Imagine dying from simple surgery for haemorrhoids, an annoying but non-lethal condition. That happened in one of Nepal’s most prestigious private hospitals recently, and this sad case is an important reminder that medical care can as easily harm as help. Studies in developed countries show that what makes people healthy is not medical care. Indeed, there are indications that in developed countries medical care may contribute to as much as one death in 10. And yet the predominant wisdom in developing societies is that the path to better health is more medical care; specifically, more specialised medical care. Thus, much public expenditure is incurred for the diseases of the few, and health facilities reflect rather than address an extremely hierarchical society.
The common perception in Nepal is that medical care must be the reason for the remarkable health advances in the country over the last 50 years. Everyone is aware that deaths among young children are not so frequent as they were even 10 or 20 years ago. The Nepali middle class is pleased with the plethora of health services available in the larger cities and towns today. There is an enormous number of nursing homes, hospitals, and an increasing number of medical schools to train the next generation of doctors. CT scans, ultrasounds and other sophisticated tests are routinely available in Kathmandu now, and this is put down with certitude as progress. And even while these advances are not unremarkable, people now routinely die of heart attacks, strokes and cancer, which was rare 30 years ago when I first worked in Nepal. Certainly back then, these were causes of deaths in Kathmandu, but they were relatively uncommon in the hills, where people were more likely to succumb to dehydration or tuberculosis (TB).
What best explains the changes in the causes and rates of death? Some of the benefit must certainly be due to multi-drug therapy, oral rehydration and immunisations. But there must also be other – population-level – factors at work, since health gains are seen where these services are available and also where they are not. ‘Epidemiologic transition’ is the name given to the process whereby “diseases of young bowels are exchanged for diseases of old arteries”. Thanks to the state’s health policy, the richer elements of society have made the transition and live longer to die from chronic ailments. Surely, the poor must also be given this privilege.
I often reflect on the changes in medical care since I first came to Nepal in 1969, when the country had few hospitals and missionaries were the main source of quality services. Compounders and medical halls delivered much of the medical care. The 1970s saw a tug of war between advocates of widely disseminated primary health care services founded on health posts throughout the country, and promoters of vertical programmes that dealt with specific conditions such as diarrhoeal diseases, tuberculosis and immunisations. In the 1980s, the vertical programmes lobby gained the upper hand although a skeletal framework of health posts and district hospitals continued to dot the countryside. Staffing the hospitals in remote locations was and still is a major problem.
In that same decade, the first doctors graduated from medical school in Nepal and post-graduate programmes in general practice and anaesthesia were instituted. Training in many other specialities was introduced shortly. By the 1990s, private medical colleges and hospitals were commonplace in urban centres. The medical fraternity in Kathmandu soon grew from a mere handful to scores of doctors, who increasingly turned to specialisation. Today, Nepal has locally trained doctors and specialists, as well as those trained in foreign countries. Today, Nepal has locally trained doctors and specialists, as well as those trained in foreign countries. Most practitioners are concentrated in the Kathmandu valley, while large numbers who have studied in Nepal, India and abroad on government scholarship have by now left the country permanently to pursue lucrative careers overseas. Rich countries such as the United States are thus saved from investing in the education of their own medical personnel while the Nepali public suffers.
In the meantime, because of the increasing incidence of chronic diseases among the better off, the focus of spending by His Majesty’s Government has switched to specialised care at a growing cost to the poor. Thus, today you take your eyes to the BP Koirala Institute of Ophthalmic Care, your heart to the Shahid Gangalal Heart Centre; soon you will be able to take your ears to the Ganesh Man Singh ENT Hospital. If you want to pay for medical care there are many private nursing homes, hospitals and ‘research centres’ ready to take your cash. If you wish to have trainees practice on you, there are more than a dozen medical schools in various parts of the country. You can choose from those that are government-run or private not-for-profit or private for-profit.
Is Nepal better served by this plethora of institutions? It depends on the goal. If making large profits from medical care is desired, there is no doubt the current panoply is the answer, but one must recognise that such a course is likely to lead to care that is under-qualified, that is careless. Meanwhile, most poor people in Nepal’s rural areas have little recourse to modern health care, and emergency services for all people in rural areas are limited. Consequently, health outcomes in rural Nepal have improved though not as much as those of urban populations.
Hierarchy and health
In order to improve the effectiveness of the health care system, we must focus on those aspects of the health care system that make a difference at the population level. Studies in the US show that primary care and sophisticated trauma care may be two of the few factors of the total health care picture that affect life expectancy positively. It is estimated that the US, for example, which leads the world in the number of homicides per capita, would have a four- to five-fold higher homicide rate if the quality of trauma care was that existing in 1960.
Trauma care requires rapid evacuation to sophisticated centres, but Nepal’s difficult topography and poor economic state mean that there is no hope of providing such care. What Nepal needs therefore is a widely decentralised primary health care system, such as exists in Kerala. That Indian state has a basic primary health care system within easy access of every village, something even the US lacks. Kerala is India’s healthiest state, despite being one of its poorest. Its health outcomes are close to those of the United States, which for its part spends half of the world’s health care budget and yet ranks behind all the other rich countries in health indicators. For example, in 1991, the infant morality rates for Kerala were 17 deaths in the first year of life per 1000 live births, while for the US they were 10, for India as a whole 74, and for Nepal 100. Ten years later the numbers were approximately 13, 7, 67 and 66, respectively.
Population health studies what makes a population healthy. In the last 25 years, we have learned that the hierarchy within society is the most important determinant of a population’s mortality. Societies that tolerate a large gap between the richest and poorest will have worse health than societies that have a small gap. While the essential concept links the range of social and economic inequalities – the hierarchy – with health outcomes, the way to measure this relationship varies for individual types of societies. In a fully monetised economy where poor people have to pay for almost every service, such as in the US, the distribution of income is strongly related to health. In countries such as Sweden or Japan, whose populations enjoy the best health, with universal health care, a strong social safety net and very heavily subsidised education, income matters less because of ‘outside of the wallet’ payments through the government apparatus. Even in those countries, people further down in the hierarchy will still be less healthy. In poor countries, basic needs take precedence over hierarchy: everyone needs enough food, clean water and appropriate shelter. Once these basic needs are taken care of for everyone, then it is the range of hierarchical ordering – the number of rungs in the ladder and the gap between the top and the bottom – that matters most to produce health in the population.
Primate research and some human population studies help us understand the mechanisms whereby a more pronounced hierarchy gets translated into worse health. The basic ideas revolve around increasing stress from being lower down the caste or class ladder. Those on top have more control in their lives and in their work, suppress those beneath them. Those people even slightly below the top cannot retaliate towards individuals above them in the ladder, and instead put down their underlings. This cascade results in the lowest ranking members in society being humiliated by everyone and being the most vulnerable to chronic stress and resulting disease. Cortisol, the so-called chronic stress hormone, is an important mediator of this pathway. People lower down on the ladder have less immunity to infectious diseases, higher blood pressures and higher blood glucose – all of which are bad for health and affected by cortisol.
It is also true that behaviours such as rates of smoking, eating disorders such as obesity, teenage births and violence in a society are related to the hierarchy within the population. In Nepal, disparities by ethnic group and caste demonstrate huge effects of hierarchy, with two- to three-fold difference in child mortality between the highest and lowest castes.
Poverty and poor health
We all cling to the idea that personal behaviours are what matter for our health: washing hands after going to the toilet, eating right, not smoking, using condoms, exercising, and the like. While these behaviours have some effect on our health, they do not matter as much as we believe. Scholars who have studied the determinants of health of populations are in general agreement that socio-economic ranking is the most important factor. As a doctor who has worked for over 30 years and has observed the vast controversies surrounding most aspects of clinical medicine, I find it astonishing that the hierarchy and health relationship is so well documented, yet so little publicised.
Amartya Sen, winner of the 1998 Nobel Prize in economics, once said, “I believe that virtually all the problems in the world come from inequality of one kind or another”. Jimmy Carter, the 2002 Nobel Peace Prize recipient, in his acceptance speech said, “The most serious and universal problem [in the world today] is the growing chasm between the richest and poorest people on earth. The results of this disparity are root causes of most of the world’s unresolved problems, including starvation, illiteracy, environmental degradation, violent conflict and unnecessary illnesses”.
Japan illustrates how a country can change its health by altering its hierarchy. In 1950, Japan was less healthy than the US is today, yet in a mere 28 years it had become the healthiest country in the world. This is true despite the presence of behaviours among the Japanese as are known to be harmful, such as having the highest smoking rate of all rich countries. Japan provides one instance to prove that personal behaviours do not matter as much as we think they do.
How did Japan become the world’s healthiest country? During the years of Allied occupation from 1945 to 1952, General Douglas MacArthur gave the country the prescription it needed to achieve stellar health. This prescription had three components: demilitarisation, democratisation and decentralisation. Japan was forbidden from having an army. Countries that spend more money on the military have worse health than countries that spend less or countries such as Costa Rica, that choose to not even have an army. MacArthur wrote the country’s constitution after studying those from other democracies. The document featured a peace clause, prescribed free universal education, enshrined collective bargaining, and gave women the vote.
Decentralisation, the final D, broke up the zaibatsu, the large corporations that dominated Japan’s feudalistic society. MacArthur mandated a maximum wage for business and corporate leaders. Finally he carried out what many historians praise as the most successful land reform programme in history. Land, purchased from the landlords, was sold to the tenants at the same price. The tenants were given a 30-year interest-free loan to make the purchase. Ninety percent of the land in Japan changed hands in this manner. As a result of this ‘medicine’, Japanese health improved more rapidly than ever documented in any country.
Given that the current health programmes can only have limited impact, what can be done to maximally improve health in Nepal? The first step would be to meet the basic needs for everyone. Food deficits in the Far Western Development Region’s hill and mountain areas need to be corrected. Health figures in the far West are among the lowest in the world with life expectancies as low as 40 years, in contrast to values 25 years higher in the healthiest areas such as the Kathmandu valley. Various inputs can remedy this disparity in the far West, especially subsidised food distribution and other welfare programmes. Another basic need is clean water. Nepal has made great strides in the provision of clean water, and it must resist the suddenly fashionable trend of privatisation in water distribution; the necessary infrastructure must be expanded rather than be allowed to deteriorate.
Where basic needs have been met, it will be much more difficult to deal with class discrimination. Bringing down the caste-based hierarchy will be the challenge. The Maobaadi represent one attempt to level the hierarchy. Populations such as the social democracies of Scandinavia, Kerala and Sri Lanka, use public revenue to provide benefits for the poorest instead of the richest. Nepal may also borrow with discretion from command economies such as Cuba, which has through similar means achieved health outcomes roughly comparable to the US, despite being strangled by economic sanctions by that superpower over the last 40 years. (Cuba’s life expectancy is 76 years and the US’ is 77 for the year 2000, while in 1992 both countries were tied at 75.6 years!) If Cuba can overcome such adversity and be as healthy as the US, so can many other countries, including Nepal.
Can Nepal, historically known as “the yam between Bhot and Muglan”, learn from the choices of its two large neighbours to achieve health? In 1950, both countries had comparable populations, give or take 100 million, and similar infant mortalities and life expectancies. By 1980, China had made remarkable health progress and continues to be far ahead of India in any health status indicator. Much of this health gain was due to the reduction of hierarchies present before the revolution (1949), and keeping them at a relatively modest range for many decades afterwards. Changes in China after the 1978 “reform”, since when the country has progressively tightened its embrace of the market, have resulted in an increasing hierarchy of class and rural/urban polarisations. The effects are already showing in the health declines in the rural interiors. The lesson for the rest of India and Nepal obviously lies in Kerala, the Subcontinent’s health jewel. That state has lower fertility rates than China, even without mandating a strict one-child family planning policy. Social justice principles in place in Kerala work non-coercively to limit the desire and need for a large family.
Since health and health care are such similar sounding phrases, but with such different implications, we still might ask what is a better medical care system be for Nepal. I advocate eliminating the two-tiered system of profit and non-profit care. The influential upper classes will not, however, hear of such a radical proposal. So, at a minimum, let us eliminate the spending of public funds for organ-based and specialist tertiary care. If a two-tiered system with public and private components is allowed to exist, the hidden public subsidies for private services must be exposed and removed. Public and private care must be carefully scrutinised to concentrate on delivery of quality basic services to everyone. To limit medical harm, the ‘less is more’ philosophy works well; the best motto is “don’t just do something, stand there” unless it is obvious that doing will help.
Despite widespread pessimism for Nepal’s failed initial attempts at democracy, there is reason to hope for better. The self-respect of the hill peasant is still there, and represents the country’s most neglected resource. Even today, Nepal has better health outcomes than South Africa, which carried out the world’s first heart transplant in 1968. Additionally, the high death toll there from HIV/AIDS has had a profound effect on South Africa’s health, something that Nepal has been spared to date.
Countries have goals, and one fears that Nepal has taken on the American example to heart, namely making the rich as rich as possible and hoping something will trickle down to the poor. But that strategy does not work in the US or anywhere these days, as increasing hierarchies worldwide demonstrate. And it is the health of the public that suffers.
If we ask the wrong question, the answers do not matter. The right question is what makes a population healthy. Nepal can write its own structural medicine prescription, perhaps drawn on the one that worked in Japan. Strong economic growth need not pave the road to health, as the cases of the healthy publics of Kerala, Sri Lanka and Cuba prove. It will take powerful resolve involving both the poorest and strongest segments of Nepali society to limit the country’s hierarchy. Social and economic justice is the road to health, not sophisticated medical care.