up to eight hours of daily power cuts in the dry season. Nepali’s are now paying one of the highest electricity rates in the world: 9 times more than those in neighbouring Bhutan and 5 times more then in the US or India. Of course, this will not worry the three quarters who don’t have electricity!

The ADB figured it could help Nepal by teaming up with the Australian Snowy Mountain Engineering Company (SMEC), Chinese banks and India to build a 1.2 billion US $ dam project. Technically, the project is a dangerous mess. At a height of 195m the dam across the West-Seti river will be the highest concrete faced rock filled dam in the world. SMEC preferred this type in a bid to keep the 1.2 billion US $ budget, almost half of the total Nepalese annual government expenditure, ‘under control’. Several highly respected experts have repeatedly warned the government about the dangers of such a dam design. Surya Shresta from the National Society for Earthquake Technology claims that: “Especially in West-Nepal, pressure that has build-up suggests that a very large earthquake is long overdue”. SMEC responded on our inquiries that the dam cannot break, but Shresta confirmed that the companies who build the project also financed the only study on earthquake resistance of the dam.

Downstream, thousands of acres will get submerged with or without dam collapse. A large canal that takes water from the West-Seti for irrigation of North-Indian fields already causes widespread floods in Nepal during the monsoon season. Water expert A.B. Thapa says that once the West-Seti dam and reservoir are completed it will cause year-round flooding for villagers in south Nepal. These aid induced refugees will have to be added to the 13 000 farmers upstream who will see their whole world disappear under water once the reservoir behind the dam fills up.

According to a Japanese research centre the mega project is far from sustainable or environmentally sound and will cause massive social upheaval. It cites several violations of the ADB’s own policies on information disclosure, consultation with affected persons and possible livelihood losses, to name but a few. The only document for the uprooted farmers was an English summary of temporary employment benefits for them, which almost none of them could read.

Once completed, 90 percent of the electricity will be sold to India, while they will take all the water for free. Incredibly, Nepalese business is not involved.

Only 0.1% of the revenues will go to wages for Nepalese workers, according to Ratna Shrestha, a former board member of the Nepal Electricity Authority. After paying back debts, overheads and other costs less then 3% of total export earnings will enter the Nepali economy. While the profits flow to India, China and Australia, Nepal foots the bill for the environmental and social damage. Most of the thousands of villagers whose homes will be flooded are forcibly relocated to an area that has a totally different culture, language, climate, soil and agricultural system.

The taxpayer will have to pay back the loans and bear all unforeseen costs. Thirty years after construction, Nepal will be handed the dam as a poisoned chalice. Studies show that due to the incredibly high transport of sediments in Himalayan rivers, the dam will probably have to be dismantled soon after this period. Even according to SMECs own conservative estimations there will be a huge cost on the dam 50 years after construction, which of course is not included in the contract. By the time this comes out all greying politicians, Australian consultants and ADB bankers involved in signing this contract will be retired or dead.

Foreign aid or aid to foreigners?
To Nepalese lawyer Rabin Subedi from WAFED (Water & Energy Users’ Federation-Nepal) this is a case where “foreign aid violates human rights and works against the interest of Nepali people.” He is not surprised about the timing of signing away Nepal’s resources. He added: “Previous sharing of water resource agreements between India and Nepal have always been signed when Nepal was in a period of political transition like now.” The Nepalese constitution is about to be rewritten and management of resources will be taken over by a number of newly formed federal states. The dam on the West Seti is just one example of a big project pushed through just before the federal states get hold of them.

There’s another fishy thing about the deal, as water resources expert B. Subba wrote as early as 2002. “India actually wants the water but does not wish to pay for it, while Nepal wants to sell electricity but does not get the price it demands.” India wants to interlink dozens of rivers and desperately needs Nepalese water to make the giant scheme work, an enormous bargaining position Nepal is not playing out at all. At the same time, Nepal will now sell electricity from West-Seti to India at a little more then half the price it pays India to import electricity elsewhere

Rabin Subedi claims that by not mentioning the regulation of a shared river they have managed to circumvent Article 156 of the Constitution, which states that a two-third majority in parliament should approve the sharing of natural resources between two or more countries. All this makes things very clear for Subedi “Either they (Nepali politicians) are in the money game, they just don’t understand or they don’t care.”

In their response SMEC gives us detailed figures of the future change in water flow, while admitting literally that they will regulate the West-Seti river.

Shockingly, the construction and operational costs of locally financed projects are much lower than large donor-funded schemes, as research shows. Dipak Gyawali, the former minister of water resources, is only one researcher to come to such conclusions in the book ‘Aid under Stress’. All argue that this is because it is much easier to cover up corruption in the dense thicket of procedures and rules of big projects.

Large aid projects usually have a complete disrespect towards local structures. Gyawali quotes the notorious example of a Finnish forestry project, which destroyed local sawmills and wood industry. He writes: “Both the private foreign actors and the state domestic actors shared a fundamental distrust of the capacity of the local community to take care of the commercially valuable forests”.

And yet even the World Bank admits that including locals in the choice and design of projects increases the chances of success. People in Palpa district have known this all along. They have build a micro hydro project that produces electricity at a tenth of the price then the national electricity supplier, without daily power cuts or massive destruction. Not a dollar of foreign aid was involved.

Thirsty for real development
Unfortunately, the West-Seti is not an exception. There is a revival of large-scale projects as the mainstream development strategy all over the world. In Nepal they seem to do more harm then good.

One such project aims at quenching Kathmandu’s thirst by diverting river water through a tunnel. The 317 million US $ Melamchi Water Supply Project, which is partly financed with ADB loans, is already 13 years overdue for completion and is rife with corruption. Many politicians were convicted for fraud. A joint review mission from both government and donors in 2003 came to the conclusion that; ‘...environmental, social and occupational safety issues have not been adequately addressed in the earlier contracts, while in later contracts these issues are largely ignored by the contractors.’ Of the five-year government budget for water and sanitation 70% goes to the Melamchi project, although it will ‘benefit’ only 10% of the population.

Furthermore, thousands of people downstream of the river where the water is taken from will not only loose almost 80% of their crucial water in the dry season, but their whole way of living from irrigated fields and water mills … which were originally built with other ADB loans. Tank Gajurel, chairman of a local action group, complains; “The new access road to the construction site has already cut through the irrigation system, making our watermill useless.” Tank now uses a diesel generator for his mill in the dry season, but with diesel becoming so expensive he runs on losses. Seven years after their complaint they still have to see the first compensation, but even then, life will never be as it was before. Whole newly constructed villages will disappear again due to the lack of water. Tank; “We don’t want money, we just want our own water.”

The World Bank withdrew from the Melamchi project in 2002 concluding that ‘important options have not been explored to utilize the water resources within the Kathmandu valley’. Gyawali told us the government, in the mid 1980s, choose the most remote and expensive project out of 30 alternatives as potential water supply options for Kathmandu. "They prefer a large project that they alone could manage, furthering their empire-building wit lucrative results for themselves." The Norwegians and Swedish quit in 2005 and 2006. In May 2007 the ADB threatened to leave as well if the distribution of water was not privatised, which they believe would make the venture more efficient. Even Hisila Yemi, the Maoist minister for Physical Constructions, bowed for their condition. At least she managed to keep the UK company Severn Trent out, which got the contract for building the tunnel without any bidding. A fierce campaign against Severn Trent actually forced her to do so.

The Kathmandu Valley Drinking Water Company Limited (KVDWC) will now take over the water distribution, but will also sell the water for profit. The price will increase about threefold up to 13$ a month, which is half the average income in Nepal.

Experts claim that this project is a white elephant anyway. They have proposed alternatives that could deliver the same amount of water in a much faster and cheaper way.

Capturing 15% of rainwater in the Kathmandu Valley would completely solve the problem.
If just 1.5% of the land in the Valley were used as reservoirs the water table would be recharged.
Repairing the current leaks alone would increase supply by 70%.
Monsoon water could be stored in underground reservoirs.

All these solutions would create more labour intensive jobs for poor people and do less harm to the environment. The problem with the alternatives lies in the smaller scope for personal benefits among politicians or profits for companies. According to Gyawali, just building many small reservoirs in 1,5% of the Valley would cost around 7 million US $ to provide the same amount of water as Melamchi. Additional benefits come from the aesthetics and the more equal distribution of groundwater. He goes on to claim that; “repairing leaks does not help hydrocrats in their mission of managing scarcity. They first create scarcity which can subsequently be managed with large and expensive projects” Human rights activist Gopal Siwakoti says in his book ‘The Reality of Aid’, also the name of the International NGO who has studied the Melamchi project that: “The problem is not the lack of alternatives, but the denial of these alternatives due to the big project mind-set and the role of the water mafias.”

Foreign aid to the Maoists
Political analyst E.B. Mihaly concludes in his book ‘Foreign aid and politics in Nepal’ that “on balance the impact of foreign aid has probably harmed rather than furthered Nepal’s economic growth and political stability”.

There are of course notable exceptions. British therapists from Seeing Hands Nepal train blind people to be independent therapists who earn money by massaging tourists.

The Belgian NGO Shangri La Home not only educates street children but also provides them specific skill trainings until they find a job.

Micro credit programs financed by the Dutch organisation ICFON give poor people the chance to manage their own development according to their priorities. However, all these small projects are dwarfed by the budgets and impact of large foreign aid.
Foreign aid is actively influencing the political scene in Nepal. Nepal’s most famous writer, Manjushree Thapa, told us that the development agencies are very much part of the political system, although they will never admit it. The Nepali’s did not only vote against the establishment, but also against the aid industry. Here’s a hard question for them: Is it a coincidence that in all of the project’s area’s mentioned in this article the Maoist have won? The aid industry has certainly ‘helped’ some in Nepal, but most probably not in the way they first envisaged.

In an interview with Sri Ram Dhakal, secretary of the Maoist party headquarters, he boldly stated that “From now on any aid project will have to be approved by the people.” How he thinks to realise this is unclear, but one can only hope that the former communist rebels will bring foreign aid back to what it was all about: reducing poverty.

Nick Meynen
Kathmandu, 12 May 2008

This research was realised with the support of the Pascal Decroos Fund for Investigative Journalism. Info: www.fondspascaldecroos.org

On the Tamang heritage trail

While snowflakes mingle with steam from the hot spring bath, babies, men and grandmothers alike are enjoying their daily dip. As the only bidesi’s we’re an attraction ourselves. The Ganesh Himal area is one of those rare places where Nepali tourists outnumber foreigners, although both are still very rare. A new trade and religion are the more powerful forces revolutionizing this ancient society of mostly Tamang people.

A few years ago, efforts were made to promote tourism in this rural backwater. Under a ‘Tourism for Rural Poverty Alleviation Program’ (funded by UNDP), several organisations joined hands to work out a route, inform locals and attract tour operators. The latter came at the official opening, noticed no views on 8000m mountains or glaciers, no heroic stories from climbers or explorers and left Ganesh Himal largely where it was. However, in the last few years some volunteers, long time Nepal travellers and foreigners who live in Nepal are attracted to the region by the calm pre-touristic atmosphere, the beautiful views, the friendly people and the large hot spring bath at Tatopani. The latter attracts lodge owners from nearby Langtang (where a history of tourism already transformed society) for two-week winter holidays, government officials from nearby Syabrubesi and some rich Kathmanduïtis who can reach here after a day’s bus ride and halve a day of walking. Despite increasing visits, tourism has not yet transformed society in this region as it did in neighbouring Langtang.

Other foreigners have come with other intentions. Protestant evangelists from the United States are trying to teach the bible in Nepal. There are small villages like Tipling with several churches. There’s a hospital that only allows Christian people in. Local conflicts have arisen as a result, for example because Christians bury the dead. The branch of Christianity promoted here is also a very exclusive one. While Nepali’s are famous for their tolerance towards other religions, the few baptized locals don’t go to other festivals anymore. A Belgian film crew came all the way to Ganesh Himal to make a documentary called ‘Little Jesus’. Benjamin Heuschen, co-founder of the non-profit organisation ganesh-himal.be, explains the methods of the priests. “They hand out comic books featuring Jesus and bring electricity to villagers who are converted.” It reminds me of the teenagers from a private bible university in Germany which I met in Mugu, wondering around to search for opportunities to ‘help’ people. If anything they need it’s certainly not a foreign religion brought upon them.

The strong historical ties with Tibet shape recent evolutions in the area in another way as well. Since a few years a new local economy has literally mushroomed. According to several locals, the illegal trade in yartshagumba has risen sharply in the last years. The main market is China. Local claims over the use of the untraceable yartshagumba by Chinese athletes in preparation of the Olympics are supported by the Manual of Important Non-Timber Forest Products in Nepal. It states that “Once reserved only for emperors, this versatile mushroom is now the tonic of China’s elite athletes”. Of the whole range in Nepal where yartshagumba grows, from the North-West frontier till here, Rasuwa district is nearest to the Chinese market where it is mainly sold. It can be no surprise then that especially here this trade has boomed. According to Tsering, a local lodge owner, “until some years we only used to get some yartshagumba for personal use, but nowadays I know of at least three grass slopes where intensive harvesting and smuggling takes place.”


Small-scale tourism, evangelist missionaries and a lucrative, booming but illegal trade are changing the traditional lifestyles of the Tamang in Rasuwa District at an historically neck breaking speed. Another wave of change originating from outside their area are the Maoist militia, who still control some of the villages here. When they claim an inning of 180 million Rs in taxes on the yartshagumba trade in 2004 alone, one can wonder what the true motivation to occupy these villages is. The government policy to ban any trade in the product, not based on any scientific research, is an open invitation to smugglers and those who prey on them.

Friday, January 4, 2008

Dying to get better + Sick System (Nepali Times 4/1/08)

Dying to get better
The government has legislated free health care to the poor by next month. As with all previous promises, this is unlikely to be kept.
The last place it may happen is in Nepal’s remote northwestern corner in the districts of Humla, Mugu and Dolpo. Every health indicator here is much worse than the rest of the country. The child mortality rate is nearly four times the national average. Many more mothers and babies die at child-birth here than anywhere else. Vaccination programs don’t get to remote areas and people can die of simple infections. Life-expectancy is 44, and many of the remote areas are even more cut off after Maoists bombed bridges during the conflict.
The health gap is being filled by well-meaning foreigners, but when they leave, the problem remains. A local Maoist leader in Dolpo, when asked why not a single health post had been built in the areas they controlled, replied: “First comes destruction, then construction."
Sick System
Medical charities in remote parts of Nepal are trying to fill the vacuum left by the government, but this has brought a host of other problems.
Because the government has neglected health for so long, providing care is like buying political support: it brings the NGOs working on health in direct confrontation with the Maoists.
There are now about 130 NGOs based in Humla working for the development of Nepal’s most remote district. Some work on health and it didn’t take long before Maoists closed the first health post. Doctors, mainly western, used to fly into health camps by helicopter to distribute free medicines, like candies to begging kids.
David Citrin, who is working on a doctorate, is not impressed: “Due to a lack of research on what people really need, not enough awareness on how to use medicines and a complete lack of follow up, the camps are more like a medical circus.”
People came on the second day, saying they didn’t feel any better after swallowing all their medicines, meant to last for two weeks. Instead of treating 8,000 people, the same 2,000 people show up four times on average to stock up on as much free medicine as they can get. Villagers are disappointed when referred to an Indian doctor.
Shanti, a woman in Simkot, told us at least three people died last year, shortly after one of the health camps ended. Citrin says he saw children playing with used needles and later learned of people dying due to infections. “The concept of a bidesi doctor flying in by helicopter to give free medicine is just so powerful in an area where the government hardly bothers to do anything,” he told Nepali Times. “Health camps obscure the real political and economic origins of sickness, they’re a band-aid on a festering wound.”
The government has promised free health services and free medicine for the poor from February. This sounds promising because 75 percent of the health care expenses of Nepalis are met by out-of-pocket payments, the highest percentage in Asia. As with everything else, the problem will be in making sure it works. When 97 villagers in rural Myagdi were asked recently what they really needed, the majority simply said: “An honest doctor who’s here with us.”
The government doctor at their health post came once a week, sometimes not at all. He sold medicines from his private clinic in Pokhara, claiming government medicines had run out. Village nurses who study in the city usually don’t come back to work in the village.
Health care still hasn’t recovered from the years of conflict. On a recent trip through Mugu, where the life-expectancy is 44, large parts of both districts are almost cut off from the world since Maoists bombed the only two bridges over the Karnali eight years ago.
There is only a fragile cable crossing in place. Medical personnel have left the area since, sick or elderly people can’t cross the river anymore. Most people here don’t beg for money, they beg for medicines, any medicines. A sick baby had only a plastic bag on his head. A dead dog lay next to the only tap in the village.
A woman asked us: “If you’re not here to distribute medicines, then why are you here?” Locals in Mugu, Dolpo and Humla now perceive foreigners as doctors by definition. In Mugu, almost two out of ten babies die at birth, more then three times the rate for Nepal. In Dolpo the situation is not much better. When the local Maoist leader, who controlled most of the area for 10 years, was asked why not a single health post had been built in the areas they controlled, he just said: “First comes destruction, then construction”.
In Nepal it is time somebody starts the construction. Not just of big hospital buildings, but of a functioning, visionary health care system. Health experts say that instead of a paternalistic top down-approach, Nepal needs to train local doctors and nurses and gear the health system towards creating wellness rather than treating illness.
Pictures from before-and-after facial surgeries on disabled Nepali children may be effective fund-raising visuals in Europe, but if the health of Nepal’s poor is going to be dependent only on foreign well-wishers or profit-minded doctors in the cities, Nepal will remain a sick nation. In the abscence of a functioning rural health care system, the people of west Nepal will have to do with foreign medicine band-aids.