Mysterious afflictions

Why have some unidentified ailments begun to take a toll in rural Nepal?

It is the season of distress yet again. News reports filter in partial images from different locales: heat strokes in and mass exodus from Andhra Pradesh, malaria and encephalitis deaths in Assam, and ´monsoon-induced´ diarrhoea, influenza epidemics and measles outbreaks in many of Nepal´s districts.

The list of ´medical´ afflictions'for this calendar year was long already, and now with the arrival of the monsoon it seems to be unending. Cough, cold, headache, high fever, jaundice, dysentery, diarrhoea, vomiting, flu, heat, dehydration, measles, typhoid, and acute respiratory infection are here, and presumably there is more to come. The  Kathmandu Post on 5 March, 2003, reported that jaundice, detected in a few persons sometime earlier, had broken out on an epidemic scale in Manthali, headquarters of Ramechaap district of Nepal.

News coming in from the so-called 'remote' districts has been grim. There have been several reports of children, women and the elderly falling prey to some ´mystery´ disease or the other. Such is the regularity with which this kind of news has appeared that the death of such large numbers of people is no longer scandalous. We have been seeing them year after year in the same form and magnitude, with occasional variations in detail and presentation, sometimes on the front page or, more often, tucked away in the corner of the ´region´' page. The irony is that this spate of reports only partially represents  what is really happening in Nepal, and that is voluminous enough to inure reader to the repetitive daily rituals of death, often attributed to various unspecified diseases.

In the first week of February 2003, for example, six people, four of them children from the Chepang community, died of measles in Makwanpur´s interior villages, south of Kathmandu valley. Several hundreds, mainly children, were taken ill but eventually recovered. In the same village, reports say, almost all of the children have severely low body weight. According to a report published by a Kathmandu-based NGO working among the Chepang community for several years, in some villages members of this community have among the lowest life expectancies in Nepal–less than 30 years, which is half the national average. Of course, the same reports also tell us, tangentially though, that the people so affected by disease and death have been living in a state of chronic hunger for years in this area. It is a different matter that journalists blame "lack of health services and inadequate drug supply" for the deaths.

News of pretty much the same kind continued unabated in the months following the February reports. Between March and June 2003, 38 of Nepal´s 75 districts had continuous bouts of epidemics of different varieties and proportions. This much can be gleaned from a cursory survey of  the reports published in two national dailies. There is no reason to assume that the rest of the districts have been spared such calamity. Anybody even remotely familiar with the terrain in Nepal can immediately see that if an epidemic has arrived, say, in Jumla, then the adjacent districts of Mugu, Humla, Dolpa, Jajarkot, and Dailekh will also be affected. Therefore, if they have not figured in the news, the most that must have happened was that the reports from these other districts either did not reach the editor´s desk or these reports were found to be just too repetitive to be published regularly.

On 17 March, the Kathmandu Post published another news report. This time  21 people had died of yet another mystery disease"in Kalikot, a mountain district in Nepal´s Far Western region (far to the west' from Kathmandu). The disease had apparently been prevalent in the area for the previous two months. The numbers ran to several hundreds in villages spread over a wide and rugged terrain of the district. What were the symptoms? "In the beginning, people suffer from severe fever and feel dizzy," an assistant health worker and chief of the district public health office, was quoted as saying. In January, in Gela village of the same district, seven people had succumbed to this disease. In months that followed, 14 more died of this mystery"ailment. By 18 March, the number of reported deaths had climbed to 26. What happened to those remaining hundreds who were taken ill? We do not know.

And then there is influenza. It is everywhere. From east to west, and north to south, the flu has forced the closure of schools and 'affected what is often loosely called ´normal life´. In some places it obliged health personnel to scurry around, medical kits in hand, "to bring the runaway disease under control". District after district and village after village came down with high fever, cough, cold and running noses. Some unfortunates never recovered, as has happened many times in the past.

It killed people in Udayapur to the east, Dadeldhura in the west and Dolakha of the central region. Tens of thousands fell ill all over Nepal. Who did it kill? Prise open the can of worms and some clues are to be found there. In a some of Dadeldhura´s far-flung villages, of those who died, many were dalits. Though the Kalikot deaths were blamed on a "mystery disease, the symptoms sound identical to those of influenza.

There is no slack in the ´discovery´ of new tuberculosis cases either. And this despite claims of a more than  95 percent success rate in the department of health´s much acclaimed Directly Observed Treatment  Short Course (DOTS) programme. Malaria is also not to be forgotten. In fact, it is unlikely to let itself be forgotten. Malaria is back with a vengeance, even in the middle-hills, where it was once mistakenly thought to have been banished forever. And the fact that these are reports coming from villages distant from Kathmandu (and therefore deemed '´remote´) is an indication that the sick are also those excluded from the socio-economic mainstream.

Naturally culpable
If the news reports are taken at face value than nature is of course the invariable culprit. There is a tendency to blame every calamity that overtakes people on the seasonal vagaries of nature. The temperature is temperamental. The precipitation is too precipitate. Clouds burst, rivers flood and lands slide of their own accord. It is world of chaos. The ´monsoon´, ´change of weather´, ´floods, ´rise in temperature´, ´drop in temperature´, are among the many causes ritually invoked to explain away society´s own role in the diseases and the deaths. But epidemics talk. They speak quite bluntly about how society functions: who lives and who dies in which society, where and when.

They also tell us about the faith that reporters and their informants have in the miraculous power of medicines, health services and health personnel to set things right–an unquestioned, self-evident truth propagated for several decades of development in Nepal. Why else would the affected residents and locally stationed paramedics both blame inadequate supply of drugs and medical personnel for the epidemic running out of control ?

Why did the disease strike in the first place? The assistant health worker of Kalikot sees it as an "ordinary common cold" resulting from seasonal change. One does not need to be an expert, however, to stop and ponder how this ordinary common cold could have killed so many people in Kalikot, when it is just a few days of nuisance for people in the capital city. Something much more serious than just some passing mystery of nature must have been involved here.

Journalists are occasionally perceptive. So, these news reports, by telling us about where people live, the water they drink, the food they eat (or did not get to eat), and their distance from emergency health services, also tell us why certain people  — like the dalits of Dadeldhura — die of a ´common cold´, while so many others who contract it escape unscathed. Lack of medicines or medical personnel does not tell the entire story.

So we piece together the picture from other reports that tell us, to cite one instance, that Kalikot, among many other districts, has been perennially suffering from food scarcity, out-migration, lack of clean drinking water and lack of access to basic health services for most of its population. Kalikot, according to the Nepal Human Development Report 1998, is also the third from the bottom in human development progress. This in a country that is 30th from the bottom in global human development. Little wonder that average life expectancy there in 1996 was just 42 years, that is to say two-thirds of the national average.

Measles struck hundreds of small kids in remote villages of Bajhang district. Three died. But measles does not kill anybody and everybody so routinely and randomly. And then we learn, again from other unconnected reports, that just incidentally Bajhang also happens to be one of several western districts reeling under famine-like conditions for the last several months and is among the two districts at the bottom of the human development index. It then comes as a surprise that only three children died. Those killed were dalits. "Dalits are not aware of the danger of this disease," say the reporter of a Kathmandu newspaper. Back in February, Mohan Mainali of the Centre for Investigative Journalism did a report on famine in Bajhang. From this we can deduce with  reasonable certainty that it was not the lack of awareness about disease that killed people. It was just a lack of food.

Such news is not peculiar to Nepal. What are the ´starvation deaths´ in Andhra Pradesh if not a variant of what is happening in these districts of Nepal? At least, there a spade is called a spade. The deaths are not attributed to killer diseases, but to starvation. Those denied adequate nutrition for extended periods of time have a habit of dying when a heat wave or influenza strikes. While the elderly and the children are left to eke out whatever living they can, the more able bodied head out to the nearest metropolis in search of wages. It is the same old drama, with a script that is improvised now and then to suit the context in different parts of South Asia.

These deaths in Nepal are not peculiar to this season or to this year. They appear in the news every year, as events caused by each season, mechanically recorded as deaths due to natural factors. Occasionally there is a recognition that these are preventable deaths, but typically the solutions are way off the mark. On 7 August 2001, in a letter to the editor of Kathmandu Post, one correspondent from Kathmandu implored the health ministry to wake up and deal with the potential death of people from ´preventable diseases´. "Due to inadequate medical supply, and negligence of health workers, the death toll could rise" and "our government is hardly doing anything to contain the epidemic". It went on to say "the Ministry of Health cannot turn a blind eye to this health hazard". What was missed in the letter was that the these deaths occur year after year because they are not amenable to prevention by health ministry intervention. At its fundamental core it is not a health ministry issue.

Asking different questions
Instead of looking to the health ministry to solve the problem more purpose will be served by asking some uncomfortable questions about the economy, the polity and the development apparatus that thrives on poverty. What is it about the Kathmandu-centric resource guzzling state that districts like Kalikot, Bhajhang or Bajura must be arrested in a perpetual state of peripheral existence. Why are people in many districts not getting enough to eat and why is nobody doing anything about it? The answer to that question will provide the explanation for why ´killer diseases´ and ´behavioural inadequacies´ always come to the rescue when such deaths become a rural routine.

Come next monsoon, we will again see a repeat of this year´s morning news — of people dying of the same mystery diseases, with the seasonal patterns replicated in all their fine detail. The health personnel will be kept on alert to deal with reports coming in from all the remote corners. Experts will trot out the prescribed seasonal cause and the reporters will again discover to their utter disgust that drugs and medical personnel are in short supply.  Those who live in unfortunate places die in unfortunate ways and all the institutions of good governance have not been able to work out the specifics of their life and death.

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Himal Southasian