Harvesting of orchids for medicine and salep production is a traditional practice, and increasing market demand is spurring illegal harvest. Ethno-ecological studies in combination with the effect of anthropogenic disturbance are lacking for orchids. We compared population density and structure, and tuber biomass of Dactylorhiza hatagirea (D. Don) Soó for three years in two sites: Manang, where harvesting of medicinal plants was locally regulated (protected), and Darchula, where harvesting was locally unregulated (unprotected). Six populations were studied along an elevation gradient by establishing 144 temporary plots (3 × 3 m²) from 3,400 to 4,600 m elevations. Mean density of D. hatagirea was significantly higher in the locally protected (1.31 ± 0.17 plants/m²) than in the unprotected (0.72 ± 0.06 plants/m²) site. The protected site showed stable population density with high reproductive fitness and tuber biomass over the three-year period. A significant negative effect (p <.1) of relative radiation index (RRI) on the density of the adult vegetative stage and a positive effect of herb cover on juvenile and adult vegetative stages were found using mixed zero-inflated Poisson (mixed ZIP) models. The densities of different life stages were highly sensitive to harvesting and livestock grazing. Significant interactions between site and harvesting and grazing indicated particularly strong negative effects of these disturbances on densities of juvenile and adult reproductive stages in the unprotected site. Semi-structured interviews were conducted with informants (n = 186) in the villages and at the ecological survey sites. Our interview results showed that at the protected site people are aware of the conservation status and maintain sustainable populations, whereas the opposite was the case at the unprotected site where the populations are threatened. Sustainability of D. hatagirea populations, therefore, largely depends on controlling illegal and premature harvesting and unregulated livestock grazing, thus indicating the need for permanent monitoring of the species.