Keynote Address

Epidemic of Cynicism and Fatalism:
As Major Challenges for Nepal’s Health and Development

Kul C. Gautam
Deputy Executive Director, UNICEF

America Nepal Medical Foundation Convention
Atlanta, 10 June 2000

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Let me start with a confession.

Your invitation to give a keynote address to ANMF presented a real dilemma for me.

On the one hand, ANMF has been so kind and generous to me . I was invited to join its Board at the very beginning – which I did. But unfortunately, I was unable to attend any of its meetings, until today. I have, therefore, had a certain nagging sense of guilt in not being a more active member of the Foundation. So I saw this opportunity to join you today as a chance to redeem myself.

On the other hand, I also felt a certain awe in addressing such a distinguished group.

What can I say about health and medical situation in Nepal that will be unknown to you?

As physicians and specialists, you certainly know far more about health than an international bureaucrat like me. Most of you have studied and practised in the finest universities and medical establishments in the world. And I presume most of you have first hand experience in working in the field of health in Nepal.

I am not a medical doctor. So I hope you will forgive me if sometimes I sound like a quack prescribing inappropriate remedies for our country’s illnesses.

Since this is a keynote speech about health and development in Nepal, I want to start with some reflections on what are in my view the most prevalent diseases that hamper Nepal’s development.

During my many visits to Nepal in recent years, I have concluded that there are two diseases that to me seem most common among the Nepalis. One afflicts the poorest people of Nepal and the other targets the middle and upper-middle class.

The disease afflicting the poor is not, as you might suspect, either diarrhea or pneumonia. It is not tuberculosis or HIV/AIDS. Nor is it really a disease specifically linked to malnutrition or poverty.

Instead the disease is what Dor Bahadur Bista called FATALISM.

I have seen far too many of our compatriots accepting their pitiable situation as unavoidable destiny. Tolerating injustice. Suffering indignities. Women being mistreated and accepting their subjugation as their poor karma. The elderly waiting for their death with melancholy self-pity.

For sure we have had some examples of heroic struggle against fatalism. Many hill people go off to far away lands to secure jobs to improve their lot. We have seen the slow emergence of a women’s movement against traditional male domination, domestic violence and emancipation through education. More recently we have seen the emergence of the Maoist movement, which is an extreme reaction to the age old fatalism.

But still far too many people suffer in silence and accept fatalism as destiny.

Now let me turn to the second disease that afflicts mostly, middle and upper-middle class Nepalis. And it is not, as one might guess, a disease of affluence such as coronary heart disease, or gout or cancer. Nepal’s most prevalent middle class disease, my friends, is called: CYNICISM.

It is not only widespread in Nepal, it is found even among expatriate Nepalis. All of us care passionately about Nepal and would like to contribute to its development. But far too many of us seem infected by this virus of cynicism. We think Nepal is just hopeless, too corrupt, too mismanaged, too stubborn against positive change.

As someone whose job involves overseeing the work of a UN agency in over 150 countries, I would like to share with you my unvarnished assessment that Nepal is NOT a hopeless case. In fact, Nepal is in much better shape than many other countries.

Nepal may not be progressing as fast as we would like, or moving in the direction in which we would like to see it develop and prosper. But it certainly is not going backwards, as are many other countries.

Compare it with Afghanistan where religious fundamentalism is dragging the country backwards. Compare it with Burma where an authoritarian military regime is letting a rich country retrogress. Compare it with Sierra Leone or Liberia or Somalia where warlords are preying on their citizens. Compare it with North Korea or Yugoslavia where half a century’s progress has been reversed. Compare it with Cambodia and Rwanda where genocide of unimaginable proportions ravaged entire nations.

Yes, Nepal has many problems. But we continue to move in a forward direction, even if slowly. Sometimes, it seems like we take one step backward for every two steps forward. But that is still net progress, net forward movement. And it is our duty, those of us who are fortunate enough to get out of the cycle of poverty, to inspire hope and optimism among our compatriots.

You are doctors, trained to heal. Although I know you did not learn how to treat fatalism and cynicism in your medical schools or hospitals, as professional health workers, please fight against these diseases and try to be professional optimists.

Towards the end of my speech, I will make a few suggestions for some specific initiatives you might take to instill a dose of optimism among yourselves and our compatriots. But first, let me turn to a more classical review of health and development in Nepal.

Let me start with a couple of facts and figures, probably well-known to you, but which will be helpful to set the context for my remarks and some messages I want to leave with you.

It would not be unreasonable to think that in spite of its spectacular beauty, clean air, and immense water resources, Nepal is quite an unhealthy country in many ways. With almost fifty percent of the population earning less than one dollar per day, poverty is endemic. Maternal mortality is one of the highest in the world. Female literacy at 20 percent is among the lowest in the world. Life expectancy is just 55 years, compared to 77 years here in the USA.

The under-five mortality rate is currently 100 per thousand live births. Translated into absolute numbers, approximately 80,000 young children die each year in Nepal – 220 children every day. In the period of the 1990s alone, it is estimated that almost one million young Nepali children died before reaching the age of five years, mostly from readily preventable causes - acute respiratory infections, diarrhoeal dehydration and vaccine preventable diseases, such as measles.

Maternal and perinatal ailments and nutritional deficiencies are the major causes of avoidable sickness and death in Nepal. The problem is particularly severe among children under five, among whom intestinal infectious diseases, other bacterial diseases, pneumonia, and perinatal factors account for 80 percent of all deaths.

Malnutrition is an underlying factor of this high morbidity and mortality. It weakens the child’s immune system creating a vicious cycle of infection and wasting which stunts both the physical and mental growth of the child. The downward spiral of infection and malnutrition gradually draws the child towards an untimely death.

It is estimated that malnutrition in one degree or another is associated with over half of these young child deaths.

Official government survey data indicates that child malnutrition has shown little, or no improvement in 25 years. More than half the children of our country remain chronically undernourished and underweight. This, despite three decades of planned national development and millions of dollars in assistance from the international donor community.

Almost every five minutes every day of every year, in the villages and cities of our country, another child becomes a statistic in the national mortality records.

Such facts and figures do indeed paint a very sobering and depressing picture. But let me tell you, if it is any consolation, that Nepal ranks better than 50 other countries in the world in terms of child death rates. There are a dozen countries in the world with double the U5MR of Nepal, and about a dozen countries where, unlike in Nepal, life expectancy is declining rather than increasing.

We at UNICEF are acutely aware that against all odds, Nepal is still making positive gains in health compared to many other countries, especially in sub-Saharan Africa. Though still very high, under-five mortality rate has declined from 300 in 1960 to 200 in 1980, 150 in 1990 to 100 in 1999 – a significant progress indeed. But there are great disparities within Nepal. Life expectancy nationally is only 55 years, but it ranges from 74 years in Kathmandu – close to the level of Washington, DC - to only 37 years in Mugu district – lower than that of Sierra Leone, Malawi, Rwanda or Afghanistan.

And while mortality rate has gradually declined, the fertility rate remains relatively high. As a result, the population continues to rapidly grow and is estimated to double in the next 35 years from its current level of 23 million to 46 million. Obviously, this increase in population will exert an even greater pressure on the existing strained basic services.

Over time, there have been many encouraging improvements in the health of the population. The expansion of rural drinking water schemes to many rural villages of the country has drastically reduced the high levels of diarrhea among the population. Similarly, an effective social marketing of Jeewan Jal has insured that 90 percent of mothers know about home-based rehydration. Iodine deficiency disorders linked to goitre and mental retardation which were so prevalent in the country before1980 have been almost eliminated through an effective programme of salt iodization.

The national programme of vitamin A distribution in Nepal is considered one of the most successful in the world. It has reduced blindness and mortality in children in 64 districts of the country. It is estimated to have reduced under-five mortality by 24 percent.

Polio will surely be eradicated in the next few years, as was smallpox two decades ago.

In terms of infrastructure, Nepal’s health system now comprises 76 hospitals, 754 health posts and 3,185 sub-health posts. Regrettably the system is under-resourced and suffers from a lack of well trained human resources particularly in the districts most in need.

To make matters worse, we have had a very unhealthy trend recently of excessive political interference resulting in frequent changes in the management of the health services and constant staff transfers within the system.

Despite the fact that the country now has several medical schools, a great number of district hospitals do not even have a single doctor in position. The vast majority of medical staff are to be found in Kathmandu, other urban centres and abroad. Dr. Carl Taylor who returned to Nepal in 1999 to review the health situation 50 years after his first survey in 1949, describes the current health system as having a basic anatomy but lacking a functioning physiology.

The current health care system is a poor mix of unregulated private clinical practice superimposed on an inefficient government operated health service. If you are wealthy you can get decent health care through private hospitals and nursing homes in Kathmandu. If you are poor and live in a remote area, your only hope is to rely on the nearest government health post or the traditional dhami jhankris.

But the commercialization of medical practice is not restricted to the cities. Even in small towns and villages all over Nepal, one is struck by the fact that medicine shops are the most common of commercial establishments. In contrast to chronic lack of medicines in government health facilities, these shops are well-supplied and re-supplied once or twice per month. Many poor people seeking relief from ill health go to these shops and are prescribed expensive and inappropriate medication, including useless tonics and vitamin preparations.

Regrettably the system is not adequately regulated by the health authorities, so there is no consumer protection.

Low level of investment in the health sector is clearly one of the underlying causes of the poor state of health in Nepal. Total annual spending on health care is estimated at US$10 per capita. Of this amount, private expenditures comprises US$7 or 70 % of the total bill. Estimated public per capita spending on health care from all sources, government and external, is just over US$2 per year. This figure is about one quarter of the level of investment recommended by the World Bank for a basic package of essential health services for a typical developing country.

So what can be done in the future to significantly improve public health Nepal?

Coming from a UNICEF official, you will not be surprised to hear that the top priority should be given to reducing the burden of disease caused by the most prevalent illnesses. Interventions must focus on reducing childhood illness, promoting child survival and treating nutritional and related conditions. Targeted interventions should be aimed at disadvantaged areas and the poor.

One area that needs increased support is the Female Community Health Volunteer programme which involves 43,000 women providing health education and dispensing simple drugs to women and children within each village ward. It is essential to recognize the important role these female volunteers play in improving health at the community level.

I hope you would not be offended if I said that to the vast majority of the poorest people in the most remote communities of Nepal, these barely literate women volunteers probably contribute more to public health than all of Nepal’s medical doctors combined. They need to be considered part of the health system and investments should be made in developing their skills and knowledge.

Although we all lament the deplorable situation of specialized medical care in Nepal, public sector investment must continue to be made in primary health care rather than in expanding expensive specialist services. Unfortunately allocations to the primary health care sector have declined in recent years, falling from 77 percent to 57 percent of total sector spending between 1991 and 1996.

The poor absorptive capacity of the Ministry of Health must also be addressed. You may be surprised to note that during the last 12 years as much as 20 to 40 percent of an already low development budget in the health sector has remained unutilized. This is a serious issue which merits urgent attention and priority.

The care provided by the private sector and NGOs is of uneven quality. Lack of regulation means that many providers are unqualified or underqualified. New mechanisms must be adopted and put in place to improve performance and accountability.

These are a few of my thoughts on the public health situation in Nepal and what can and needs to be done in the public as well as the private sectors.

But what can we, members of ANMF, do to help?

I know that ANMF is already doing many good things at the level of medical schools, continuing medical education, specialized medical care, etc. And I commend you for that. But if we wanted to do something special in the domain of public health care for the masses, perhaps over the long haul, here are 4 suggestions I would make. They range from rather ambitious to the readily doable:

Could ANMF pick one district, and working with one or more NGOs develop a model district health programme, combining preventive, curative and promotive health services? There are several good NGOs involved in child survival programmes in a few districts. With support and guidance from ANMF they could expand their services to cover all communities in a whole district. I know that is a tall order for this small organization. But perhaps ANMF could team up with the Association of Nepali physicians in Britain who might supplement our efforts. What is needed is a good replicable model to inspire action by local communities themselves.

A less ambitious version of this would be to link up with a district hospital and to help develop it into a model community-oriented hospital. ANMF might provide some essential equipment, technical inputs and make it a place for US-based medics to spend a few weeks during their visit to Nepal.

Develop a partnership with a hospital such as the one in Banepa which deals solely with childhood disabilities. A Human Touch Fund established by UNICEF staff in Nepal works with this hospital where children with cleft lips and other physical disabilities who require surgical interventions are assisted. It is so wonderful to literally add a pretty smile in the face of children who are otherwise despised and stigmatized.

Support the work of an NGO such as the Nepal Trust which works in Humla. Nepali doctors could be assisted to spend some time in such remote districts providing basic health care – as do British, US and Canadian doctors and nurses at United Mission hospitals for short periods.

Whatever we do, the essential thing is to instill a sense of hope and can-do spirit among Nepali medics and radiate their enthusiasm to others.

I would implore you that through our contacts, writings and visits to Nepal, let us become advocates for an improved health deal, especially for the children of the country. By focussing on their right to better health, I am confident that it would be possible to influence the national health authorities and contribute to a transformation in the health of the people.

I recall once a professor telling me the story of a young man and a fortune teller. The fortune teller advised the young chap that he would be very poor and unhappy until he was 45 years old. Grasping at the straw, the young man asked, "What will happen when I am 45?". The fortune teller said, "You will get used to it"! Well, friends, your job – our job - as health care professionals is to ensure that no one ever gets used to poor health as preordained destiny.

Let us not get used to fatalism, cynicism and pessimism. Let us be professional health workers and leaders, but also professional optimists.

To have medical and public health knowledge and remain silent would be to turn our backs on our own people. I would ask you as members of a professional, medical association to speak up and to speak out - not just to criticize what is wrong with health or other development policies in Nepal but to offer solidarity and support to make a positive difference.

Thank you.