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$Unique_ID{bob00409}
$Pretitle{}
$Title{Nepal
Chapter 6.    Health and Welfare}
$Subtitle{}
$Author{George L. Harris}
$Affiliation{HQ, Department of the Army}
$Subject{health
katmandu
medical
government
country
hospital
hospitals
nepal
water
development}
$Date{1973}
$Log{}
Title:       Nepal
Book:        Nepal, Bhutan, Sikkim, An Area Study: Nepal
Author:      George L. Harris
Affiliation: HQ, Department of the Army
Date:        1973

Chapter 6.    Health and Welfare

     The mode of life of the majority of the people reflects the isolation and
poverty of rural areas and the concentration of the nation's small wealth in
the hands of a few. Most families are poor and many are deeply in debt.
Serious deprivation is apparent in the bad diet and inadequate housing of most
of the people and in the general unavailability, particularly in the
countryside, of modern medical care, education and other social services.
Floods, droughts, famine and landslides periodically strike various
localities. The few rich live comparatively well, but share with the rest of
the people such problems as the lack of an abundant and pure water supply and
the prevalence of a great variety of virulent diseases.

     Despite these conditions there is optimism about the future in many
villages where private citizens or groups of citizens are trying to raise the
level of health and welfare and to fill deficiencies in public services. In
some predominantly Gurkha areas, for example, returning soldiers have taken
the initiative in organizing and financing schools and small dispensaries.
Elsewhere, local authorities have formed committees to provide a public water
supply or have seen to the improvement of trails, roads and bridges.
Development schemes introduced and maintained by the central government are
also bringing about long-term improvements on a nationwide scale, but their
effectiveness is often attenuated by the shortage of funds or by
administrative problems caused by transportation difficulties and the lack of
modern communications.

Standards of Living

     The country is economically undeveloped, and its limited wealth is
unevenly distributed among the population. The few sizable estates belong to a
handful of leading families in Katmandu, whose incomes derive principally from
land and foreign investments and whose standard of living is substantially
higher than that of the rest of the people. Smaller but still appreciable
differences in living standards are apparent in different parts of the
country, and even within a small village there may be a great disparity
between the resources of one or two affluent families and those of their less
fortunate fellow villagers. The problem of poverty is most acute in the west,
especially in the Piuthan district about 145 miles west of Katmandu, which is
said to be the most destitute and backward district in the kingdom. The east
includes relatively prosperous sections such as the predominantly Sherpa
Okhaldhunga district, south of Mount Everest.

     Peasant cultivators, who comprise the overwhelming majority of the
population, live typically in simple, sparsely furnished dwellings of mud,
wattle or stone. They produce all or nearly all their own food, which is none
too plentiful, even during the best harvest, but must barter for or buy other
needed commodities such as salt, cloth and kerosene. Most farms are too small
to produce a sizable, salable surplus, so that the average cash income among
families of this group is the equivalent of from $5 to $10 per year.

     Many farmers are deeply in debt. Interest rates are high and loans are
frequently carried over extended periods of time. The usual sources of credit
are Brahman moneylenders, mostly former civil servants who built up their
personal wealth while in office, and the relatively large landowners of the
village, in whose hands money and land were becoming increasingly concentrated
before the initiation of the land reform program in 1955.

Health

Diet and Nutrition

     The common diet is high in carbohydrates and low in protein and vitamins.
Nutritional deficiencies are manifested in all parts of the country in low
resistance to disease and in the prevalence of beriberi and goiter. Shortages
of food develop in particular sections from time to time because of droughts,
floods or marketing and transport difficulties.

     Rice is the staple food wherever it can be grown; elsewhere, dependence
is on potatoes, corn, millet or barley. One of these foods is the basis of the
main meal of the day, eaten in late morning. If income permits, a similar meal
is eaten in the early evening. It is customary to drink tea in the morning
and at other times during the day.

     Rice is ordinarily accompanied by dal, a sauce made of lentils cooked
with salt and saffron, and sometimes a few onions fried in ghee (clarified
butter). A rough kind of bread is made from millet; other cereals are made
into porridge. Onions, beans, radishes and a variety of additional vegetables
and fruits are consumed when available.

     Milk, cheese and ghee represent a regular and important part of the diet,
but meat, fish, game, poultry and eggs are relished luxuries. Not all such
foods are considered suitable for consumption by all ethnic and social groups,
however. In addition to abiding by the proscription against the killing of
cattle or eating of its flesh as do Hindu of all castes, those of the highest
and most orthodox castes may also refuse to eat chicken or ducks. On the other
hand, all will usually eat wild game, including pigeons, deer, wild boar and
goat meat. Most Newar eat buffalo meat, but the highest castes among them do
not.

Water Supply

     The four major rivers and their tributaries drain nearly the entire
country, but public water supply systems making use of these resources have
yet to be developed. Consequently, there are intermittent or chronic
scarcities of water in both urban and rural areas. Low pressure often causes
stoppages in piped water systems. Even in places where wells, springs and
rivers furnish an adequate supply, the water is generally contaminated and
dangerous to drink without boiling. Development and purification of the water
supply should, in the opinion of many Nepalese, have priority over programs
to improve sanitation, medical care and agricultural methods.

     In early 1963 both the central government and local authorities were at
work on irrigation and drinking water projects with Indian financial support.
Part of the funds were to be spent for improvement of the water supply at
Katmandu, where engineers hoped to increase the daily available supply from
10 to 25 gallons per person.

Diseases

     Poor health conditions in the early 1960s were evident in the high rate
of infant mortality, the short life expectancy, the prevalence of disease and
the large number of persons suffering from physical handicaps of various
kinds. It was estimated that as many as two out of every three children failed
to survive infancy and that life expectancy averages between 25 and 30 years.

     The most prevalent of the more serious diseases are malaria and
tuberculosis. Malaria is most common in the central part of the Tarai, but it
also occurs over the entire southern portion of the country from the Indian
border northward to the lower slopes of the high Himalayan range. Over 1.2
million persons in the eastern part of the country alone are said to have the
disease. The incidence of tuberculosis is high throughout the country,
especially in urban areas.

     Other diseases of major importance are smallpox and cholera-which occur
in epidemic form and are greatly feared-typhoid, syphilis, leprosy, filariasis
(a parasitical infestation), trachoma and, in the mountain regions, goiter.
Dysentery and other intestinal diseases are so commonplace that they are
thought of as normal rather than as pathological conditions. The incidence of
asthma seems to be relatively high. Alcoholism is a problem among returned
Gurkha soldiers, a number of whom reportedly drink heavily out of boredom in
their retirement.

Medical Practice

Popular Medicine

     Popular medicine derives from a large body of commonly held assumptions
about magical and supernatural causes of illness. Sickness and death are
thought to be caused by ghosts, demons and evil spirits or to result from the
evil eye, planetary influences or the displeasure of ancestors. A variety of
precautions against these dangers is taken, including the wearing of charms,
the avoidance of certain foods or sights during pregnancy, and the
propitiation of ghosts and gods with sacrificial gifts.

     When illness strikes or an epidemic threatens, the counsel of one of a
variety of types of medical practitioners is sought. Among the Rai of the
Eastern Mountain Region, it is the custom, for example, to consult a bijuwa
(a shaman whose treatment consists mainly of the recitation of sacred
literature in the presence of the patient). If planetary influences are
suspected, the family may seek the services of a more costly and usually
less available jotishi (Brahman astrologer), who determines which planet has
been offended and as a result is causing the illness, as well as the type and
size of offering required to placate the planet and restore the patient to
health.

     Beliefs of this sort are widespread, especially in rural areas, where
they are taken most seriously. But word of the wonders of modern medicine
and its effectiveness against diseases hitherto accepted as incurable has
spread to the remotest parts of the country, and its benefits are greatly
valued, if not frequently experienced or scientifically understood.

     Also practiced generally throughout the country is the Ayurvedic system
of medicine, which evolved among the Hindus about 2,000 years ago. It was
originally based on the Ayur-Veda (the Veda of Long Life), but a vast
literature has since accumulated around this original text. According to
Ayurvedic theory the body, like the universe, consists of three forces-phlegm,
bile and wind-and physical and spiritual well-being rests on maintaining the
proper balance among these three internal forces. Ayurvedic pharmacopoeia is
based on roots, herbs and plants. Nepal is reported to have about 140
Ayurvedic physicians, popularly called vaid, 34 Ayurvedic dispensaries and
a national college of Ayurvedic medicine in Katmandu. Ayurvedic medicine is
subject to some administrative control by the Nepalese Government.

Modern Health Services

     Government activities in the field of medicine and public health are
largely the responsibility of the Department of Health in the Ministry of
Health, Irrigation and Power. The Department's principal functions are the
administration of existing government hospitals and rural health centers and
the construction and development of additional facilities of this type;
supervision of the training of nurses and other health personnel; promotion
of improved sanitation; collection of vital statistics; promotion of health
education; and direction of a malaria eradication project in cooperation with
the World Health Organization (WHO). The Department also conducts smallpox
and cholera projects, which by 1963 had vaccinated more than a quarter of a
million persons. The Department is headed by a director and deputy director.
Both of these officials are doctors, but the Department suffers from a lack of
trained medical and paramedical personnel.

     The Department is responsible for the support and administration of about
40 hospitals, which range in capacity from 7 to 168 beds. Among them are 36
general hospitals (of which 4 have 50 or more beds), a tuberculosis
sanitarium, 2 leprosariums, and a maternity hospital and child welfare center.
Also under the jurisdiction of the Department are 93 district health
centers-small clinics with less than 10 beds, under the care of partially
trained technicians.

     Other medical facilities are maintained under private auspices. One such
institution is the small hospital in Pokhara, in the Western Mountain Region,
maintained by the District Soldiers Board, a charitable committee composed
chiefly of Indian army pensioners. Another is the 100-bed Shanta Bhawan
Hospital in Katmandu. Staffed by 6 physicians and 35 graduate nurses, it has a
network of affiliated clinics and a nurses' training school. It is the main
project of the United Medical Mission, a Protestant organization founded in
1954 by several American physicians. It has also established two other
hospitals, several dispensaries and a leprosarium, and extended its activities
into the fields of education and village development. Other medical facilities
are run by the British-sponsored Nepal Evangelistic Band in Pokhara and
American Seventh Day Adventists in Banepa.

     Hospitals are in general crowded, ill-equipped and understaffed. Only
the largest have X-ray machinery and other modern equipment. Furnishings are
minimal. Beds in some institutions are of simple wooden construction, without
mattresses or linens. In the leading government hospital in Katmandu, electric
current is undependable, so refrigeration is intermittently lacking. Until a
decade ago nursing care was provided only by male attendants, called
compounders, who acted as orderlies, or by relatives of the patient who often
moved into the hospital themselves, further increasing congestion. Hundreds of
ailing persons, some coming from distant places, are turned away each month
by Katmandu hospitals because they do not have facilities to care for them.

     The government has been taking steps to improve existing hospitals and
health centers and establish new ones. Its efforts have been directed
especially at remedying the long-standing imbalance in the distribution of
medical facilities which has favored the Katmandu Valley and a few towns.
Since 1956, when the Five-Year Plan (1956-61) was launched, 93 local health
centers have been opened in outlying areas which previously were without
modern medical care, and 4 new hospitals have been established.

     The United States is assisting in a complete renovation of Bir Hospital
in Katmandu, which is the country's oldest hospital and largest, with 168
beds. With the completion of scheduled improvements, including construction of
new rooms for patients and residential medical quarters, renovation of
existing buildings, and purchase of such basic equipment as X-ray machinery,
sterilization facilities, incubators and hot-water heaters, patient care can
be greatly improved.

     A model hospital on the outskirts of Katmandu was built and turned over
to the Nepalese Government by the Soviet Union in 1963. Completely modern, it
is well equipped and has facilities for 30 adults and 20 children. The staff
is composed of 9 physicians (of whom 6 are Russians), 6 graduate nurses (1 a
Russian) and other specialists. Another Soviet-built hospital in Nepalganj was
opened in April 1963.

     Despite progress, there was still dire need for additional facilities. As
of late 1962, Nepal had only one hospital bed for about every 11,000
inhabitants. Modern medical care remained available for the most part chiefly
to the inhabitants of Katmandu Valley and a few large towns. There were no
public hospitals at all in three areas-Mahakali and Karnali in western Nepal
and Gandaki in the north-central region-and 10 of 75 administrative districts
lacked even a local health center.

     Moreover, with only 128 Western-trained physicians, or a ratio of about 1
to 73,000 inhabitants, the country had the lowest proportion of doctors to its
population of any Asian nation. Twenty-six were foreigners, principally
Russian, British and American. Most of the physicians were found in the larger
centers where the best hospitals were located, so that the villagers, who made
up about 75 percent of the population, rarely had the benefit of their
services. Information was not available on the comparative number of
physicians in government employment and private practice.

     Nepal has no medical school nor is any contemplated in the near future
because of the cost. Most medical students are educated in Indian
universities. As of late 1963, none of the country's more than 30 small
colleges offered a full premedical course, but educators were strongly urging
that the lack be remedied. There are two nurses' training schools, both in
Katmandu. One is associated with the United Mission Hospital. The other,
established by the WHO, is the larger of the two and is run by the Nepalese
Department of Health. It offers a 3 1/2-year course, divided between academic
and practical work, and leads to an examination for a registered nurse degree.
By mid-1962 it had 24 graduates, who were serving along with about 15
Western-trained nurses in various clinics and hospitals throughout the
country.

     In addition to the nurses' training school, the government also operates
an institution for auxiliary health workers in which students are prepared to
become pharmacists, sanitarians and laboratory and clinic assistants.
Established in Katmandu in 1955, it is partially supported by the United
States Government and the WHO. The training period is 2 years. Graduates are
assigned to a district health center where they perform such tasks as giving
injections, setting fractures, doing minor surgery and supervising
well-digging and latrine-building.

Welfare

     Before 1951 the responsibility of providing for the sick and destitute
fell almost exclusively on friends and families-the government remaining aloof
from such need. The overthrow of the Ranas in 1951 marked a major change in
public welfare policy, with the authorities undertaking a series of reforms
and improvement programs intended to alleviate most of the social ills. Thus,
a program of village development was initiated in 1952 (see ch. 11,
Constitution and Government). Administered since 1963 through the panchayat
system, the aim of the program is to stimulate and support economic growth at
the local level and to encourage local initiative in undertaking public
projects in the fields of education, agriculture and health and sanitation.
Evolved under the temporary guidance of the United States Operations Mission
(USOM), the program as of mid-1963 was administered through 55 village
development centers, serving 6,800 villages with a combined population of
about 2.25 million persons. Similar but smaller programs are operated in the
Katmandu Valley by the Indian Aid Mission to Nepal and in the Gurkha District
by the United Medical Mission to Nepal.

     By July 1962, total expenditures for village development amounted to
NR26.3 million (for value of the Nepalese rupee, see Glossary) out of a total
of NR73.81 million spent for public works and services under the Five-Year
Plan. The funds had gone into the construction of roads, bridges and dams, the
establishment of village schools and libraries, and the digging of wells and
latrines. Over 800 development officers, social education organizers, youth
program officers and other workers had been trained in two rural institutes
and the Home Science School, partially supported by the Ford Foundation. With
an additional allotment of NR10 million to be expended under the Three-Year
Plan (1962-65), further progress in development work is anticipated.

     A small-scale but vital relief operation for Tibetan refugees who fled to
Nepal after the Chinese Communist invasion of Tibet in 1950 is being conducted
by the International Red Cross. The refugees, said to number between 10,000
and 20,000 persons of varying regional, social and occupational backgrounds,
live mainly in the area around Mustang, on the Tibetan border about 130 miles
northwest of Katmandu. Thousands of others have settled in Bhutan, Sikkim and
widely separated areas of India. Most of the refugees in Nepal are farmers,
stockbreeders, traders and their families, and monks, but the groups
reportedly also include several thousand armed Khampa (former members of the
Dalai Lama's army) from Kham province in Tibet. The International Red Cross
has spent nearly a million dollars on emergency relief and help for the
refugees in temporary settlements and camps, pending the arrangement of a plan
for permanent rehabilitation.