NEPAL Country Studies: A brief, comprehensive study of Nepal

Nepal is a small country of about 30 million people with vast ethnic diversity that is situated between India and China in South Asia. Like many low- and middle-income countries LMICs , Nepal is battling a double burden of disease, communicable and non-communicable diseases NCDs , with cardiovascular diseases CVDs being the most common among the latter.

Research work done particularly in the last decade has shown that the conventional risk factors are present in a high proportion in the Nepalese population. The silver lining in the midst of these problems has been the formulation of an NCD policy draft 2 that can potentially be a roadmap towards the control of CVDs and other NCDs in the country. Apparently, cases of NCDs in Nepal began to be noticed only in the second half of the 20th century.

CVD was first documented in the s with cases of myocardial infarction 3 followed by occasional publications on risk factors such as hypertension and smoking in the different Nepalese and Indian journals. As there is an absence of a routine surveillance or registry system, the actual burden and trend of CVDs in Nepal is unknown.

But combined data from various sources do indicate that the problem is common, and for many CVDs, particularly coronary heart disease CHD and its risk factors, it is perhaps increasing too. The latter have been reported to be frequent in different hospital audits, with one of them reporting it to be present in 5.

Many of these factors were eventually frequently identified as major risk factors by the nationwide NCD Risk Factor Survey and other smaller studies figure 1. An overview of the risk factors for cardiovascular diseases in the Nepalese context, including the vicious cycle of socio-economic impacts and major hindrances at different levels of prevention. The figures in parentheses are approximate figures for Nepal based on different national or subnational studies carried out in the period — Examples of the rising trend of cardiovascular risk factors in Nepal: It can be said that because Nepal has similar socio-demographic characteristics to other South Asian countries and has undergone phenomena such as urbanisation and globalisation as in other South Asian countries, particularly India, the increasing trends in CVDs being witnessed in India 28 might well be taking place here as well.

Besides, it must be noted that international migration studies on CVDs involving people of South Asian origin 29 30 have so far not recruited those migrating from Nepal, although the number of people who migrate from Nepal to Europe, the Americas and Australia is also substantial.

Infectious diseases, maternal and child health and malnutrition deservedly receive the attention of the government and external development partners—more so after the endorsement of the millennium development goals MDGs. Management of CVDs in Nepal has characteristically been focused on treatment rather than education and preventive healthcare.

There has been a dramatic rise in the availability of interventional cardiology and cardiothoracic surgery services. Although these services are essential to save the lives of those who are already diseased, they have not helped to slow down the growing epidemic of CVDs in the country. The increasing annual numbers of hospital admissions with CVDs also suggest the same. But the majority of the country comprises villages and healthcare in these remote areas is provided mainly by auxiliary health staff who do not have the training needed to deal with CVDs in the primary healthcare that they provide.

Apparently, there was an attempt to produce an NCD policy in the late s but the document did not translate into anything substantial. Another effort in has yielded an NCD policy draft. Highlights include integrated management of risk factors, capacity building and training, and surveillance. Unfortunately, the draft is yet to be endorsed by the government because of the ongoing political imbroglio.

Furthermore, policies in other health-related sectors such as transport and agriculture also do not address CVD issues. Health-related legislative measures have also been absent or weak in implementation. However, there is still no comprehensive anti-tobacco legislation, which should have been immediately in place after the ratification of the framework in However, the implementation of the strategy did not take place in most of the LMICs, and was probably overshadowed by a larger global agenda, the MDGs.

The challenges and opportunities that are present in Nepal for CVD control are outlined in box 1 and feature in figure 1 as well. A concerted effort by all stakeholders at all levels is the call of the day if Nepal wants to control the burgeoning epidemic of CVD. To ensure the smooth implementation of CVD strategies, the following areas, as advocated by the Centers for Disease Control and Prevention, shall need strong individual attention.

This is an important aspect of CVD control as most of the risk factors are behavioural in origin and they need to be tackled at an incipient stage through health promotional activities. Indeed, studies have shown that cardiovascular health literacy in Nepal is poor. Primary healthcare settings that reach down to the grass-root level throughout the country would be the most sustainable way of disseminating heart health messages to the public. Such a community-based health promotional primary care approach has been successfully demonstrated in many resource-constrained settings such as in Chandigarh, India, 38 and in Ashanti, Ghana.

There is a dearth of public health personnel trained in CVDs and thus there is an urgent need to groom staff in this sector. Partnerships between government and private institutes are not conducive, leading to a lack of concerted efforts to deal with CVDs. Lately, the Nepal Public Health Foundation, a non-governmental organisation, has taken up the issue of NCDs and is working towards bringing all the stakeholders together. Work from other developing and often politically disturbed countries such as Pakistan and Iran illustrates how CVD prevention can still be carried out with vision, leadership and partnership.

The Isfahan Healthy Heart Program 42 in Iran and the Heartfile Lodhran CVD Prevention Project 43 in Pakistan produced integrated public—private partnership models to work conjointly towards improving the heart health of the country, many of which are applicable in Nepal's context as well. Although the NCD policy in Nepal was already drafted in , no short-term and long-term programmes based on the policy have been formulated yet. At present, the Ministry of Health and Population appears to be at a loss on how to implement the policy in reality. For effective implementation of the NCD policy, the geographical, ethnic, rural—urban diversities and differences must be considered while formulating action plans because the health system provision and health-seeking behaviour in urban areas are entirely different from those in the agriculture-based rural areas.

For example, physical inactivity is not a problem for farmers whereas it is one of the major risk factors for CVDs in city dwellers. Tobacco and alcohol, on the other hand, are almost equally used in both rural and urban areas, but they have to be dealt differently when it comes to their control. In the villages, these addictions are centred on the agricultural work and often they are the only means of leisurely pleasure and escape, whereas in the towns they often underline the urban despair, glamour and peer pressure. The existing hierarchical healthcare system that is decentralised from the centre to the grass-root level can be upgraded and adapted to take up CVDs.

The existing healthcare staff have to be trained in order to deal with the present situation of CVDs in the country, which might only be the tip of the iceberg. The health policy should ensure equitable distribution of the workforce. The grass-root level health workers can be used to screen for CVDs and risk factors such as high blood pressure as well as for health promotional activities as shown by the study in Chandigarh, India.

Optimal laboratory backup is essential and a hierarchical model similar to the one for communicable diseases can be adopted for NCDs as well. The use of simple techniques such as glucometers for blood sugar readings and instruments for blood pressure and body mass index measurements should be possible at the lower levels of the healthcare system. A referral system with availability of secondary and tertiary services in the district and central hospitals will ensure cost-effective utilisation of resources.

Besides, Nepal has recently witnesses an increase in the number of new private medical colleges being set up across the country.

Introduction

These private medical colleges can be involved as partners in NCD control because they have the technical workforce and laboratories and can provide tertiary care services. This has to be achieved by expanding and standardising resources and activities and by establishing frameworks, methods and core indicators for evaluation of policies and interventions. Here, it may be important to develop clinical and programme evaluation protocols that are most appropriate in Nepal's context.

The healthcare system can learn a lot from the successful adoption of health programmes for communicable diseases such as malaria, tuberculosis and leprosy. The development of longitudinal surveillance systems to monitor progress would also be beneficial in this context. Appropriate methods for translation and dissemination of knowledge must be determined and tailor-made to suit the local circumstances. Research to identify best practices for effective interventions should be carried out simultaneously along with the implementation of the intervention itself.

In this context, Nepal can initiate the NCD interventions as pilot programmes in some districts of the country and a simultaneous operational research can be carried out to provide crucial insights to expand the programme to national or subnational levels. The public health personnel and cardiologists in the region can come together, for example, to develop specific guidelines for CVD risk assessment in the South Asian population. There should be opportunities to carry out collaborative work at the regional and international levels on various aspects of CVDs—from community to catheterisation laboratory and from prevention to intervention.

International agencies should stop ignoring the rising problem of CVDs in the region. They should also coax the health policy makers in the region to initiate or accelerate programmes towards CVD control. Nepal is at an interesting juncture as far as CVDs are concerned. Although in bits and pieces, we now do have data that can no longer be overlooked but rather require us to come up with definite plans and policies for the prevention and control of CVDs.

A rejuvenated global and national interest has given us an ideal platform to launch CVD-related policies and programmes. It is now time to combine all these forces and put our plans into action. AV is the sole author of this manuscript. Provenance and peer review: Not commissioned; internally peer reviewed. National Center for Biotechnology Information , U. Journal List Heart Asia v. Published online Jan 1. Abhinav Vaidya 1, 2.

Author information Article notes Copyright and License information Disclaimer. Accepted Jul For permission to use where not already granted under a licence please go to http: Issues such as rural development, rural to urban migration, health care, education, sustainable tourism and many others remain paramount. The key to realizing your educational goals in Nepal will be your ability to communicate in Nepali. Drawing on some of the best language teachers in the country and with a 1: Classes take place in village homes, bazaars and along mountain pathways as well as in small classrooms at your program house.

A vital component of your learning will be the commitment you make, along with staff and fellow students, to creating a Nepali-speaking environment both in and out of class. Nepal Studies The course combines lectures, readings, discussions, and extensive writing with the more experiential components of family stays, study trips, and field assignments.

Lectures are given by professors from Tribhuvan University as well as scholars and specialists from government and private organizations. Assignments focus on socio-cultural studies, kinship and family relations, development, environmental issues, health, and religion, requiring you to use your Nepali language skills and integrate your personal experience in the culture with classroom learning. You will explore in-depth an aspect of Nepal through an independent study.

Projects are guided by local scholars or specialists and program staff and require a significant analytical component in the form of a written report. The program strongly recommends you select a project that involves field research, oral interviews, ethnography, and other techniques that facilitate cultural immersion and use of your Nepali language over those involving library research.

Topic selection may be limited due to available resources and local conditions. The aim of this course is to provide you with a basic working knowledge of the Nepali language and to promote communication and interaction with the people of Nepal. Instruction emphasizes oral proficiency as well as practice in reading and writing the Nepali script. Classes are taught in Nepali, with minimal English translation. All instructors are native Nepali speakers skilled in proficiency-based, communicative, interactive teaching methods.

Sentence structure, grammar and vocabulary are progressively introduced each day within situational contexts and with limited English explanation, encouraging you to understand and use Nepali in natural contexts.

Language instructors accompany students on trips and treks, providing both structured and informal field instruction. As a part of your language training, instructors emphasize the cultural context of daily lessons and incorporate cultural information into the language curriculum.

Country Studies on Somalia, Afghanistan and Nepal

Throughout the semester, classes are held hours per day, days per week, for a total of approximately in-class hours. Class size is small, with a student-teacher ratio of 3: Two Pitzer course credits 8 semester units are awarded for successful completion of the course.

You will spend the first days of the semester at the program house, preparing to move in with your Nepali host families. During this period, class is held 5 hours per day, with an emphasis on developing the oral language skills needed to communicate on a basic level. In addition, during this period, language instructors facilitate a number of hour orientations to familiarize you with specific situations you may encounter while living in rural Nepali villages and teach you the language to deal with these situations.

Classes in reading and writing the Nepali script devanagari are integrated into the language curriculum early on in the course. Although the emphasis of the course is primarily on proficiency in spoken Nepali, classes in written Nepali enable you to read signs, write letters and stories, as well as help you with pronunciation.

Intensive Nepali Language

Nepali-Speaking Environment at the Program House: In addition to the importance of formal language class, you must practice what you have learned outside of the classroom in order to become proficient in Nepali. You are asked to make a commitment to using what you have learned with your peers outside of class, thereby helping both yourself and the other members of your group in the language learning process. Each week, Nepali-only periods are scheduled during which no English is spoken, encouraging you to develop creativity and confidence in their language skills.

Throughout the semester, you are given time both in and out of formal language class to complete a series of language activities. These exercises are designed to encourage you to practice your Nepali outside of the classroom. Language instructors accompany students on all program trips outside of the Kathmandu Valley and conduct language classes for hours per day at these field sites. Both before and during each trip, language class includes vocabulary, structures and topics relevant to the area.

In addition to regular language class, you are required to complete interviews with local people on relevant topics during each trip. Preparation for Independent Study Project: After formal language classes end, you have three weeks to research a topic of your choice during the Independent Study Project period of the program. In preparation for this research, throughout the semester instructors assign practice interviews and focus on your proficiency in Nepali in order to enable you to function on your own in remote areas of the country where little or no English is spoken.

During the final weeks of the language course, class time is provided for you to learn vocabulary and develop interview questions appropriate to your research site. In addition, you are given guidance in writing about your project in the Nepali script.

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Assessment for Intensive Nepali Language course will be based on the following criteria: Description The Nepal Studies course makes use of an interdisciplinary approach to the study of Nepal and provides you with the intellectual foundations with which to pursue your own more specialized interests. In the belief that formal, academic studies are necessarily enriched by your experience of living with Nepali families, the course is designed to integrate both the academic and personal dimensions of your life in Nepal. Given the fundamental role the language learning process plays in the program as a whole, essential to this course are assignments, interviews and research projects that require you to utilize your Nepali language skills.

The Nepal Studies course includes the following components:. The lectures provide a base of knowledge, which you will expand and refine throughout the semester. Our lecturers include professors from Tribhuvan University, as well as scholars and activists from non-governmental organizations, government, and the private sector; you will typically attend three to four lectures per week.

A complete list of recent lecture topics and lecturers is included below. Day and Half Day Study Trips These study tours are led by Tribhuvan University professors and allow you to complement classroom learning with direct observation and experience in the field. A list of recent study tours appears below. Trips may include visits to Chitwan National Park, the Annapurna Conservation Area, Lumbini, Bandipur, and an extended family stay in a remote hill village. In each of these areas, you will complete a number of interviews and small projects on topics specific to the area.

Lectures, readings, and discussion sessions supplement your experience in the field. Readings In conjunction with lectures and field trips, a selection of required readings will focus and expand upon issues raised in the classroom. Readings include articles and essays by both foreign and native scholars and expose you to contemporary scholarship and debate on a diverse set of issues.

A list of required readings is included below. Discussion Sessions The program features periodic student-led discussion sessions, which provide a forum for you to discuss and explore issues raised in lectures, readings, and your own experience. These discussions also allow you a chance to articulate and refine ideas you will explore in more depth in your writing for the Fieldbook. Fieldbook In the course of the program, you are assigned a series of papers, which together comprise the Nepal Fieldbook.

Fieldbook assignments are designed to take advantage of and develop your skills in Nepali, and draw upon learning in the classroom, family stays, and research in different regions of Nepal. Assignments include focus on socio-cultural studies, kinship and family relations, development and environmental issues, and religion, and help to prepare you for the more extended independent research project you will undertake during the last month of the program.

Assignments are coordinated to support current level of language competency and in country knowledge. Family stays Living with Nepali families helps provide necessary context for issues raised in lectures and readings and is one of the foundations of your experience in Nepal. Accordingly, your participation in Nepali family and cultural life is a factor in the grade for the Nepal Studies course.

Over the course of the program, you live with two Nepali families, representing different ethnic, cultural, and economic backgrounds. For the majority of the program, you live with Brahman or Chhetri families in rural villages of the Kathmandu Valley. During trek, you live with Sherpa, Tamang, or Gurung families in the Himalayan foothills. As many of us know from our experiences with traditional coursework, ideas removed from the complicated realities of daily life can often be dry and academic at best, inaccurate and irresponsible at worst.

But experience alone, without the benefit of serious reflection, has its own shortcomings, particularly in a place as unfamiliar, stimulating, and challenging as Nepal. What factors — social, historical, religious, geographic, economic, etc. What have you learned from your relationships with Nepalis, and how have these relationships shaped your experience and understanding of the country around you? Considering these issues can lead to deeper, perhaps even more important, questions: What can I really know — about myself and others; about my own culture, and the cultures of another place and people?

What are my responsibilities and obligations here in Nepal and in the world more broadly? The fieldbook provides you with an opportunity during your time in Nepal to record, evaluate, and communicate your thoughts, observations, and feelings on a range of areas central to Nepali life: Whatever the subject, assignments will ask you to synthesize material from traditional sources such as lectures or readings with what you learn through in-depth conversations and interviews with Nepalis.

The fieldbook asks you to make the most of your valuable time in Nepal not by isolating your ideas from your experience, but by combining academic reflection and experience into a more meaningful whole. Be sure to provide necessary context and background information — cultural, historical, etc. Your writing should include and integrate academic reflection, in-depth discussions with Nepalis themselves, personal experience, and other sources — readings, lectures, study trips, etc.

Kinship and Family Relations Kinship relations affect every aspect of social relationships in Nepali society and are a constant reference point for interactions at work, school, and village life in general. Learning the Nepali kinship lexicon will be helpful and important for understanding social interactions both in and outside of your family.

Looking back on your time in Nepal, write a descriptive account pages of a cultural experience or encounter that has been especially important to you. Whatever your subject — family life, language learning, an incident during trek or your independent study project, etc.

Your writing can draw from your journal and may take the form of a personal essay or a fictional account. This is an opportunity for you to begin to process your experiences and impressions, and to present a narrative of one important aspect of your time in Nepal.

From the list below choose an article on a topic that interests you. Using this article as a starting point, explore the subject through detailed conversations and interviews with Nepalis. The article will provide background information and a point of reference, but for this assignment your main focus should be on the conversations and discussions generated by the issue — i.

Who you speak with will depend upon your topic: Whatever your topic, speak with several different people to get their perspectives and opinions on the issue, and include other sources to complement information gathered from your discussions. You will have the opportunity to work with the gurus to learn new vocabulary and practice asking questions appropriate to your topic.

After reading your article, make a list of vocabulary and questions that will be important and useful for your interviews and be prepared to discuss these with the gurus. Focus on one aspect of village life that interests you and examine it by conducting interviews with at least five people. Work with the language teachers to develop a list of vocabulary and questions appropriate to your interviews. Talk with several people in the village, making sure to include people of different backgrounds, to get their views and opinions on the topic.

Please be prepared to give a formal presentation minutes of your interview and to turn in a detailed outline of your presentation. In the presentation, please present a background and discuss the interviews as well as your own analysis and thoughts on the issue. Include quotes from your discussions and supplement your interview material with references to readings and lectures where appropriate.

Looking back on your time in Nepal so far, write a descriptive account pages of a cultural experience or encounter that has been especially important or challenging for you. You may wish to consider a single incident, or explore your on-going efforts to come to terms with a particularly challenging aspect of Nepali culture or society. You might write about your adjustments to life in a new family, your language learning experience, confrontations with caste or gender differences, or a particularly provocative conversation in the bazaar or along the trail. The experience — describe, in detail, both the experience and your reaction to the incident, conveying the intensity and complexity of the encounter from your own perspective.

Be sure to provide specific narrative detail and focused descriptions of the experience. Cultural attitudes and influences — provide an account of the larger cultural assumptions and beliefs informing each side of the encounter:. Explore Nepali perspectives of the incident, describing the individual and cultural influences, which may explain the thoughts, feelings, and actions of the Nepali or Nepalis involved. Be sure to talk to Nepalis about their impressions of the encounter and other similar incidents; speaking with many different people of different backgrounds will help to clarify your understanding of Nepali perspectives and attitudes.

Explore your own perspectives, considering both broader cultural and more personal factors, which informed your role and your reactions to the incident. Consider how much of your experience may be to traced to broader American cultural trends and perspectives, and how much of your experience is rooted in your particular personal and social background.

As you step back and reflect on your experience, also step back and reflect on your attempt to reconcile differing cross-cultural perspectives of the encounter. What kinds of difficulties do you face in trying to write about this encounter from all points of view and in explaining them honestly and objectively? Use the social, residential, and occupational history of one family as a means of understanding larger social and economic changes taking place in the Kathmandu Valley. Find one or more people in your home who can relate to you the history of your family over three generations.

Learn the educational, residential, and occupational history of each member of your immediate family, making sure to include people from three generations. After compiling these details, choose three people — one from each generation — whose lives you want to examine in more depth.

Include an overview of the educational, residential, and occupational history of each family member. Provide more detailed description and discussion of the lives of three individuals from different generations. Discuss the changes and continuities you observe from one generation to the next; choose one or two topics of particular interest and focus your discussion accordingly. What differences do you observe, for example, in the educational achievements between the youngest and oldest generations?

Do you find significant changes in religious practice and belief between generations? What social, cultural, historical, economic, and other factors would help to account for these changes? Although your main source of information should be your observations and discussions with your family, supplement these with relevant information from lectures and readings. Essential for understanding religion in Nepal is an appreciation of not just the philosophical or conceptual dimensions of Hinduism and Buddhism, but an understanding of religious practice on a concrete, daily level.

Choose a public temple or shrine that is small enough to observe closely and that has several visitors 5 or more performing puja in the mornings and evenings. Plan to spend four half-hour sessions, ideally two in the morning and two in the evening, at the site. For the second two sessions, talk with worshippers about the puja — what do they say about the role of the ritual in their daily life?

Do you come to the temple every day? Why do you come to this particular temple? Do you always perform the same puja?

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Or maybe there is something that you have heard about but not yet seen and want to look into. Whatever it is, the Design Your Own is an opportunity to be creative or explore a quirky interest. The project can take an offbeat approach or can be a more conventional look into something that has struck you about Nepal. We encourage you to find some alternative method of presenting your findings—through photo essays, maps, charts, drawings, or demonstrations.

If you find some graphic way to display your research, the written component of your project need only be 2 pages min. If the heart of your project is in a written medium, then your write-up must be pages. For example, if you choose to focus on Nepali poetry, you could examine the writing of several Nepali poets, write poems of your own in the style of these poets, and then write about the tradition of poetry in Nepal. Write-Up Be sure to consider the cultural context of your subject, and its role or function in the lives of Nepalis.

If appropriate, describe the traditions — technical, cultural, etc. Also consider the impacts your subject has on the social environment of which it is a part. If you choose to study Nepali music, for example, you could focus on changes and continuities in particular musical traditions, and the social and cultural role of music in a specific community. In order to complement our lectures, and as a means of fostering discussion and analysis of both lecture material and related issues, we will hold periodic student-led discussion sessions throughout the course of the program.

Though there are many possible topics to discuss, and though we could spend a good deal of time on any one topic, the demands of our schedule will have to limit our discussions somewhat. For each session, we will focus on two topics from the lectures we have heard; two to three students will be responsible for each topic. For each topic, the students should briefly recap the main points of the lecture, highlight any unclear or controversial points, suggest a few topics for discussion, and then open up the session to the rest of the group. The students presenting the topic will then have responsibility for directing or mediating the discussion as needed.