Epidemic of Cynicism and Fatalism:As Major Challenges for Nepal’s Health and Development

By Kul Chandra Gautam
America Nepal Medical Foundation Convention
Atlanta 10 June 2000

Let me start with a confession.
Your invitation to give a keynote address to ANMF presented a real dilemma for me.
On the one hand, ANMF has been so kind and generous to me . I was invited to join its Board at the very beginning – which I did. But unfortunately, I was unable to attend any of its meetings, until today. I have, therefore, had a certain nagging sense of guilt in not being a more active member of the Foundation. So I saw this opportunity to join you today as a chance to redeem myself.

On the other hand, I also felt a certain awe in addressing such a distinguished group.

What can I say about health and medical situation in Nepal that will be unknown to you?
As physicians and specialists, you certainly know far more about health than an international bureaucrat like me. Most of you have studied and practised in the finest universities and medical establishments in the world. And I presume most of you have first hand experience in working in the field of health in Nepal.
I am not a medical doctor. So I hope you will forgive me if sometimes I sound like a quack prescribing inappropriate remedies for our country’s illnesses.
Since this is a keynote speech about health and development in Nepal, I want to start with some reflections on what are in my view the most prevalent diseases that hamper Nepal’s development.
During my many visits to Nepal in recent years, I have concluded that there are two diseases that to me seem most common among the Nepalis. One afflicts the poorest people of Nepal and the other targets the middle and upper-middle class.
The disease afflicting the poor is not, as you might suspect, either diarrhea or pneumonia. It is not tuberculosis or HIV/AIDS. Nor is it really a disease specifically linked to malnutrition or poverty.
Instead the disease is what Dor Bahadur Bista called FATALISM.
I have seen far too many of our compatriots accepting their pitiable situation as unavoidable destiny. Tolerating injustice. Suffering indignities. Women being mistreated and accepting their subjugation as their poor karma. The elderly waiting for their death with melancholy self-pity.
For sure we have had some examples of heroic struggle against fatalism. Many hill people go off to far away lands to secure jobs to improve their lot. We have seen the slow emergence of a women’s movement against traditional male domination, domestic violence and emancipation through education. More recently we have seen the emergence of the Maoist movement, which is an extreme reaction to the age old fatalism.
But still far too many people suffer in silence and accept fatalism as destiny.
Now let me turn to the second disease that afflicts mostly, middle and upper-middle class Nepalis. And it is not, as one might guess, a disease of affluence such as coronary heart disease, or gout or cancer. Nepal’s most prevalent middle class disease, my friends, is called: CYNICISM.
It is not only widespread in Nepal, it is found even among expatriate Nepalis. All of us care passionately about Nepal and would like to contribute to its development. But far too many of us seem infected by this virus of cynicism. We think Nepal is just hopeless, too corrupt, too mismanaged, too stubborn against positive change.
As someone whose job involves overseeing the work of a UN agency in over 150 countries, I would like to share with you my unvarnished assessment that Nepal is NOT a hopeless case. In fact, Nepal is in much better shape than many other countries.
Nepal may not be progressing as fast as we would like, or moving in the direction in which we would like to see it develop and prosper. But it certainly is not going backwards, as are many other countries.
Compare it with Afghanistan where religious fundamentalism is dragging the country backwards. Compare it with Burma where an authoritarian military regime is letting a rich country retrogress. Compare it with Sierra Leone or Liberia or Somalia where warlords are preying on their citizens. Compare it with North Korea or Yugoslavia where half a century’s progress has been reversed. Compare it with Cambodia and Rwanda where genocide of unimaginable proportions ravaged entire nations.
Yes, Nepal has many problems. But we continue to move in a forward direction, even if slowly. Sometimes, it seems like we take one step backward for every two steps forward. But that is still net progress, net forward movement. And it is our duty, those of us who are fortunate enough to get out of the cycle of poverty, to inspire hope and optimism among our compatriots.
You are doctors, trained to heal. Although I know you did not learn how to treat fatalism and cynicism in your medical schools or hospitals, as professional health workers, please fight against these diseases and try to be professional optimists.
Towards the end of my speech, I will make a few suggestions for some specific initiatives you might take to instill a dose of optimism among yourselves and our compatriots. But first, let me turn to a more classical review of health and development in Nepal.
Let me start with a couple of facts and figures, probably well-known to you, but which will be helpful to set the context for my remarks and some messages I want to leave with you.
It would not be unreasonable to think that in spite of its spectacular beauty, clean air, and immense water resources, Nepal is quite an unhealthy country in many ways. With almost fifty percent of the population earning less than one dollar per day, poverty is endemic. Maternal mortality is one of the highest in the world. Female literacy at 20 percent is among the lowest in the world. Life expectancy is just 55 years, compared to 77 years here in the USA.
The under-five mortality rate is currently 100 per thousand live births. Translated into absolute numbers, approximately 80,000 young children die each year in Nepal – 220 children every day. In the period of the 1990s alone, it is estimated that almost one million young Nepali children died before reaching the age of five years, mostly from readily preventable causes – acute respiratory infections, diarrhoeal dehydration and vaccine preventable diseases, such as measles.
Maternal and perinatal ailments and nutritional deficiencies are the major causes of avoidable sickness and death in Nepal. The problem is particularly severe among children under five, among whom intestinal infectious diseases, other bacterial diseases, pneumonia, and perinatal factors account for 80 percent of all deaths.
Malnutrition is an underlying factor of this high morbidity and mortality. It weakens the child’s immune system creating a vicious cycle of infection and wasting which stunts both the physical and mental growth of the child. The downward spiral of infection and malnutrition gradually draws the child towards an untimely death.
It is estimated that malnutrition in one degree or another is associated with over half of these young child deaths.
Official government survey data indicates that child malnutrition has shown little, or no improvement in 25 years. More than half the children of our country remain chronically undernourished and underweight. This, despite three decades of planned national development and millions of dollars in assistance from the international donor community.