Population health issues relevant to neuroscience in Nepal
Bezruchka, S. (2004). Population health issues relevant to neuroscience in
Nepal. J Neuroscience 1(1): 4-9.
http://www.neuroscienceforum.org.np/
Neuroscience provides understanding of the mechanisms through which the
determinants of population health act. After basic needs are met, a
population with a smaller hierarchy will have better health than one with
a bigger gap. Neuroendocrine aspects of the hypophyseal-pituitary-adrenal
axis in which the hippocampus plays a key inhibitory feedback role are the
mechanisms at work. In Nepal, basic needs, such as food and clean water
are lacking for a substantial portion of the population. Remedying this is
the first priority of the population health doctor. Thereafter, decreasing
the hierarchy is necessary for Nepal to achieve good health.
Neuroscientists can play a critical role by not promoting extensive
clinical interventions, but using their understanding of the mechanisms of
action of population determinants to advocate for social justice.
Key Words: Hierarchy, Hippocampus, Kerala, Population health, Social
justice, Sri Lanka, Structural adjustment
Neuroscience is intimately connected with issues of the health of
populations, whether specific to Nepal or more broadly throughout the
world. In fact, discoveries in neuroscience over the last several decades
have shown that this biomedical subject helps explain the mechanisms
through which the determinants of health of populations act. It has been
observed for several millennia and more often during the last several
centuries and especially for the last several decades, that poor people
have poor health. The ancient Greek and Roman civilizations understood
this and also gave us some of the earliest documented population health
statistics. The Roman data showed life expectancies for Rome around 21-22
years, except for the slaves for whom it was around 17 years. In fact, for
much of civilized life, the average length of life ranged from a high of
about 35 years to a low around of 20. In the Paleolithic, before the
advent of tools, when we lived a forager-hunter lifestyle, and hadn't
domesticated plants and animals, life expectancies have been estimated to
be in the 30 to 50 year range. What is evident, then, is that with the
progress of the development of agriculture, human health declined. This
counter-intuitive finding is not disputed by any scientist who has studied
this aspect of human demographic history. 9, 18
Over the last century, health of some populations has improved and
surpassed that of peoples of the Stone Age, the Paleolithic. However, a
large proportion of humans on the planet still have health statistics
little different from the average over much of human history. In other
words, many Sub-Saharan countries of Africa, such as Sierra Leone, Zambia,
Zim use would emphasize teaching lowtech clinical examinations, extolling
the value of extensive discussions with friends and family of patients
about how to care for them, and fostering minimal use of various
pharmaceutical nostrums. My personal clinical motto is "Don't just do
something, stand there." Meaning that I avoid clinical interventions just
for the sake of doing something -- the old adage of "don't just stand
there, do something," unless they have significant benefit and are not
extravagant.
Another way is to model good primary care of neurological conditions
themselves, not just in teaching others, but in everyday practice.22, 23
That way, you can tell your students that they can treat a patient just as
well as you can or perhaps even better.
Another way is to support the development of primary care facilities
staffed by local mid-level practitioners throughout the country.
But all these methods will have limited effect on improving health in
Nepal. What might really make a difference is to understand the importance
of neuroscience physiologic and pathophysiologic mechanisms, which impact
the determinants of health of populations that depend on the gap or range
of hierarchy. Since neuroscientists are the ones who stand a better chance
to look at how chronic stress in populations affects health, they can
teach this to others, both clinical people and the ordinary public. These
ideas can get into public and private school curricula. I have been doing
this in grades 7 through 10 in Seattle public schools and find great
student interest. You can write articles for the mainstream press, have
discussions on various radio and TV venues. The strength of your expertise
will convey the ideas powerfully to ordinary people** . (** Population
Health Forum's website: http://depts.wwashington.edu/eqhlth)
So the role of neurosciences in Nepal in producing health must be an
activist position. You should enter the political arena to structure
policies that decrease the gap as a population health doctor. You should
recognize your tendency would be to advocate for increasing the economic
gap through promoting the desire for using expensive technology,
procedures and pharmaceuticals that are of little value for improving
population health. Neuroscientists in Nepal could be world leaders in this
aspect of population health. It would not be out of line for a country
within which sits Sagarmatha (Mount Everest), the churning stick of the
ocean of existence.
References
1. Bezruchka S: An Rx for health care in Nepal. Himal 16: 30-33, 2003
2. Bezruchka S: Is globalization dangerous to our health? West J Med 172 :
332-334, 2000
3. Bezruchka S: Is Our Society Making You Sick? Americas health lags
behind that of more egalitarian nations. Newsweek 14, 2001
4. Bezruchka S: Social Ordering in Developing Countries: Does Hierarchy
Have t he Same Effect as in Post-Industrial Nations? A look at Nepal. Ann
N Y Acad Sci 896: 490-2, 1999
5. Bezruchka S: Societal hierarchy and the health Olympics. CMAJ 164 :
1701-3, 2001
6. Bezruchka S: Tourism and the health of local populations. Wilderness
Environ Med 8: 73-74, 1997
7. Carey A: Taking the Risk out of Democracy: Propaganda in the US and
Australia:
Champaign. Illinois: University of Illinois Press, 1997
8. Casinader R: The Kerala Model: Some comparisons with the Sri Lankan
experience. Kerala: The Development Experience . London: G. Parayil, Zed ,
pp 198-211, 2000
9. Cohen MN: Health and the Rise of Civilization. New Haven. Yale
University Press, 1991
10. Corrao MA, Guindon GE, Sharma N, et al (eds): Tobacco Control: Country
Profiles. Atlanta: American Cancer Society, 2000
11. Gunatilleke (ed): Intersectoral Linkages and health development: Case
Studies in India (Kerala State), Jamaica, Norway, Sri Lanka, and Thailand.
Geneva: WHO, 1984
12. Herman ES: The Global Media: the new missionaries of corporate
capitalism. London: Cassell, 1997
13. Jamrozik K, Hobbs MST: Medical care and public health, in Detels R,
McEwen J, Beaglehole R, Tana H (eds): Oxford Textbook of Public Health.
Oxford: Oxford University Press, 2002, pp 215-242
14. Kapur A: Poor but prosperous. Atlantic Monthly (September): 40-45,
1998
15. Kawachi I, Kennedy BP, Wilkinson RG, et al (eds): The Society and
Population Health Reader, Volume I: Income Inequality and Health. New
York: New Press, 1999
16. Kim JY, Irvin A, Millen JV, et al (Eds): Dying for growth: Global
inequality and the health of the poor. Monroe, Maine: Common Courage
Press, 2000
17. Kristenson MK, Orth-Gomr: Attenuated Cortisol Response to a
Standardized Stress Test in Lithuanian Versus Swedish Men: The LiVicordia
Study. Int J Behav Med 5: 17-30, 1998
18. Larsen CS: Biological changes in human populations with agriculture.
Annual Review of Anthropology 24: 185-213, 1995
19. Macinko JA, Shi L, Starfield B: Wage inequality, the health system,
and infant mortality in wealthy industrialized countries, 1970-1996.
Social Science & Medicine 58: 279-292, 2004
20. Macinko JB, Starfield, Shi L: The Contribution of Primary Care Systems
to Health Outcomes within Organization for Economic Cooperation and
Development (OECD) Countries, 1970-1998. Health Serv Res 38: 831-865, 2003
21. Nag M: The Impact of Social and Economic Development on Mortality:
Comparative Study of Kerala and West Bengal, in Halstead SB, Walsh JA,
Warren KS (eds): Good Health at Low Cost. New York: The Rockerfeller
Foundation, 1985, pp 57-77
22. Rai SM, Bezruchka S: District Hospital Based Continuing Education to
improve surgical skills of doctors posted to remote areas of Nepal.
Regional Health Forum 2: 45-49, 1997
23. Rai SM, Thapa BK: District hospital workshops to improve surgical
skills of doctors posted to remote areas. J Nepal Medical Association
35:198 -202, 1997
24. Sapolsky RM: Endocrinology alfresco: psychoendocrine studies of wild
baboons. Recent Progress in Hormone Research 48:437-68, 1993
25. Sapolsky RM: Glucocorticoids and hippocampal atrophy in
neuropsychiatric disorders. Arch Gen Psychiatry 57: 925-35, 2000
26. Sapolsky RM: Poverty's Remains. The Sciences 31: 8-10, 1991
27. Sapolsky RM: Why Zebras Don't Get Ulcers: An Updated Guide to stress,
stress-related diseases and coping. New York: Freeman, 1998
28. Sen A: Inequality Reexamined. Cambridge: Harvard University Press,
1992
29. Shi LB, Starfield B, Kennedy B et al: Income inequality, primary care,
and health indicators. J Fam Pract 48: 275-84, 1999
30. Shi L, Starfield B, Politzer R et al: Primary care, self-rated health,
and reductions in social disparities in health. Health Serv Res 37:
529-50, 2002
31. Shively CA, Clarkson TB: Social status and coronary artery
atherosclerosis in female monkeys. Arteriosclerosis and Thrombosis
14:721-6, 1994
32. Thankappan K: Some health implications of globalization in Kerala,
India. Bull World Health Organ 79: 892-3, 2001
33. UNDP: Human Development Report 2003: Millennium Development Goals: A
compact among nations to end human poverty. New York: Oxford University
Press, 2003
34. Wilkinson RG: Mind the gap: Hierarchies, Health and Human Evolution.
London: Weidenfeld & Nicholson, 2000
35. Wilkinson RG: The Culture of Inequality, in Kawachi I, Kennedy BP and
Wilkinson RG: The Society and Population Health Reader, Volume I: Income
Inequality and Health. New York: New Press, 1999, pp 492 -498
36. Wilkinson RG: Unhealthy Societies: The Afflictions of Inequality.
London: Routledge, 1996
37. World Bank: The East Asian Miracle: Economic Growth and Public
Policy. Oxford University Press, 1993
38. Zachariah KC, Rajan SI: Kerala's Demographic Transition - determinants
and consequences. New Delhi: Sage, 1997
Stephen Bezruchka, MD, MPH Department of Health Services School of Public
Health and Community Medicine University of Washington Box 357660 Seattle,
Washington 98195-3576 USA Email: [log in to unmask]
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