Title: Author:

Health Issues in Nepal Barbara J. Deslich Everett High School, Lansing School District Lansing, Michigan 10 12 Science, Health 3 4 class periods To examine how culture and environment affect the health of a nation.

Grades: Subject Areas: Time Required: Objective:

Science Benchmarks: III.5.HS.6 II.1.HS.5 III.2.HS.5 Explain the effects of agriculture and urban development on selected ecosystems. Explain the social and economic advantages and risks of new technology. Describe technology used in the prevention, diagnosis, and treatment of diseases and explain its function in terms of human body processes.

Materials Required: Background information provided, library and/or internet for research. Procedure: Present background material giving information on health issues in Nepal. Ask students to address the Constructed Response Questions in the Assessment Section. Responses can be used to generate class discussions related to the topic. Students interested in pursuing further study of the topic can use Research Topics for Extended Study.

Background: Health in Nepal Three of the major areas of development in Nepal focus on population, water resource management, and health. The health of a nation is generally determined by a number of indicators reflecting the major health concerns of its individuals. These major indicators are life expectancy, infant mortality, maternal mortality, and the under 5 mortality. Once these statistics have been compiled and analyzed, questions can be asked concerning the causes of these numbers and solutions offered based on governmental services and primary health care offered to the citizens of Nepal. Three main factors that impact state of health in Nepal are its high rate of poverty, illiteracy, and its physical geography. The life expectancy rate for Nepal is low, estimated to be about 55 years. This number has increased by 13.5 years in the twenty years between 1976 and 1996, but remains the lowest in Southern Asia. Nepal is one of three countries in the world where the life expectancy for women is lower than for men, which is an indication that health care for men has a higher priority than for women. (1) The highest risk group for poor health are children under five (particularly girls) and females of reproductive age. The mortality rate for young females is significantly higher than for males (by 24%). According to a 1996 Nepal Living Standard Survey, only 41% of households have access to a health facility within walking distance of 30 minutes or less. (2) Nepal is one of the least developed countries in the world. It is estimated that 60% of its 23 million people live below poverty level. The per capita income is around $200.00 per year. Along with this is a traditionally high level of illiteracy. There is a strong correlation between literacy and the health of a population. (4) Preventative health care measures, control of communicable diseases, and nutritional programs are heavily dependant on the education levels of a populace. Control of disease is also dependant on the availability of safe drinking water and proper sanitation procedures and facilities. Many of the diseases in Nepal are infectious and can be prevented by the development of service water, sewage systems, and safe drinking water which would create a more hygienic environment. Only about 37% of the population (34% of rural and 66% of urban) has access to safe drinking water and only 6% have access to proper sanitation facilities. (3) The overall pattern of morbidity in Nepal is dominated by reproductive issues (both maternal and perinatal), infectious disease, and nutritional disorders. These are responsible for approximately 68% of the disease burden. Degenerative and noncommunicable diseases account for 23% of the burden, with accidents and injuries comprising the remaining 9%. (1) Maternal and Child Morbidity The maternal morbidity rate is linked to services provided for in prenatal, delivery and post-natal care. In 2000, the morbidity rate was 539 per 100,000 live births. (4) This number is especially high when compared to countries of similar socioeconomic status. The number of births attended by a health care provider is a low 10.8% in 2001. Early marriage and childbirth also contribute to maternal mortality along with weak infrastructure and health services. Nutritional deficiencies also exist with an estimated 75% of all mothers suffering from anemia caused by iron deficiency. (5) Culturally, it has

been a tradition for women to have their babies at home without any health care officials attending the birth. This cultural tradition will have to be overcome before women are comfortable seeking health care at delivery, whether in a health care facility or attended by a trained health care professional. The child mortality rate has decreased significantly in the past 30 years but remains at a high level of 91 per 200,000 live births. (4) Gains have been attributed to control of malaria, eradication of small pox and a reduction in cholera due to education. Child malnutrition still exists at alarmingly high levels. The large number of people below the poverty line, lack of nutritional education, inadequate health services, lack of clean drinking water and proper sanitation all contribute to the child mortality rate. Infectious Diseases Some of the most common diseases of concern in Nepal are malaria, kala-azar, Japanese encephalitis, tuberculosis, dysentery, Hepatitis A and HIV/AIDS. Estimates from the World Health Organization predict that conditions will not improve over the next 8 years. (2) According to public health officials in Pokhara, an urban area 60 miles west of Kathmandu, the main health problems are dysentery, parasites, and other water borne diseases. In the villages outside of Pokhara, major problems are skin disease, which results from lack of proper hygiene and sanitation, acute respiratory infection, and lung disease that results from indoor cook fires, and malnutrition. Some people know how to boil and filter their water for drinking, but cannot afford to or do not have the resources to do so. People have been taught to treat water borne diseases with jeevan gel, used specifically for the dehydration that is caused by diarrhea. Jeevan gel is a solution of sugar and salt that is distributed by health care officials, or can be bought in stores. Previously, it was common to withhold water from patients with diarrhea. There is also a marked lack of nutritional education among the population. Officials stated that while some people may be getting enough to eat, their diet is not nutritionally balanced. Health Care Issues Directly Linked to Water Quality Cholera is a severe infectious disease caused by the bacterium Vibrio cholerae. The symptoms of cholera are diarrhea and the loss of water and salts in the stool. In severe cholera, the patient develops violent diarrhea with vomiting, thirst, muscle cramps, and sometimes circulatory collapse. The mortality rate is more than 50 percent in untreated cases, but falls to less than 1 percent with proper treatment. The means by which a person can be infected is from food or water contaminated by bacteria from the stools of cholera patients. Prevention of the disease is a matter of sanitation and proper hygiene practices. Typhoid Fever is an acute infectious disease caused by the typhoid bacillus Salmonella typhi. The bacillus is transmitted by milk, water, or solid food contaminated by feces of typhoid victims or of carriers, that is, healthy people who harbor typhoid bacilli without presenting symptoms. Prevention of the disease is, again a matter of

sanitation and proper hygiene practices. Hepatitis A is an acute viral infection that causes inflammation of the liver. Symptoms begin with fever, usually followed by extreme weakness, loss of appetite, nausea, vomiting, and muscle pains. The upper abdomen may be painful and tender. The virus will usually run its course in about two weeks. Hepatitis A is caused mainly by poor sanitation and lack of hygiene. It is transmitted by food or water contaminated by excreta; by other objects taken into the mouth; from person to person. Outbreaks often occur in refugee camps and in institutions where small children are crowded together. Dysentery is a severe inflammation of the intestine characterized by passage of loose feces, severe abdominal pain and cramps, diarrhea, and mucus or blood in the stool. The two most common causes of dysentery are infection with a bacillus of the Shigella group, and infestation by an amoeba, Entamoeba histolytica. Both bacillary and amoebic dysentery are passed from one person to another and spread by fecal contamination of food and water. They are most common where sanitation is poor. Health Issues Directly Linked to the Use of Human Waste in Agriculture Use of human waste as an agricultural fertilizer has been in practice since ancient times. Human excreta is a rich source of nitrogen and other nutrients required for plant growth, it encourages the formation of humus, improves soil structure making it easier to cultivate, and contains trace elements which naturally control plant parasites and disease. There are health risks associated with this practice, so in many countries chemical or other organic fertilizers have replaced the use of human excreta. In Nepal, many farmers have no other alternative; they have a choice of using human waste as fertilizer or nothing, and therefore, a reduced food output. Health risks are associated with use of human waste as fertilizer; pathogens can remain viable for extended periods of time on the crops and in the soil. The dangers exist for people who work with the fertilizer, the soil, or with unwashed crops. Parasitic eggs and cysts may exist in the soil, the water, or on plants for many months, creating ongoing hazards. Burning eyes, burning lungs, skin rashes and other symptoms of illness have been found in rural farmers and residents who use human waste as fertilizer. Some of the same diseases found in unsanitary water can be spread through untreated human waste; polio, typhoid fever, amoeba, giardia, hook worm, pin worm, round worm, tape worm, and trichina worm. The excreta can be treated in various ways to eliminate disease-causing pathogens. Composting is an option as is the use of a double-pit latrine. Composting encourages biological decomposition of solid organic matter and produces a humus substance which can then be used as fertilizer. The process can be aerobic or anaerobic. If oxygen is present, bacteria will consume the organic matter, carbon dioxide is produced, and energy is released in the form of heat. The temperature of a compost can reach temperatures of over 70C. At this temperature there is rapid decomposition of protozoa, worm eggs, and pathogenic bacteria. All fecal microorganisms, including enteric viruses will die if the temperature exceeds 46C for one week.

Geographic and Economic Challenges A major problem with treatment of health issues is the geography and lack of infrastructure in Nepal. With 80% of the people living in agricultural areas, there is a lack of distribution not only of medicine and medical supplies, but of food itself. In many rural areas, people eat only potatoes supplemented with small amounts of green vegetables. Many infants are breast fed for up to two years with no food supplements. This results in malnutrition for babies. The widespread poverty in Nepal prevents the country from large-scale expenditures on public sewer systems. Nepal is a country of hills, mountains, and low-lying regions. Infrastructure is weak, with very few roads. The roads that do exist are in poor condition. This prevents the effective allocation of medical staff and medicine throughout the country. National Health Policy (1991) A National Health Policy (NHP) was developed in 1991 to address the health of the nation. It addresses delivery of health care services as well as information and administrative issues. Its prime objective is to approach health care at the district level and below. The policy emphasizes community involvement, encourages participation of the private sector, and national and international NGOs. The 8th Health Plan (19921997), the 9th Health Plan (1997-2002), and the Long Term Health Plan (2002-2017) have since been developed, all in keeping with the objectives of the National Health Plan. All plans focus on implementation and development at the community level, using district health systems as a means of health care delivery. The people of Nepal realize that improvement in health care for its citizens is closely tied to reducing poverty, improving literacy, reducing the rate of population growth, successful management of its water and natural resources, and an improved infrastructure for delivery of services. In planning for the development of Nepal, officials and citizens will work together in all of these areas. The fundamental relationship among these factors will influence the future of improved health care in Nepal. Obstacles to Success of a National Health Policy A lack of funds to service and maintain health cares facilities. Shortages of medicines and instrumentation along with the uneven distribution of medicines and facilities. A mitigating circumstance that must be considered is the culture and religious traditions of the Hindu people that believe human excreta should be kept away from the house. This would prevent the use of an enclosed bathroom in the home. Also they do not believe that human excreta should be kept in one place, which would preclude the use of a bathroom inside and the use of a public latrine in a village setting. The physical geography of Nepal and lack of good roads prevent the availability of accessible services, especially for those living in villages in the mountains, and hill regions. High level of illiteracy among the population.

A lack of decision-making and implementation by the government with regard to training skilled health care workers.

Solutions to problems with health care in Nepal are closely linked to education, poverty, a governmental commitment to improved services, the Hindu religion and its culture, and the infrastructure to support change. Water resources management and solid waste management are two of the most critical issues that must be dealt with as Nepal plans to develop its vision of a society where all of its citizens have access to proper health care and education. Works Cited 1. Karki, Yagui, Status Review: Health, Population and Drinking Water & Sanitation Sectors, National Strategies for Sustainable Development, 15 November 2003. http://www.nssd.net/country/nepal/nep05.htm 2. Wagner, Klaus and Aung, Lin, Country Health Profile: Nepal, Deputy Regional Director: World Health Organization. 11 November 2003. http://w3.whosea.org/drd/hlth_sit_nepal.htm 3. An Introduction to Health in Nepal: NepalNet an electronic networking for sustainable development in Nepal http://www.panasia.org.sg/nepalnet.health/medicine/health.htm 4. Ligal, Rithivi Raj, Vice Chairman, National Planning Commission, Millennium Development Goals: The United Nations System in Nepal United Nations. 11 November 2003. http://www.un.org.np/ 5. Savada, Andrea, Nepal: Country Studies, Library of Congress, Federal Research Division. 5 November 2003, http://lcweb2.loc.gov

Assessment: Constructed Response Questions: Students (individually or in teams) can address these questions and then prepare and present their responses to the entire class. 1. What suggestions would you have for a very poor country such as Nepal (where at least half of the population can not read) to increase peoples understanding of the importance of sanitation and disease prevention? How would you measure the success of your suggestions? 2. In Nepals National Health Policy, the government has chosen to concentrate on the delivery of health care services at the district (local) level. The country of Nepal is divided into many districts. Explain why you think the decision to implement and deliver health care support this way was made in Nepal? How can Nepal measure the impact of their health policies and ensure that their limited health care budget is spent efficiently? 3. Nepals National Health Policy is focused on education of the people. Keeping human waste contamination away from food and water is very important. Many restaurant and grocery store restrooms in the US have signs on the walls instructing employees to wash their hands before returning to work. Why is this important? How could Nepal get this message to their people when at least half the population cant read? Support your ideas with specific suggestions. Research Topics for Extended Study: Students interested in conducting further research on this topic can explore the following issues and present their findings to the class. 1. Present a solution as a public health policy regarding solid waste disposal and treatment for the rural areas of Nepal. Be sure to include economic considerations. 2. Present a solution as a public health policy regarding solid waste disposal and treatment for the urban areas of Nepal. 3. Present a solution as a public health policy regarding water quality and treatment for the rural areas of Nepal. Be sure to include economic considerations. 4. Present a solution as a public health policy regarding water quality and treatment for the urban areas of Nepal. Be sure to include economic considerations. 5. Describe current technology used to diagnose and treat some of the most common diseases in Nepal. 6. Describe measures that can be taken in rural villages to improve the quality of water and byproduct disposal. Use methods that would be of minimal economic impact.