Nepali Times
The health of nations


Are bideshi doctors good for Nepal? I don't think so. This is not to say that I am against the spirit of volunteerism that brings several medical personnel to Nepal each year, but rather I want to emphasise the importance of prioritising structural medicine.

Take the case of the US. As a country, America has about four percent of the world's total population, yet Americans spend almost half of all the money spent on medical care. With such a record, America should be pretty healthy. But this is not the case. In 1970, the US stood 15th in what I call the "Health Olympics", the ranking of countries by life expectancy or infant mortality. Twenty years later, the US is about 20th, and in recent years has plunged even further to around 25th, behind almost all the rich countries, and a few poor ones. For the richest and most powerful country in the world's history, this is a disgrace.

Widening disparities between rich and poor are responsible for poor health, and medicare in Nepal is too urban-centric and of little benefit to the bottom half of the population. The rich do not have medical insurance. The increasing number of tertiary-care hospitals only serve to subsidise medical services for the rich.

More private hospitals is not the answer either, in fact it's something I describe as the growing "nursing-home-isation" of Nepal. It is structural medicine that Nepal needs, and that can come through minimising disparities-not only raising the level of the poor but also lowering that of the rich. Quite radical ideas for such an economically-driven society.

One radical idea for keeping Nepal healthy was abandoned soon after it was implemented. In 1978, a group of WHO consultants helped set up the first medical school in Nepal, with the idea of training doctors to work in rural areas. The purpose was not to give them MBBS degrees, but a Bachelor's in Community Medicine. Since this degree was not recognised overseas, graduates demanded to know why their chances of going abroad were being limited. So the initial plan was subverted, and we're feeling the effects, as Nepali health care professionals take off to greener pastures.

There are three main laws of population health: 1) human populations are by nature healthy, 2) health is primarily related to the hierarchical structure of society (poorer people have poorer health), and 3) structural medicine is the primary means to achieve health for populations. But people are indoctrinated to think in terms of what we can do individually to produce health. Research during this last decade has shown that the health of a group of people is not affected substantially by individual behaviours such as smoking, diet and exercise, by genetics or by the use of health care. In countries where basic goods are readily available, people's life-span depends on the hierarchical structure of their society; that is, the size of the gap between rich and poor. A good idea is to look at countries that are healthy.

Japan has the highest life expectancy in the world. Twice as many Japanese men as American men smoke, yet deaths attributable to smoking are half those in the US. This is because after WWII, Japan's hierarchical structure was reorganised so that citizens shared more equally in the economy. That the structure of society is the key to well-being becomes evident when we look at Japanese who emigrate: their health declines to the level of the inhabitants of the new country.

So, what makes a population healthy? What happens to the average Nepali in this situation? As the gap between rich and poor increases, s/he feels so much more marginalised. This is clearly the major structural factor that affects society. A recent review of archaeological data on the health of pre-agricultural populations has lessons for all of us. The evidence gleaned from skeletal remains suggests that health declined with the advent of agriculture. If we consider the health of a population as its average height (stature), those earliest peoples were tall, and their bones did not show signs of infection or nutritional deficiencies. There were fewer smaller skeletons representing children and infants. All this changed with the progress implied by domesticating plants and animals.

With agriculture, diets became more monotonous and lacked the nutritional variety that hunter-gatherers enjoyed. Workloads increased. But more importantly, a hierarchy emerged, because suddenly there was something to acquire and store. Some could have it while others could be denied. So if you buy the hierarchy-health argument, it was all downhill from there. This is not to imply that hunter-gatherer populations were as healthy as some people today, but one could speculate that there might not be all that much difference. In the process of progress, we have lost the sense of community and solidarity that characterised early societies, and we have used technology to make up for those losses.

As a physician obsessed with understanding what makes groups of people healthy, I am dumbfounded that America's low ranking doesn't raise more concern in the medical and public-health communities. Is it because experts in these fields don't want to question the role of medical care in producing health? Does the focus on diseases-including the search for risk factors, cures and specific preventive answers-stop Americans from looking at what would really keep them well? I suspect part of the explanation lies in Americans' "cradle to grave" relationship with the health-care industry, which represents one seventh of the US economy. We actually come from a culture of harm in medicare. If all the medical services in the US were stopped now, there wouldn't be many deaths. The same goes for Nepal.

If equality is good medicine, then what can be done to improve our well-being? The primary goal is to reduce today's record gap between rich and poor. Prescriptions for such "structural medicine" might include having more manned health posts in Nepal's vertical terrain, and teaching medical professionals to think of simple, safe, cost-effective therapies, like ether anaesthesia, which Kathmandu's medical school ignores in favour of more expensive, relatively dangerous forms of anaesthesia. The dominant idea, "modern is better", is also what makes bideshi doctors welcomed so unquestioningly here. There are better ways to keep our population healthy, like taxing consumption rather than income, or increased support for public transportation and schools, all of which would reflect a change in how the population shares in the economy. The best prescription for health is not necessarily one we get from doctors.

(Stephen Bezruchka, who first came to Nepal in 1969, is best known for his classic guide-book, Trekking in Nepal, first published
in 1976.)

(11 JAN 2013 - 17 JAN 2013)