After almost a half century of development in Nepal, there have been substantial health gains in Kathmandu, eastern and central districts. But the farwest and northwest are little changed over this period.
The recent census shows a gap of 30 years of life expectancy separating those areas. The health of people in Nepal's west is on a par with those in high AIDS prevalence countries in sub-Saharan Africa which represent the worst health conditions in the world. Yet the causes are not the HIV virus, the causes are starvation and inadequate food.
Research over the last 30 years has demonstrated that determinants of health of populations are different from the common perceptions of personal hygiene, a balanced diet, environmental sanitation, health education, and the need for health checkups that Nepalis are taught to recite when asked what produces health.
What matters first was covered by the basic needs concept enunciated by late King Birendra 30 years ago: enough food matters most, whether or not there is a balanced diet. One needs to avoid marginal nutrition that leads to infection and death. That is what is lacking in Nepal's northwest where people are mostly socially egalitarian, at least in terms of landholdings, but that land doesn't produce enough to eat.
Before democracy, the Nepal Food Corporation subsidised food in that region as the marginal nutritional status was recognised. These days such subsidies are inconsistent with a market approach to life. So people there are dying much younger than the rest of Nepalis because they don't have the economic means to sustain life.
What is a better solution? Other countries like Canada, Sweden, Sri Lanka and Kerala in India have legislated that wealthier parts of the country subsidise the underprivileged areas. Could Nepal also legislate such a Robin Hood policy to take from the rich and give to the poor?
Once basic needs are satisfied, creating a society which cares and shares matters most in producing a healthy population. It is the nature of human relationships, the psychosocial and cultural elements that matter for health. That is why Cuba is as healthy as the world's richest and most powerful country, the United States. Cuba's infant mortality is lower than in America even though it spends much, much less on medical care. It is clear it's not just spending in health care that makes people healthy.
How can Nepal learn from this example and promote the caring and sharing that has previously characterised marginal existence in this country? Obviously peace is the first priority. After that, dealing with the results of physical and psychic trauma will be necessary. This can be a useful role for newly graduated Nepali doctors from the current epidemic of medical schools.
It is early childhood where caring and sharing is most important for producing good health. The key element is mother-child contact in infancy. Nepali mothers used to wear their infants for the first year of life and never allowed them to cry but put them to the breast or massaged them and played with them. As Nepali women are 'empowered' they will increasingly leave the task of feeding and attending to infants to others. Research shows this may produce behavior problems later and worse health.
Research also shows that where women do better, everyone's health is better including that of men. In Sri Lanka, too, health is almost as good as in the United States and it is the women that inherit the family land. The country has enjoyed a series of women prime ministers. Despite the civil war there the health of the population is remarkably good.
As the famous British epidemiologist, Geoffrey Rose, concluded in his monograph The Strategy of Preventive Medicine: 'The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social. Medicine and politics cannot and should not be kept apart.'
Stephen Bezruchka MD, MPH is senior Lecturer in the School of Public Health and Community Medicine at the University of Washington, and works in Nepal to help remote communities have appropriate medical services.