The coexistence of diverse forms of biomedicine and local health traditions makes the Nepali medical landscape unique. Nepali medical pluralism combines traditional systems of medicine, such as Ayurveda, Yoga and Naturopathy, Homeopathy, Unani, and Sowa-Rigpa, and local health traditions, such as home remedies and folk healing with biomedicines, including jadi-butis, plants and food items. However, with recent developments in modern medicine and the formal health care system, people have experienced a loss of local health traditions as well as experiential health.

Loss of experiential health

Many people, especially from urbanising areas of Nepal, feel that they are not as healthy as their parents and grandparents. The logic goes that their (grand) parents used to keep a large number of domestic animals and had plenty of milk/milk products. They used to eat what is now known as organic food, grown with compost manure rather than chemical fertilisers and pesticides. They also used to eat natural fruits and vegetables, had more physical strength and stamina, and would often live healthier and longer if not exposed to fatal diseases.

Indices show that Nepal has made significant progress in the health sector. People’s experiences, however, tell a different story. They give importance to food and nutrition rather than hospitals and medical care. Overcrowding in hospitals is not an indication of a healthy population. This reminds us of McKeown’s thesis.

McKeown’s thesis

The primary reasons for the rise of population in 18th and 19th century Europe, according to Thomas McKeown, a British physician and medical historian, were improvements in food and nutrition rather than medical care. After analysing historical data, McKeown concluded that the decline in infectious disease mortality was the most important factor for population growth. The decline in mortality was due to a significant increase in the food supply, which resulted in improved nutrition, sanitation, and hygiene. He observed that curative medical services had no significant impact on the decline in mortality. McKeown’s thesis is that nutrition and improved living standards, rather than drugs and vaccines, play a larger role in reducing mortality. Though his thesis is not free from criticism, the way he presented his interpretation is highly valued in public health. McKeown's thesis is notable for its emphasis on nutritional, behavioural, and environmental factors, as well as non-medical determinants.

Now, non-medical factors or the social determinants of health are viewed as critical for reducing health disparities and improving overall health and well-being. The importance of food, shelter and clothing cannot be undermined in improving the health of people. Their health depends on what they eat, where they live and grow, what they do for a living, and how their healthcare needs are satisfied.

Recognising the strengths

The formal healthcare system satisfies only a small portion of local healthcare needs. But the local health traditions, home remedies, and folk practices satisfy most of the local healthcare needs. Arthur Kleinman, a Harvard professor, talks about the popular, folk, and professional sector of healthcare. His study in the US and Taiwan found that roughly 70 to 90 percent of all illness episodes were managed within the popular sector.

The popular sector includes a wide range of therapeutic activities, such as special diets, herbs, exercise, rest, baths, massage, and self-medication carried out by families, friends and occupational groups. The folk sector includes healing practices of shamans, mediums, herbalists, bonesetters, and midwives, forming the local health traditions and playing by far the most important role in illness and health maintenance.

A study in India estimated that about 20 percent of all medical care was provided by qualified practitioners, divided half and half between the public and private sectors. The practitioners of traditional medicine provided another 20 percent of medical care. Folk healers and home remedies met the remaining 60 percent. Similarly, a study states that “the health infrastructure treats about 20 percent of the population with facility-based primary care” in Nepal.

Though the situation may have changed since these studies were conducted, a more recent World Bank and WHO report asserts that “half of the world's population lacks access to basic health services.” Indirectly, this indicates that half of the world’s population relies on local health traditions for their healthcare needs. Access to formal healthcare services must be improved, but the importance of local health traditions must not be overlooked.

Rebuilding relationships

The local knowledge of local flora and fauna is the strength of local health traditions. The medicinal plants and food items used in home remedies and folk healing, in many instances, match the philosophy of Ayurveda and other traditional systems of medicine. Local health traditions serve a variety of health needs locally at no or low cost and complement traditional systems of medicine. A vast number of people, men and women, including (grand) mothers, practise local health traditions at the household level and local healers at the community level. There used to be a connection between scholarly traditional medicine and local health traditions.

The classical Ayurveda texts such as Charaka Samhita and Sushruta Samhita emphasise the importance of interacting with the local people (shepherds, goatherds, cowherds, and other forest dwellers) and learning about medicinal plants and their uses from them. However, Ayurveda’s relationship with local communities and healers has weakened over time, resulting in a lose-lose situation.

Indian initiative

Nepal can learn from India’s policy initiative for mainstreaming traditional systems of medicine and revitalising local health traditions. In India, the textual, codified, and systematised traditions of medicine are known as AYUSH and oral, non-codified, and non-systematised traditions are known as local health traditions. AYUSH is an acronym for Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-Rigpa, and Homeopathy and local health tradition refers to the undocumented health knowledge and practices of individuals, households, and communities, including traditional healers. The collocation of AYUSH practitioners in health facilities, the promotion of herbal gardens on the premises of primary health centres and sub-centres, the certification of traditional healers, and the establishment of an institution of folk medicine are notable steps.

Upholding the traditions

Nepal needs to learn to value what it has. Scholarly traditions of medicine should get their due space in the formal healthcare systems and local health traditions should be viewed as a source of strength rather than weakness. It is important to emphasise, improve and advance the positive aspects of local health traditions.

Nepal is currently in a health crisis in which people, on the one hand, lack access to the formal health care system and, on the other, suffer from poor experiential health, owing primarily to the loss of local health traditions. Increased access to formal health care services is critical, but it will not improve people's experiential health. This necessitates a focus on local health traditions, including herbal knowledge and practices, as well as home remedies and folk healing.