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Mar 31, 2018

Learning from National Conference on Climate Change and Health (CC - Health) , Kathmandu

Climate change and its uproar all over the globe is getting louder than ever at every front, be it academic, scientific, or political as well as environmental communities. When it comes to Nepal, we are situated in such a climate sensitive geographic Himalayan region, we are affected with adverse events related with climate change never felt before couple of decades ago. With this noise that is heard and read in everyday newspaper, Ministry of Health and Population (MoHP) and National Health Research Council (NHRC), Nepal organised 2 days conference with a financial as well as technical support from World Health Organisation (WHO) country office Nepal.

Technical Session in progress at the conference (Photo Credit - Anuj Bhattachan)

As anybody else, I am always interested in listening to what chief guest and other distinguished delegates have to say on the subject that directly or indirectly affects people's livelihood on the ground. In the inaugural speech,  Dr. Bhola Ram Shrestha, Chief Curative division, at MoH said that "climate change and its affect on health is currently felt everywhere and particularly, the affect is felt the most in low income countries like Nepal. As a result, there are various negative consequences like reduction in agricultural productivity, increase in infectious diseases (even generation of new microbes). It is reported that 23 % of deaths worldwide are now related with climate change, which is a complex interaction of several environmental factors with increasing negative impact disproportionately affecting health of people living in low income countries. Noteworthy, the progressive increase in ambient temperature results in decreasing productivity of labor and thus affecting local as well as national economics. Next question that arise in this conversation is how to quantify these impacts in human health or in agriculture sectors? Therefore, there is acute need to generate data that measure and track progress and effects, enabling us with enough scientific evidence(s) for policy decision making in the ministry. Instead, if we lose track of what we need to do for future generation in climate change sector, there will be an irreversible cost to human lives. In this respect, our government is committed and working on national adaptation to climate change. Also, the recent Male Declaration will be an important document that guides us in carrying out climate change related research, in designing climate change adaptation plan in our South Asian context. 

The Mr. Tej Raj Bhatt, DG, Department of Water, Sanitation and Sewage (DWSS) said that "looking from climate vulnerability lens  – we are vulnerable to CC – and its consequences on health of the people. He stressed that DWSS is committed in working to tackle CC and there is climate change section for carrying our research  and contribute in formulating adaptation plan under ministry of environment. The WHO representative, Dr. Jos Vandelaer said that CC is not a new issue, whereby many studies have reported that increase in temp, erratic and intense rainfall, more frequent natural disaster/ extreme changes are ongoing phenomena. CC is a biggest threat to health of people and thus bringing economic change mainly through food insecurity. Undoubtedly, Nepal is the most vulnerable  as a country in terms of CC - Health.  DFID grant is also working on disease surveillance looking into climate sensitive indicators. Therefore, there is an expectation from WHO,  what is next step? and way forward to mitigate climate change and its effects on health in Nepal. 

Dr Shushil Pyakurel, Chief Specialist, MoHP illuminated all of us with his decades of public health experiences. He said that drying of water sources, a common observation throughout far west, has led to increasing trend of migration. The key reason is the increasing deforestation, which has affected farming and thus local economics. Another grave concern is the increasing trend in morbidity, mortality, disability related with vector borne diseases. He said, therefore, there is a need to explore and enforce strict rules regulation that bind transportation sector and industries (brick / cement). Also, there is increasing infrastructure development work, this also needs regulation so there is no negative environmental consequences. The is also need for inter country collaboration. 

Ms. Padma Kumari Aryal, Honorable State Minister, MoHP said in her inaugural speech that the climate change and its effect on health is government’s high priority and expect result oriented outcome from this conference. The is also a need for national as well as international collaboration and effort to jointly tackle CC – Health. Minister also stressed that there is an increasing reports of disasters (flooding/ landslide/glacier river), which are affecting directly the livelihood of communities. This is therefore a sensitive subject matter and only policy is not enough,  what we need is its real implementation with close coordination/collaboration with local government and communities, while we can’t neglect international support and collaboration. 

First day

Technical Session I
  • Climate change in Nepal: Observed trends and future scenarios
  • Overview of climate resilient health system
  • Overview of health impacts of climate change in Nepal
 Technical Session II
  • Impacts of climate change on WASH
  • Effectiveness of HH and community level WASH interventions in reducing health vulnerability to climate in Dolakha
  • Effects of climate change on diarrhoeal diseases at national and sub-national level in Nepal

Second day

Technical Session III
  • Gender perspectives on the health impacts of environmental and climate change in Nepal
  • Climate change policy and financing in Nepal
  • Health Sector response to climate change in Nepal 

31 March 2018

Mar 27, 2018

Back to Nepal from Rwanda - Post 13 / 24 (Jan 2018)

Back to home after one glorious year in Rwanda, although I was supposed to be there for at least 2 years. I visited this beautiful country of 1000 hills to  explore an idea of peace, social justice and innovative global health projects. In addition, I wanted to peep into Rwandan perspective on poverty, structural violence, equity and equality, and social inclusion. There I had great opportunities to meet public health leaders and fighters like Prof. Paul Farmer (Harvard University), Prof. Agnes (Former Health Minister, Rwanda Government/current VC of UGHE), Dr. Alex Coutinho (Executive Director, Partners in Health, Rwanda), Dr. Peter Drobac (FormerExecutive Director, Partners in Health, Rwanda / Current CEO, Skoll Foundation, UK) and many beautiful minds exploring their global health aspirations in Rwanda, where Health System Strengthening (HSS) activities are being implemented based on scientific evidences  generated by local health research bodies. On this background, there are few observations that stand out and imprinted in memory from brief but important encounter with friendly Rwandan health professionals working both in government and non - governmental sectors:

National Leadership: The present day understanding of "health" encompasses "total health", which means health of an individual is influenced by all possible factors from family structure, social practices, culture, climate, infrastructure, housing, economic policies, peer circle, advertisement, environment, law and enforcement and so on. Simply, it means "health" is in overall a developmental as well as social agenda. Testimony to this statement is the global movement of Sustainable Developmental Goals (SDG). Therefore, ill health and diseases are byproduct of socio - economic or behavioural or to go further negative consequences of political instabilities with resulting social unrest, poverty, insecurities and uncertainty. All these consequences that can be seen and felt in places with political unrest can lead to public health disasters (eg cholera outbreak in Sudan), which leads to mounting morbidities and mortalities from water borne illnesses to malnutrition affecting the most vulnerable people in the communities. In order to tackle and solve the root causes of these socioeconomic consequences, the only answer is strong leadership bringing good governance and their accountability to the people. In this respect, I have come to conclusion from 1 year of stay that Rwanda is being led by dedicated, committed and visionary leadership at social and political front. Mr. Paul Kagame, President of this beautiful country of 1000 hills has been instrumental in charting "knowledge based" economic and developmental path. Also, it is very important to note that Rwanda is considered one such East African country escaping poverty and conflict stricken early 1990s to rising economic success story at present. All these success can be attributed to stable government and good governance in all sectors including health care delivery. One such example is the ban of plastic since 10 years. Now, Rwanda is considered the cleanest country in Africa.

Leadership within health: In Rwanda, I also observed that health ministry is led by dedicated public health physicians / clinicians both at political front as well as administrative appointments. The principle idea that governs these appointments is that "right person, right job" which means that managing people's health is the primary role of health professionals and not that of "traditional " beaureucrates or administrators like it used to be / is being practiced in Nepal or India called "Babucracy". It is said that Rwandan ministry of health was streamlined through rigorous health system strengthening initiatives during Dr. Agnes for 2 terms as health minister. Dr. Agnes is also a paediatrician and an academician of high status championing the need for strong health informatics system for Data Derived Decision (3D) Making as well as "in house" research capacity to guide national health policies. It is not exaggeration in saying that it is Dr. Agnes's contribution in injecting the practice of evidence based policy decisions based on data generated from operational researches carried throughout Rwanda.

Focused but integrated approach to health care delivery: In the global health arena of implementation science, I would definitely say that the kind of work that is being done in close collaboration between Rwanda Ministry of Health and Partners in Health (PIH), Rwanda is an example that is commendable. This collaboration is such an example in the field of public health that change your perspective on how external developmental partners (EDP) should approach in dealing with public health, agriculture or climate or forestry issues. The simple goal that PIH is working hard to achieve is health system strengthening such that staff, stuff, space and system issues are addressed so the health centre can function in a sustained way. For this, I worked in Rwinkwavu hospital and 4 S's are taken care pretty well providing local people quality health care services. In addition, another remarkable achievement that Rwanda Ministry of Health is able to achieve is > 80 % coverage in health insurance (muetuelles) as a part of achieving universal health coverage (UHC).

Umuganda (or volunteering): Sometime, it is said common sense is uncommon. This means, we tend to waste our time and energy on either complex or petty things, while forgetting the basics or fundamentals. Simply saying, we need to exercise our common sense routinely and also focus on fundamentals and the culture of team work. In Rwanda, people from all sectors of lives come together during Umugunda day for social volunteering every month. In this event, all people join hand for social rebuilding from cleaning roads, parks to building schools. Since this is a monthly activities, this is also a social movement led by local as well as national leaders. Also, there are many other interesting events carried out during this days. Another event that I liked is the "car free day", when you do not see any vehicles, bringing family and children in the open and bringing people together closer in social sphere.

Now in Nepal, we are hoping for a stable government with good governance, transparency and accountability as its core guiding principle. Also, we have to say that we are in the best of time or (5% probability) worst of time depends on us. I am hopeful, we are in the best moment of our history  to turn current challenges into opportunities to rebuild our country. In this respect, we have many lessons to learn from Rwanda in its struggle to come out of genocide horror to peace and prosperity in short period of time. Therefore, there are plenty of opportunities in front of us to capitalise for the well being of all Nepalese people - the choice is up to us.

In my next post(s) - I will try to explore the idea of peace, social justice, poverty, structural violence, equity and equality, social exclusion and innovative global health projects.

March 26, 2018
Dipayal, Doti

Sep 24, 2017

Apr 16, 2017

Review and update: Worm hole, Passion and Future (Post 12/24)

I have not entered monthly blog posts since December 2016. It was tough time for me to settle leaving Seoul in search of new but meaningful jobs. Finally, I am now all the way here in Kigali, a beautiful and clean capital of Rwanda via Karachi, Pakistan, where temperature reached the highest up to 50 degree centigrade !! It was a long trip with layover for few weeks in Sacramento, California, where my youngest sister and her family are working hard to fulfil their American dream. In this difficult yet transient transition testing our resilience - I left my infant son, who was just exploring the world, with his mother for few months in Sacramento. That was too hard for me as a father and husband to be away from them for almost 6 months. Even now I have been away from them. Our temporary "post - IVI situation" demanded that I take risky and short term consultant job with Polio Eradication Initiative (PEI) at WHO, Pakistan. After months of hard work in Sindh province supporting the provincial polio surveillance team, I was lucky to be working with PIH, Rwanda office as Monitoring and Evaluation (M & E) specialist. The other hat that I also wear here in Rwanda is as "a master student pursuing 2 years course in Global Health Delivery with equity and social justice as its core principle" in University of Global Health and Equity (UGHE).

Here in this post, I would like to write what I observed, did and learnt post IVI departure. One of the reason that I left Seoul was that I was worried that if I continue the same kind of job in repetition for next couple of years (having served IVI for 5 years) lacking creativity, innovation and lively work atmosphere, I would be like a "robot" disconnected from the everyday reality. Somewhere, we can imagine a hyper city like Seoul as a "worm hole", which can literally transform or influence your behaviour in such a way that we sometime fail to realise our roots and sometime fail to understand what you want and dampens your "child like" passion. There is a danger in this, while I am not talking in terms of space and time travel but literal or else at psychological horizon. For me, I am a Nepali health professional, who landed in IVI with dream to excel in research capability, so I would be able to translate those knowledge, skills and tools into our context. Our context is very different to hyper cities like Seoul. So, the whole 5 years of IVI experience was like a travel through "worm hole" of differential treatment, which means that when you travel through "worm hole" of space - time reality then, you are bound to get influence of "radiation, magnetic energies". For me likewise, the influences of differential treatment of such magnetic nature was (may be) not by design but by default. In this context, we (privileged ones) may talk about poor people and sympathise their suffering of those living with poverty. In contrast, we sometime fail or forget what needs to be done is at the community level and that is where we will be able to serve people the best and better. Sometime, we live in virtual reality or in "worm hole" influence and we may write poems about others suffering by passing your everyday chores in a palace like shiny buildings, without a faintest idea of what suffering means to be living with poverty. Sometime, people criticise such tendencies as "crocodile's tear" in others suffering. I may also criticise in the same way. Somewhere someone great said that "it is only through dirtying your hands helping people in need and being with them in their company that we can be more useful to the communities in need." So, now I realise if anyone of you is thinking hard about your career and of course work life balance, then we need to definitely ask ourselves the following questions:

  1. What am I deeply passionate about?
  2. What taps my talent and passion?
  3. What meets a significant need in your work area?

Somehow I now realise that I was struggling to find out the professional niche suitable for myself. Enough has been written in my previous post and in the previous paragraph - the reason why I could not or able to fully achieve the goals which I was determined while at IVI. This is partly me and equally organisational culture and "inside" practices, which were subtle in nature. Somewhere in sarcasm, I have written in similar thought process in Jan 2016 post "After all - it is the truest analysis and understanding of poverty that will help us deal with "real" public health challenges that we face and have to solve in coming years to come. Here, I also urge all those national and international staffs, who perceive and claim to work for the upliftment of people in the developing countries, have to understand poverty and visit those places to understand in real sense "what is suffering, as a result of poverty,  means?", otherwise we need to question the very work ethics of developmental works in the name of poverty !! So I would ask you - "have you seen very closely what is poverty? Have you seen children die because the nearest health post is 2 hours walk uphill? Have you dealt with a situation that family does not want to vaccinate their child because they do not know or have an idea what vaccine is and for?"

In search of my passion and channeling professional competencies for right cause, my brief experience in Karachi, the provincial headquarter of Sindh province of Pakistan was meaningful working in extreme heat and security challenges. You can read the details of thoughts in August 2016 post titled "From Karachi: the final battle against Polio" and also June 2016 post titled "From the field: Using tweeter feeds to share polio eradication activities from the field" Persistence and hard work pays and this is an universal principle which all of us believe. This happened when I was in Karachi, when I was offered a seat at UGHE to pursue master in global health delivery, which is related with my passion in evolution. Along with UGHE came an opportunity of profound significance, this was a chance to serve Partners in Health (PIH), Rwanda, which was an organisation cofounded by Prof. Paul Farmer, Harvard University and Dr. Jim Kim, World Bank President.

15 April, 2017

Nov 7, 2016

Relationship between Population Health and Development Post 11/24

The whole period of 19th century was characterized by colonialization of Latin American, African, and Asian subcontinents, while the early 20th century saw the epochal changes through two world wars. These wars led to the shift of military might from Europe to the United States of America. As a result, Europe had to struggle with the politico – economic restructuring with change in power dynamics. The United States of America (USA) was also pulled into this European affair. This engagement in a decisive role to end the war led the USA undoubtedly becoming a new superpower in global political leadership and principal advocate for neoliberalism in global affairs. This essay explains the dynamic relationship between population health and development with some examples of its advantage and disadvantage.

First, let us explore and try to understand the advantage in considering population health and development together. Although there was continuous shift in understanding the relationship between development and health in academia and developmental sector, all the discourses were heavily influenced by ideological divide that exist between socialism and capitalism. In the midst of these changes, the movement of comprehensive Primary Health Care (CPHC) lead to the Alma Ata Declaration by the World Health Assembly (WHA) in 1978. This CPHC movement brought an overwhelming shift in the thought process dealing with health of the community and its link with socio – economic development. One of the key principle that was enshrined in the declaration was that health is basic human right (Basilico, Weigel, Motgi, Jacob, & Keshavjee, 2013). The Alma Ata declaration also recognized that the investment in health strengthen the local health infrastructure and improve access to essential health care services with community participation. This meant that health was treated as an end, while socio – economic development was the means to address the challenge of poverty and disease in the community through community participation. One of the legacies of such though process that started with CPHV movement today would be Millennium Developmental Goals (MDG) which have now streamlined as sustainable developmental goals (SDG).

Although the CPHC movement brought enthusiasm in health and developmental sector, it was short lived with the rising influence of neoliberalism, which considered health as commodity to be bought and paid in contrast to health being basic human right. However, on positive side, the world witnessed the birth of numerous international institutions like the United Nations (UN), the World Bank (WB), the International Monetary Fund (IMF), the World Health Organization (WHO), UNICEF (for children’s safety and health) and several rich governments funded overseas development agencies like USAID. Majority of these organizations were harbinger of colonial legacies like the Pan American Health Organization (PAHO). All of these new organizations were also headquartered in Europe and few in the USA became the powerhouse for providing policy direction on the subject of development and health across the world. With complex bureaucratic processes (Kleinman, 2010) and its ramifications within the organizations, the discourse on population health and socio economic development in low income countries were influenced by rapid changes in the socio political and economic landscape of the world. There was also parallel rise in independence movements all across Africa and Asia. All previous colonial states like India were exercising their self-determination rights for freedom and sovereignty. However, there political and economic situation was very fragile in post-colonial period. (Basilico et al., 2013) Sadly, all key international developmental organizations like World Bank, IMF, UNICEF and other bilateral donors were dictated favoring neoliberal ideas and principles against the basic needs of the population in low income countries. All these organizations also used this international platform as means to exercise their political and economic interests. This meant that all those countries in Africa or Asia, who received huge development loans from WB and IMF, were heavily influenced in the framing of their national policy and its implementation. All of these practices were clearly against the spirit of Alma Ata Declaration. The outcome of these neo liberal ideas and principles dictated the development and health related policies, resulting into failure or poor performance of health care delivery in targeted countries in the long run. (Basilico et al., 2013)

In summary, the start of debate in considering the role of population health in the socio economic development brought serious discourse among world leaders, policy makers, planners, and funders. As a result of this discourse, there is a serious academic and policy interest in the relationship of poverty and diseases and socio economic development in low-income countries. Also, we need to acknowledge that there is always the push and pull between different socio – political ideologies, which play important role in dictating the course of population health in a community through their influence on the policies and its implementation.


Basilico, M., Weigel, J., Motgi, A., Jacob, B., & Keshavjee, S. (2013). Health for All? Competing Theories and Geopolitics. In Reimagining Global Health: An Introduction (pp. 74–110).
Kleinman, A. (2010). Four social theories for global health. Lancet, 375(9725), 1518–1519.

Anuj in Himalayas

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