Nepal Health Survey, 1965–1966 9780824885199

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Nepal „Health Survey

Nepal ^Health Survey 1965-1966

ROBERT M. WORTH and NARAYAN K. SHAH

U N I V E R S I T Y OF HAWAII HONOLULU 1969

PRESS

A SURVEY CONDUCTED AS A JOINT PROJECT OF: His Majesty's Government Kathmandu, Nepal The University of Hawaii Honolulu, Hawaii The Thomas A. Dooley Foundation, Inc. San Francisco, California The Bishop Museum Honolulu, Hawaii

Copyright 1969 by the University of Hawaii Press

Library of Congress Catalog Card No. 72-76764 Printed in the United States of America

Acknowledgments THE NEPAL HEALTH SURVEY of 1965-66 was the product of the labors of many people. It was truly a team effort, and it would not have been possible without the contributions of each member of the team. Dr. Narayan Shah together with Dr. Emmanuel Voulgaropoulos conceived of the idea of a Nepal health survey in 1962 while both were students at the Johns Hopkins University, School of Hygiene and Public Health. Dr. Shah was instrumental in making the necessary contractual arrangements with the Government of Nepal. He also helped in the survey planning, served as its Medical Director, and filled in as its field physician when illness struck those assigned to this task. Dr. Robert Worth led the group at the University of Hawaii and was, with the assistance of Dr. Myrtle Brown, responsible for the establishment of the protocol, recruiting and training of personnel, selection of equipment, supervision of field team activities, data analysis, and preparation of the final report. Dr. Verne Chaney, President of the Dooley Foundation, had the monumental task of raising the $250,000 ultimately needed for the survey, all of which funds came from public contributions in Hawaii and the mainland United States. Freight costs were subsidized by the Agency for International Development. Miss Zola Watson, Nursing Director of the Dooley Foundation, assisted Dr. Chaney with the preliminary arrangements in Nepal and handled personnel problems in addition to the procuring and shipping of all supplies and equipment. Mr. Robert Murphy had the difficult role of Administrative Director, responsible for solving, with limited resources, the overwhelming logistical v

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problems in the field. Dr. Rosemarie Lenel served as field physician during most of the survey, preceded by Dr. Virginia Singleton during survey of the first four villages. Miss Carolyn McCue was in charge of the laboratory group, and with the guidance of Dr. L. Poudyal, Bir Hospital, Kathmandu, supervised the work of laboratory technicians Miss Dodie Stokes, Miss Renda Lindley, and Mr. Richard Mitchell, all of whom spent a large part of their time in the field. Miss Joan Butler served faithfully the multiple tasks of nurse with the medical team. Captain M. R. Thapa was the leader of the field team during most of the survey, made local arrangements with village leaders and, along with Rama K.C., Pampa K.C., Manik Tuladhar, and Sulochana Rai, served as interpreter. Mr. and Mrs. Peyton Rowan were with the advance party, serving as engineer and interviewer, respectively, both crucial roles. Miss Diane Brown was with the team at the beginning of the survey, setting up some sociologic interview schedules, and later did the data analysis and preliminary draft leading to the section in this report on reproductive practices. Dr. Larry Quate of the Bishop Museum (Honolulu) and Mr. M. Nadchatram of the Institute for Medical Research (Kuala Lumpur) each accompanied the team for some time, collecting entomologic specimens. These two entomologists, along with Dr. R. Traub, Department of Microbiology, University of Maryland School of Medicine, did the necessary taxonomic work. Thanks are also due to Dr. Charles Wisseman, Jr., Chairman of the above department, for undertaking the very laborious task of serologic analysis of the filter paper blood discs. Special appreciation is due to the several members of the team who carried on admirably in spite of repeated illness, and special appreciation should be expressed for the adaptability of all members in filling each other's roles during illness in the field. Special thanks are due to Dr. Robert Marks, Chief of the Tuberculosis Division of the Hawaii Department of Health, who volunteered his services in reading all chest x-rays. It should be noted that the School of Public Health of the University of Hawaii, with a grant (No. GM15421) from the National Institutes of Health, supplied computer time and programming services. Miss Sakiko Okubo volunteered as supervisor of data processing and programming, and she performed a monumental and tedious task with remarkable grace. Free clerical services for data processing were obtained through the student work-study program of the Office of Economic Opportunity. Dr. Carl Taylor of Johns Hopkins University was kind enough to give encouragement and advice during the entire process of planning, execu-

ACKNOWLEDGMENTS

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tion, and analysis. We also wish to thank the many members of the faculty at the University of Hawaii who have given valuable help in editing the manuscript. The U.S. Operations Mission Public Health staff in Nepal were most helpful, especially Mr. Larry Cooper of the Malaria Control Program. A special word of thanks should also be reserved for Ambassador Henry E. Stebbins, then the U.S. Ambassador to Nepal, who was most cordial and assisted immeasureably in getting the completed data forms forwarded safely to Honolulu for data processing and analysis. All ministries and departments of His Majesty's Government were extremely cooperative and helpful in every stage of the planning and execution of this survey. Mr. Howard Kresge, Director of the Committee on Voluntary Foreign Aid, U.S. State Department, was personally cooperative and helpful far beyond any reasonable limits in making arrangements for air and sea shipments of equipment and supplies to Nepal. A volunteer committee of citizens of the state of Hawaii organized itself to raise funds in that state for support of the Nepal survey. Their invaluable help and confidence in the program and its principles was deeply appreciated. This group certainly must include the newspapers, radio and television stations, school children, university groups, churches of all faiths, business groups, banks, and many wonderful individuals, all of whom gave freely of their time and talents to make this program a success.

Contents

1 Introduction 2 Environmental Description 3 Estimates of Vital Statistics 4 Reproductive Attitudes, Beliefs, and Practices 5 Nutrition and Nutritional Deficiency Diseases 6 Diseases Transmitted by Direct Contact 7 Diseases Transmitted by the Respiratory Route 8 Diseases Transmitted by Fecal Contamination 9 Diseases Transmitted by Insect Vectors 10 Other Conditions Eye ENT, Dental Lung Cardiovascular Diabetes Bladder Stone 11 Summary and Specific Recommendations 12 General Recommendations Appendix A — Sample Forms Appendix B — Entomological Report Bibliography

ix

1 5 18 32 42 58 61 72 79 93 93 96 99 101 103 104 106 113 117 123 157

CHAPTER

ONE

Introduction

BECAUSE of its geographical isolation, successful avoidance of foreign domination, and political isolation until 1950, the rural parts of Nepal represent one of the few areas of the world in which a traditional, pre-industrial ecologic balance between man and his environment might be studied with modern investigational techniques. With the very rapid introduction into rural Nepal of schools, improved communications, transportation, agricultural and public health services in the current decade, this is a vanishing opportunity. With the modern tools of social and economic change now available to a strong central government, there falls upon that government the awesome responsibility of using these tools wisely and with foresight. This book is dedicated to the assistance of those who shoulder this responsibility. The purpose of this book is not to be encyclopedic but to give a concise, quantitative picture of the most important current health problems of Nepal in order to assist in comprehensive health planning. This book does not pretend to give definitive data on any one topic but will add, it is hoped, a significant and orderly increment of knowledge to that already available, both from published sources (Taylor, Svensson, Millar, Dunn) and from the unpublished data available to the Ministry of Health in its own files, in the U.S. Operations Mission Public Health files, and in the store of practical experience being rapidly accumulated by Nepalese physicians 1

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working in the increasing number of small hospitals and dispensaries being opened in the remote, but populous, areas of the country. In August, 1963, a contract was signed between the Ministry of Health, His Majesty's Government of Nepal, and the Thomas A. Dooley Foundation, under the terms of which the Dooley Foundation was to conduct a national health survey in Nepal to supply baseline quantitative data to assist the Ministry in its planning and to be useful in measuring future progress of health work in Nepal. In September, 1964, the Dooley Foundation reached an agreement with the School of Public Health, University of Hawaii, under which the School (in cooperation with the East-West Center of the University) was to develop the general survey plan, work out a detailed survey protocol, provide a list of equipment and personnel needed, assist in recruiting and training personnel, provide continuing professional consultation during the course of the survey, process the data derived from the survey, and, together with representatives of the Ministry, write up a final report to the Ministry. During the fall and winter of 1964 preliminary planning commenced at the School, assisted by the visit during February and March, 1965, of Dr. Narayan Shah, who was designated by the Ministry and by the Dooley Foundation to direct the survey. It was decided to use the village as the sampling unit and to use a sampling ratio of approximately 1 /1500 (one village per 1500). On the assumption of a sample of 24 villages with an average of 270 people per village, about 6,480 people would be seen, or a sampling ratio of about 1 person seen per 1,500 Nepalese (assuming a national population of about 10 million). Dr. Shah obtained a large-scale map based on aerial photographs of Nepal. A small-square, numbered grid system was placed over this map, and a random sample of 24 grid squares was selected, with the village nearest the center of each selected square designated as a sampling site. It was also decided to have a single team in the field (a small advance party of 4 people and a medical team of 7 people) supported by helicopter from a base laboratory in Kathmandu (staffed by 1 administrator and 2 laboratory technicians). The plan was to spend about two weeks

INTRODUCTION

3

in each village in order to gather demographic, nutritional, and sanitation data from each household, and to attempt to examine every person in the village to assess disease prevalence. The survey was to be finished in about one year. Dr. Shah then returned to Nepal with the map to make the necessary arrangements with the government and to recruit the Nepalese members of the team. Data-gathering forms were then printed (Appendix A), final equipment lists made out, and the American members of the team recruited (predominantly from Honolulu). During the first week of June, 1965, the American members of the team camped out near a small village on Oahu, Hawaii, to test the equipment and to practice with the forms and protocol. During this encampment, with the help of several Nepalese students at the University of Hawaii, parts of a 16mm color movie narrated in Nepali were made to show in detail the exact procedure of the survey in a village. Arrangements were also made for entomologists from the Bishop Museum, Honolulu, and the Institute for Medical Research, Kuala Lumpur, to accompany the team during part of the survey to make collections of small mammals and medically related insects (reports in Appendix B). During July, 1965, the team members and supplies were assembled in Kathmandu. During the first part of August, training exercises were held in Kathmandu, with Dr. Worth present, and the remaining parts of the 16mm color film were made "on location," to be used in subsequent villages to allay the suspicions and anxieties of individuals invited to participate in the survey. The survey actually got under way during the second half of August and proceeded more or less on schedule, in spite of illness of team members and prodigious transportation problems stemming from the fact that the team never obtained a helicopter fully committed to its support. In fact, the survey would have ceased after the third or fourth village if the Royal Flight, Ltd. had not made its helicopter available. By a combination of part-time use of the Royal Flight helicopter, DC-3, truck, jeep, bullock-cart, elephant back, and trekking on foot, the team had completed 18 of the 24 selected villages by the end of May, 1966.

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At that time the wet monsoon was approaching. Three hill villages in the west-central mountains and three higher hill villages in the eastern mountains remained as yet unexamined. Many of the team members had other commitments; so they could not wait for the end of the monsoon to complete the six remaining scheduled villages. Furthermore, funds to support the survey were exhausted. It was therefore decided to apply the survey procedure to all the occupants of one discrete villagesized block in urban Kathmandu for comparative purposes, then to terminate the survey. In the following section on environmental description, Table 1 shows the villages surveyed, giving for each village the region, the order in which it was visited (numerical sequence), the name of the village, the altitude, the total population at the time of the survey, a brief summary of the principal occupation of the adult men, and the proportion of youngsters in school. Each village which was surveyed is identified by number on the map (p. 7), while the six villages not surveyed are unnumbered.

CHAPTER TWO

Environmental Description

NEPAL is where the Indians from the southern Asian plains have met the Mongoloid people of the central Asian mountains and plateaus. The dominant geographical feature is the Himalayan range, which forms the northern border of Nepal and sends countless steep ridges irregularly southward, creating almost impenetrable barriers to any easy travel within the country. These ridges terminate in the Churia Hills, a range of foothills that are fringed to the south by a narrow, discontinuous segment of the northern Indian plains, known as the Terai. It is in this narrow, warm, well-watered strip (9,518 square miles) that about 2.8 million people live, mostly Hindus of Indian stock (25 per cent of Nepal's approximately 10 million people). Another 600,000 people live among the inner Terai foothills (4,749 square miles). The northernmost 40,296 square miles of the country consists of the Himalayan range and its southern valleys, populated by 6.6 million people of mixed Indian and various non-Indian Mongoloid tribes. The largest of the mountain valleys is Kathmandu Valley (209 square miles), the fertile, silted-in bed of an ancient lake, the home of about 500,000 people, and the seat of the government (Karan 1960). Each June the warm, moist winds from the Indian Ocean sweep northward and are raised and cooled against the southern slopes, turning the rivers into raging torrents, the Terai into a flooded lake, and obscuring the Himalayan ridges in constant 5

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NEPAL HEALTH SURVEY

clouds. In the autumn the pattern reverses, and the cold dry winds come down out of Tibet and central Asia, and cool weather extends well down into the southern foothills. Both the rainfall and the population are heavier in the eastern two-thirds of the country, which is roughly in the shape of a rectangle, extending 500 miles in an east-west axis and 100 miles in a north-south axis (Karan 1960; Hagen 1961). At each survey site the engineer in the advance party was responsible for mapping and for gathering simple observations about water supply and fecal disposal patterns, while the two women doing the household interviews were also responsible for filling out a household environment check list from observations made by them during their interview. These two sources provided data for a brief standardized description of village environments, which are summarized below by region in a pattern corresponding to Table 1. WESTERN MOUNTAINS This region was represented by four villages: No. 13 Bhawanipur (287 population, 50 households) a foothill village bordering on the Terai at 1,100-foot elevation just south of the Rapti River near Dang, about 30 miles east of Nepalganj, is a Chetri* and lower caste Hindu village of subsistence farmers. Schooling through grade 5 is available across the river. No medical services are available locally. Water is obtained from the river. This village is transitional in ecology between the Terai and the foothills. No. 15 Bajura (310 population, 59 households) at 4,500-foot elevation about 25 miles northeast of Silgari is a predominantly Chetri and lower caste Hindu village of subsistence farmers. There are schools through grade 7 available within walking distance. There is a Panchayat (local government) health office, but without supplies. Water is obtained from a mountain stream. No. 16 Dandagau (352 population, 36 households) at 5,400*The Hindu caste system is still strongly felt in Hindu-dominated central and southern Nepal. The major caste groupings are designated in this report as: Brahmin, Chetri, Baisya, and lower castes.

ENVIRONMENTAL DESCRIPTION

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