Urbanisation in a Low-Income Country: A Case Study of Health System Challenges in Kathmandu

This article addresses the challenges that the health system in Kathmandu faces as a result of rapid urbanisation, and follows with some recommendations for improving the resilience of the Kathmandu health system. Throughout this essay, “Kathmandu” refers to the Kathmandu Valley, including the municipalities of Kathmandu, Lalitpur, Bhaktapur, Kirtipur and Madhyapur Thimi.




There are good reasons why people move from rural areas to the city. In Nepal, rural-born individuals moving to urban areas have a 28% higher chance (increasing from 38% to 66%) of obtaining better occupations than their fathers. (World Bank, 2016). Between 2011 and 2021, Nepal’s urban population increased by over 300% (National Statistics Office, 2022), reflecting a global urbanisation trend of people moving from rural to urban areas. Indeed, Nepal’s urbanisation is the fastest in South Asia (World Bank, 2016). The population density of Kathmandu is 5,169 people per km2, in stark contrast to rural districts such as Manang that have a population density of just 3 people per km2 (National Statistics Office, 2022). These disparities alone lead to numerous resourcing and infrastructure challenges, whilst the pace of urbanisation in Kathmandu is straining the city’s infrastructure, which isn’t able to adapt in such a short period of time. Additionally, those who move from rural to urban areas are rarely, if ever, seen as a distinct population group in their own right, with their own needs and challenges (Khadka et al, 2023). Urbanisation itself has been recognised as a determinant of health (Vlahov, 2007), and the rapid pace urbanisation results in a widening in health and wellbeing inequities (Wamukoya, 2020).

Hospitals and health services


This rapid urbanisation, the impact of Covid, and a recent deal with the UK government (Aryal and Pollitt, 2022) that allows healthcare professionals from Nepal to be recruited to work in the NHS contribute to a system that struggles to cope with demand. In 2016, Nepal had a density of seven health service providers per 10,000 people; the WHO-defined critical threshold is 23 per 10,000 (Pandey, 2016). During the Covid-19 crisis, hospitals in Kathmandu were overwhelmed, and despite having adequate supplies of vaccine, were not able to get vaccines to the people that needed them. Reports were of mismanagement, overcrowding, and long queues whilst the hospital ran out of vaccination cards (Ojha, 2021). Medical supplies are not necessarily the issue in Kathmandu – it is instead the capacity of the system to adequately serve the population. As of 2022, Nepal has on average, 2.8 nurses and midwives for every 10,000 people, compared with 13 in the UK (Haakenstad et al, 2022), and whilst plans exist to build further healthcare facilities with much greater capacity, a shortage of healthcare workers remains a significant challenge (Dhakal, 2023).


Increased pollution and health impacts


An increasingly dense population in a city such as Kathmandu causes increased pollution, and a core challenge is the management of municipal solid waste (MSW). Collection services are rare, and only two municipalities in Kathmandu dispose of waste in sanitary landfills. In most instances, waste is disposed of at riverbanks, dumps, open pits, or simply burned (World Bank, 2016). The release of untreated wastewater into water bodies and the mismanagement of solid waste have polluted Kathmandu river systems, and compounding the problem, Kathmandu faces a scarcity of drinking water: access to piped water over the past decade has actually decreased (Muzzini and Aparicio, 2013).


Nepal has the highest age-adjusted death rate globally for chronic lung disease, 182.5 per 100,000 people (Carson-Chahhoud, 2019). Kathmandu in particular, faces a greater challenge due to its topography – an enclosed valley surrounded by mountains – which traps airborne particulate pollution. Levels of small particulate matter in the Kathmandu Valley can exceed 500 micrograms per cubic metre (Gurung and Bell, 2012), 20 times the World Health Organisation’s safe upper limit. In March 2023, Kathmandu registered the world’s highest Air Quality Index at 181, predominantly due to vehicle emissions and waste burning (Himalayan News Service, 2023). Open burning of MSW is a significant source of air pollution: an estimated 7,400 tons of MSW was burned in just three municipalities near Kathmandu in 2016 (Das et al., 2018). 

Figure 1: ‘Rubbish’, Kirtipur. Credit: Ammalal Sejuwal, Khila Karki, and Vishan Thami. (Khadka et al, 2023)


Of 1.2 million vehicles in Nepal, about 34.25% are primarily in the Kathmandu Valley, and are responsible for around 89% of PM10 emissions (Dhital, 2017). While Nepal has vehicle emission standards, the limited number of Vehicular Emission Testing (VET) centres, all situated within Kathmandu Valley, leads to little testing outside this area. There is even a thriving market in fake test stickers to suggest the vehicle is compliant. A lack of an efficient public transport system also means that many Kathmandu residents are forced to use private vehicles to get around (Saud and Paudel, 2018). This increased traffic has also resulted in an increase in road traffic accidents and traumatic injuries or death (Huang et al, 2017).


Rise of NCDs


Urbanisation increases the major behavioural risk factors for NCDs, namely physical inactivity, low fruit and vegetable consumption, and tobacco and alcohol use (Oli et al, 2013). The prevalence of NCDs such as hypertension and diabetes is increasing across Nepal (Mishra, 2015), with a higher prevalence of conditions such as diabetes in Kathmandu compared to rural areas (Rimal and Panza, 2013). In urban areas, NCDs were the leading cause of mortality, exceeding the rates of death from accidents, suicides, and criminal incidents, according to the 2021 census in Nepal (CHORUS, 2023). Across Nepal, NCDs are estimated to account for 66% of all deaths (WHO, 2016) and this rise in NCDs causes a corresponding increase in demand upon an already burdened healthcare system, particularly challenging because Nepal’s healthcare system isn’t accustomed to treating NCDs, having been traditionally focused primarily on infectious diseases (Rai et al, 2001).




In 2015, Nepal adopted a new constitution, transitioning from a unitary form of governance to a secular federal democratic republic: power and resources were devolved from the central government to seven newly created provinces and 753 municipalities, which also resulted in significant reforms of the health system. Federalisation can lead to both challenges and opportunities, as local governments may be better positioned to understand and meet the specific needs of their communities, but they may also face difficulties due to limited resources, lack of experience, or coordination challenges with other levels of government (Belbase, no date). Since the federalisation of Nepal’s health system, its performance has been improving, though significant work remains (Chen et al, 2023). More health workers are available locally than previously, with less absenteeism, however there are challenges around skills and training. Challenges also exist where local policymakers are less experienced in effective budgeting, compared to their central government counterparts (Wasti et al, 2023). One example of federalisation success is Pokhara, where local government enabled urban primary healthcare clinics to identify vulnerable groups and individuals in their catchment areas and identify ways of improving their access to services (Elsey, 2019).




In order for the health system in Kathmandu to adequately address the a challenges of rapid urbanisation, a number of strategies should be considered:


1 – System resourcing: 

The establishing of baseline requirements for municipalities, such as specific provider-to-patient ratios and the availability of essential resources would guide local healthcare providers in aligning their healthcare systems with national objectives, while still allowing them the flexibility to prioritise local needs. Improved training, recruitment and retention of healthcare workers at the local level is also necessary to reach and maintain an appropriate level of resilience in the healthcare system.


2 – Prevention and treatment of NCDs.

The prevalence of NCDs in the population of Kathmandu is increasing. Education on the causes, harm and impact of NCDs, steps that people can take to prevent them, alongside greater education on treatment, will ease the pressure on the health system.


3 – Addressing social determinants of health:

Addressing air pollution and MSW management, as well as prioritising the supply of clean drinking water is critical in order to reduce the prevalence of NCDs and reduce the burden on the health system. Effective waste segregation and collection would reduce the amount of MSW that is openly burned; bio-gasification of commercial waste and composting of household waste combined with recycling, falling back on well-managed landfill where necessary, would be cost-effective and reduce air pollution significantly (Singh et al, 2014 and Dangi et al, 2009). Measures to improve traffic management, including a transition to electric vehicles, will improve air quality in the Kathmandu Valley and reduce the harmful effects of air pollution.


Kathmandu’s health system faces many challenges arising from rapid urbanisation, including strained infrastructure, increasing pollution, and increased prevalence of NCDs. Addressing these issues requires an approach that includes improving healthcare resourcing, enhancing education and prevention strategies for NCDs, and tackling social and environmental determinants of health. Building on federalisation, improving local governance and providing tailored local healthcare strategies is crucial in adapting to the demands of an increasingly urbanised population. 




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Health Promotion and HIV/AIDS pandemics the UK and South Africa

(Originally submitted as coursework towards my Masters in Global Public Health at the University of Manchester)

It is quite clear that the UK and South Africa are in very different situations with respect to the HIV/AIDS epidemic. This is due in large part to behavioural changes in injecting drug users (IDUs) (Stimson, 1995) and adoption of safe sex practices including increased condom use amongst gay men, in the UK (Fitzpatrick et al, 2013).


As this chart shows, the disparity between the two countries is huge. In 2017, there were 7,149 new cases of HIV in the UK, but 276,496 in South Africa. 

Chart 1. New cases of HIV in the UK and South Africa, 1990 to 2017. Roser and Ritchie, 2019.

Chart 1. New cases of HIV in the UK and South Africa, 1990 to 2017. Roser and Ritchie, 2019.


Whilst it is clear that new cases in South Africa are falling, prevalence of HIV/AIDS continues to increase as shown in chart 2:

Chart 2. Prevalence, new cases and deaths from HIV/AIDS in South Africa, 1990 to 2017. Roser and Ritchie, 2019.

Chart 2. Prevalence, new cases and deaths from HIV/AIDS in South Africa, 1990 to 2017. Roser and Ritchie, 2019.


The decreasing number of new infections in South Africa is due in large part to increased condom use and anti-retroviral treatment (ART) ((Vandormael et al, 2019), alongside higher engagement by women in the healthcare system – women who are more likely than men to request tests for HIV, request and access ART and therefore become non-infectious for HIV (Birdthistle et al, 2019). 


However, ART is expensive. Behaviour change is more difficult, but has a much greater ROI (Return On Investment). Due to the UK’s early approach of addressing behaviour change in high-risk groups, prevalence of HIV/AIDS has remained low, which, combined with increased safe sex and drug use practices, helps to keep incidence rates low (Stimson, 1995). Thus, the UK does not need to rely on large-scale ART interventions like South Africa, which is reflected in the costs each country must bear as shown in chart 3.

Chart 3. HIV expenditure on prevention and treatment, 2006 to 2014. Roser and Ritchie, 2019.

Chart 3. HIV expenditure on prevention and treatment, 2006 to 2014. Roser and Ritchie, 2019.


In 2009, South Africa spent $2.33billion on HIV prevention and treatment, whilst the UK spent $80.3million. It is unfortunately true that whilst prevalence is so high, ART is necessary to prevent significant increases in incidence rates, and increased cost-effectiveness may indeed be achieved by oral pre-exposure prophylaxis (PrEP) – the provision of ART treatments to individuals in high-risk contexts (Alistar et al, 2014).


Whilst in South Africa, increased ART provision (and spending), including to those high-risk groups not (yet) infected with HIV, is necessary for the promotion of health, in the UK the story is somewhat different. The low prevalence of the disease means that safe sex practices – the continued emphasis on condom use – and expansion of access to HIV testing, alongside continuation of ART for people living with HIV/AIDS and the use of PrEP for those with an HIV-positive partner, could result in the near-elimination of HIV transmission (Brown et al, 2018).


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Alistar, S.S., Grant, P.M. and Bendavid, E., 2014. Comparative effectiveness and cost-effectiveness of antiretroviral therapy and pre-exposure prophylaxis for HIV prevention in South Africa. BMC medicine, 12(1), pp.1-11.


Birdthistle, I., Tanton, C., Tomita, A., de Graaf, K., Schaffnit, S.B., Tanser, F. and Slaymaker, E., 2019. Recent levels and trends in HIV incidence rates among adolescent girls and young women in ten high-prevalence African countries: a systematic review and meta-analysis. The Lancet Global Health, 7(11), pp.e1521-e1540.


Brown, A.E., Nash, S., Connor, N., Kirwan, P.D., Ogaz, D., Croxford, S., De Angelis, D. and Delpech, V.C., 2018. Towards elimination of HIV transmission, AIDS and HIV‐related deaths in the UK. HIV medicine, 19(8), pp.505-512.


Fitzpatrick, R., McLean, J., Boulton, M., Hart, G. and Dawson, J., 2013. Variation in sexual behaviour in gay men. In AIDS: individual, cultural and policy dimensions (pp. 129-140). Routledge.


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Stimson, G.V., 1995. AIDS and injecting drug use in the United Kingdom, 1987–1993: the policy response and the prevention of the epidemic. Social science & medicine, 41(5), pp.699-716.


Vandormael, A., Akullian, A., Siedner, M., de Oliveira, T., Bärnighausen, T. and Tanser, F., 2019. Declines in HIV incidence among men and women in a South African population-based cohort. Nature communications, 10(1), pp.1-10.


Health System Service Delivery in Mexico and the Oportunidades programme

(Originally submitted as coursework towards my Masters in Global Public Health at the University of Manchester)

This discussion focuses on strengthening health system service delivery and accessibility in Mexico, via the “Oportunidades” programme. The Oportunidades programme is a useful one to explore, firstly because its horizontal approach “has led to increased health service utilization” (Blas et al p.155, 2011) and improved school attendance and nutrition of children across Mexico. Secondly, it has wider applications, as over 50 countries have since replicated the Oportunidades model (Lamanna, 2014). 


Oportunidades has also been known as “Progresa” and “Prospera”, but for the purpose of this discussion, “Oportunidades” will be used throughout.




Mexico is a Lower and Middle-Income Country (LAMIC) with high degrees of social inequality. It encapsulates many of the challenges experienced by countries of all income levels (Frenk, 2006). Poor children in Mexico are more exposed to health risks and hazards than their wealthier counterparts and have less resistance to disease due to undernutrition; reduced access to healthcare further compounds this inequity (Victora et al, 2003). A commitment to Universal Healthcare (UHC) is embedded within the constitution of Mexico, and was achieved in 2012 via a national health insurance programme called Seguro Popular (Knaul et al, 2012), alongside universal education, shelter and social security (Lárraga, 2016). 


As such, Mexico is an excellent candidate for research into strengthening health systems, particularly through a Social Determinants of Health (SDH) lens. Under the direction of Julio Frenk, Health Minister 2000-2006, SDH and evidence-based approaches were used to develop policies which focused on equity and quality (Lancet, 2004). 


The health system in Mexico is a hybrid model of publicly and privately financed and delivered healthcare and is segmented via three categories: salaried and retired citizens, self-employed or unemployed workers, and those with the ability to pay (Frenk and Gomez-Dantes, 2016). 


Health System Service Delivery Improvement


Founded in 1997, Oportunidades is a conditional cash transfer (CCT) programme, funded through general taxation. Unlike vertical, selective interventions, Oportunidades takes a horizontal approach. This reflects the Alma-Ata statement that realising ‘Health For All’, “requires the action of many other social and economic sectors in addition to the health sector” (WHO, 1978, I). It is intended to lift families out of cycles of poverty through combined healthcare, nutrition and education approaches, which aligns with the first five Sustainable Development Goals (SDGs) set in 2015 by the United Nations General Assembly, of No Poverty, Zero Hunger, Good Health and Well-being, Quality Education and Gender Equality.


The programme is centrally administered and initially covered 300,000 families across 12 states with a budget of 58.8 million USD (Levy, 2006). By 2006, the programme covered 5 million families across 32 states (Bautista Arredondo et al, 2008). The programme now covers over 6.4 million families, alongside training programmes to boost employment, and programmes to support the elderly (Sedesol, 2012). 


Conditional payments are made directly from the government to the primary caregiver (usually the mother) of eligible children if they meet requirements, such as school attendance, registering with health clinics, accepting preventative healthcare, attending prenatal and postnatal clinics, and visiting nutrition clinics (Gertler, 2000). The money goes into beneficiaries’ banks accounts or onto prepaid debit cards and consists of contributions for nutrition, health and education, alongside food supplements. This incentivises the uptake of health system services while giving families autonomy over how they spend payments.


Crucially, education is integrated into Oportunidades – the strong universal correlation between education and health outcomes is well-established (Holmes and Zajacova, 2014). The programme further demonstrates its SDH credentials and alignment with the goal of Gender Equality, by providing larger incentives for girls to remain in school (Darney et al, 2014). Girls’ education is closely linked to health outcomes; women with higher levels of education have fewer children (Darney et al, 2014), experience fewer childbirth complications because they are more likely to seek medical assistance (Mainuddin et al, 2015), and have greater employment opportunities which help break the intergenerational cycle for families in poverty. Over medium and longer terms, this reduces the burden on health system service delivery. 


Operational and strategic strengths


One of the programme’s strengths is that two of its key functions facilitate a robust evaluation and improvement feedback loop. Firstly, the well-defined target populations and sequential rollout aids in assessing effectiveness and provides researchers with a Randomised Control Trial (RCT) model (Ambroz and Shotland, 2013) which can compare treatment group families with control group families in locations not yet covered by Oportunidades. Secondly, information collected before payments begin is compared with later results, to establish longitudinal data about the intervention effectiveness (Skoufias, 2005). This has allowed service delivery improvements to be evidence-informed and targeted. 


For example, continuous evaluation and improvement has enabled controlled scaling of the programme. Initially, only families that fell below an “extreme poverty” line in rural areas with schools and healthcare facilities within five kilometres were targeted (Ordóñez-Barba, 2019). Using evidence-based decisions, the criteria have since been revised to include urban families above the extreme poverty line (Lárraga, 2016).


Another strength is that the programme’s Operational Monitoring Model (MSO) combines national oversight with empowered, autonomous local delivery, which enables rapid response to feedback and systemic changes to service delivery. In 2010, mobile devices were introduced to carry out the ENCASEH (Socio-Economic and Demographic Characteristics of Households) eligibility survey. This increased the pace of eligibility interviews, and allowed staff to inform beneficiaries of their eligibility immediately. However, after staff reported negative reactions to delivering news of ineligibility, including having mobile devices destroyed or stolen and individuals refusing to let them leave, this was quickly changed to ensure that families were not informed until staff had left (Lárraga, 2016).


Through the MSO, an Operational Monitoring Report is produced every two months, and references 41 key performance indicators organised around themes of “i) enrollment of families; ii) continuity of beneficiaries in the roster; iii) education; iv) health; v) nutrition; vi) certification of co-responsibilities; and vii) payment of cash benefits” (Lárraga, 2016). The short reporting cycle with accurate indicators of performance has allowed for rapid evaluation of programme changes and early identification of issues or trends. 


Although the programme strategy is defined nationally, it is coordinated through 32 state offices. Within each state, local organisations are coordinated within zones, and component “microzones” serve local families who are visited regularly by staff. This presence on the ground has facilitated communication with beneficiaries even in remote areas, aiding early problem detection and improving engagement (WHO, 2014).


By making direct payments to families, Oportunidades reduces the potential for corruption and improves financial efficiency. For every $100 allocated to the program, $8.20 is absorbed by administrative costs, compared with equivalent programs such as LICONSA and TORTIVALES where $40 and $14 are absorbed respectively (Coady, 2000). Building on that strength, payments are made to the mother “to guarantee that the spending of these resources would be directed toward buying food for the most vulnerable members” (Skoufias, 2005, p88), thus maximising the return on investment in service delivery.


Another strength of the programme, and one reason it has survived changes of government, is its transparency and lack of political alignment. In election years, there has been little or no mass enrollment, to avoid any suggestion that the incumbent government is “buying” votes of beneficiaries. In 2003, workshops and marketing campaigns adopted the slogan “In Oportunidades we all do our share”, to embed a sense of collective ownership and responsibility for the programme. There is therefore little political profit to be gained from a new government changing the scope of Oportunidades, or halting it altogether.


Success of UHC requires health-care service delivery to be managed efficiently (Sumriddetchkajorn et al, 2019). Financially, Oportunidades has proven to be efficient and stable at scale. Whilst the coverage and the budget of the programme has increased from 0.3million to 6.4million families from 1997 to 2017, the share of the federal expenditure never exceeded 2.3 percent (Ordóñez-Barba and Silva-Hernández, 2019). 


Impact on service delivery and access


In respect to service delivery, the impact of Oportunidades is striking. Access to healthcare services has increased: more than 93 percent of beneficiaries in the programme have access to regular medical care, including preventative medicine and treatment (ASF, 2016, in Ordóñez-Barba & Silva-Hernández, 2019), compared to the average of 51.5% across the population (Gutiérrez et al, 2014). 


Access to prenatal and postnatal healthcare increased by 12.2% over a ten-year period (Barber & Gertler, 2009). In the programme’s first year, healthcare clinic visit rates grew faster than in control areas, as did immunisation rates and prenatal and postnatal care. The increase in prenatal care also significantly reduced the number of first visits in the second and third trimesters of pregnant women (Gertler, 2000). Maternal and child mortality has improved significantly (Gertler, 2000) and the number of children suffering from malnutrition dropped from 25% to 8.2% between 2000 and 2015, “alongside a greater efficiency in relation to the cost of medical attention” (Ordóñez-Barba & Silva-Hernández, p.97, 2019). A 2004 study on Oportunidades’ impact on growth and anaemia in children, showed that haemoglobin levels were higher in children in treatment groups, and the programme was associated with better growth among the poorest and youngest infants (Rivera et al, 2004). 


Participation in Oportunidades also correlates with increased diabetes mellitus detection and treatment (Behrman and Parker, 2011) through improved healthcare access.


Weaknesses in relation to health system service delivery 


Oportunidades is not without weaknesses. Errors are prevalent in targeting, to the exclusion of eligible, and inclusion of ineligible, families (Ordóñez-Barba and Silva-Hernández, 2019). Some have critiqued the programme’s RCT methodology, suggesting that a quantitative approach that drives towards binary options of success or failure leaves little room for qualitative debate and nuance (Faulkner, 2014). Another criticism is that “contamination” of the treatment groups could occur through members of control groups immigrating to treatment group locations in an attempt to become eligible (Behrman & Todd, 1999). 


The programme has been criticised for perpetuating “family-ism”, and the gender inequality inherent in assuming “the role of mothers in guaranteeing the effectiveness of public investments,” (Barba and Valencia, 2016, in Ordóñez-Barba and Silva-Hernández, 2019, p.86), though the same authors also recognise the programme’s commitment to addressing gender inequality through its potential to transform the traditional roles of women.


Some critics doubt how much impact CCT has on the trajectory of families in areas of low job availability. (Ordonez-Barba & Silva-Hernández, 2019) Likewise, it is of little use sending women to health clinics and children to school if the health clinics and schools are poor (Marmot, 2015; García-Guerra et al, 2019). To realise genuine improvements to health systems, the programme must be closely linked to economic strategy to ensure that it can improve “the productivity of families so that they are able to generate income through their own efforts and diminish their dependency on monetary transfers” (Presidencia de la República, 2014, para. 20). 


Finally, some consider CCT programmes authoritarian. Whilst Oportunidades is intended to empower beneficiaries: “development can be seen as a process of expanding the freedoms that people enjoy” (Sen, 1985, p.3), imposing conditions upon payments can be seen as infringing on “freedom and dignity, creating disempowerment and power imbalances between programme providers and beneficiaries” (Scheel et al, 2020, p.718). Therefore, whilst Oportunidades aligns with the Alma Ata principles of “comprehensive healthcare for all” (WHO, 1978, VII, 6), it could be argued that its use of CCT conflicts with its spirit of self-determination.




Through their themes of “dignity, people, planet, partnership, justice, and prosperity for majority” the SDGs align with the WHO definition of health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (Oleribe et al, 2015, Commentary). They therefore provide an appropriate ‘North Star’ for improving health system service delivery.


The Oportunidades programme supports the SDGs, particularly as they reflect the interrelationships and dependencies of escaping poverty through education, equality, economic development, partnerships and strong institutions (UN, 2015). Despite its critics, it has proven highly effective in strengthening health system service delivery and access, through its SDH approach.


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To what extent social science is appropriate as an alternative to epidemiological methods when studying health risks?

(Originally submitted as coursework towards my Masters in Global Public Health at the University of Manchester)

Social science approaches to research differ from epidemiological approaches in a number of ways. Whilst epidemiological approaches are deductive (that is, typically starting with a hypothesis to be proven or disproven) quantitative, social science methodologies may typically be inductive (beginning with an observation that may result in a hypothesis being created), and qualitative. The two approaches are still regarded by many researchers as incompatible means for knowledge construction (Teddlie & Tashakkori, 2003).


Both approaches align with the scientific method: methodologies are explained so that studies may be understood and replicated by others, results are presented clearly, and conclusions are stated. The two approaches could be considered complementary to each other, each providing the foundation for further research and generation or confirmation of hypotheses as in figure 1 below.

The complementary nature of Social Science and Epidemiological Methodologies.

Figure 1: The complementary nature of Social Science and Epidemiological Methodologies.


The 2013-2015 ebola outbreak in Sierra Leone presented urgent clinical and epidemiological challenges, whilst cultural, sociological and political aspects complicated and compounded the situation. 


Park et al (2015) analysed sequences from 232 patients in Sierra Leone, along with 86 previously released genomes from earlier in the epidemic, in order to establish whether the virus was being transmitted inter or intra-country. The study took 7 months to complete and provided strong evidence showing that ebola transmission was primarily within-country, not between-country. This provided decision makers with actionable rationale for controlling the movement of people; however it did so only after a full 7 months, by which time over 9,430 cases had been reported (CDC 2017 data).


Ebola is transmitted via bodily fluids including blood, faeces and vomit. The cause of death includes hemorrhaging from orifices and the skin, and as a result, the corpses of ebola victims are highly infectious. In Sierra Leone, washing a corpse prior to burial and touching a corpse during a funeral are common and important elements of local funeral traditions (Richards et al, 2015). Therefore, it was important to quickly understand how to reduce the ebola infection rates related to funerals and burials, and how safe medical burials may be encouraged through understanding local beliefs and practices.


Lee-Kwan et al (2017) carried out a rapid qualitative assessment using focus group discussions that explored community knowledge, attitudes, and practices towards safe and dignified burials in seven chiefdoms in Bo District, Sierra Leone. The study took place over the week of October 20th, 2014, and identified perceived barriers to accepting safe burials that were then used to inform emergency response teams with the goal of reducing transmission of the disease. In less than a month, this data was accessible by aid workers and humanitarian agencies who were able to improve the way they worked with affected communities and slow the spread of the disease.


These examples show that whilst an epidemiological approach provided valuable, precise, and reliable confirmatory data regarding the spread of ebola, a social science approach provided rapid, actionable information that could be used to slow the spread. 


Social science methodologies that use qualitative assessments, despite a potential for lower reliability and validity, can generate rapid and actionable insights. This is where the RAR (Rapid Assessment and Response) emerges. RAR is not a single method but a collection of largely qualitative tools, such as interview guidelines and surveys, designed for a particular public health issue. RARs utilise the strengths of social science methodologies such as highly contextual, informal and rapid data gathering to identify existing resources and opportunities for intervention, and help plan, develop and implement interventions and programmes. (Boyce et al, 2004). The goal of a RAR is “to accumulate just enough information to be able to assess whether a particular problem is occurring and how this may be resolved.” (McKeganey, 2000). RARs, and other social science approaches, possess strengths in being able to utilise local expertise, tools and resources which improves cost-effectiveness and provides training for the local community to mitigate health risks. Additional RAR guides are available specifically for use in other health issues, such as working with vulnerable young people (Malcolm & Aggleton, 2004). 


Some practitioners and policymakers may see qualitative research, RARs in particular, as weaker in validity than quantitative methods, though it should be seen as an indicator reliable enough to start effective health promotion interventions. (Trautmann & Burrows, 1999)


Not only can social science methodologies provide more rapid data and actionable outcomes, but these types of research methods have an unrivalled capacity to constitute compelling arguments about how things work in particular contexts. (Mason, 2002) Social science methodologies can “explore the perspectives, experiences, relationships and decision-making processes of human actors within health systems, and in so doing, help uncover and explain the impact of vital but difficult-to-measure issues such as power, culture and norms” (Topp et al, 2018). 


However, in the power of highly specific context resides a weakness: quantitative evidence possesses less validity in different contexts to the original study, thus it is more difficult to transpose findings into different contexts. It is also more difficult to control for a variety of biases such as recallability or framing, with such methodologies.


Combining social science and epidemiological methods can be powerful. A mixed-method approach can provide the means to more accurately target qualitative research studies. For example, Wilson et al (2016), used an epidemiological approach to analyse cell phone data to rapidly identify population displacement from affected areas in Nepal after the 2015 earthquake. This quantitative data was used to direct, triangulate and strengthen the findings of immediate aid and further qualitative studies. 


The essential rationale of the mixed methods approach is that through a multidisciplinary approach that combines qualitative and quantitative methods, one can utilise their respective strengths and escape their respective weaknesses (Tashakkori & Teddlie, 1998) (From Lund, 2012). 


When studying health risks, social science approaches can provide rapid, actionable data, deep context, and additional benefits to the communities in question. Quantitative epidemiological approaches provide greater validity and reliability, and may facilitate more robust decision making. Ultimately, a mixed-methodology approach provides actionable, context-rich data in the shortest possible timescale.


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Cultural lessons learned from Spanish Flu and how these influenced response to the Covid-19 pandemic.

(Originally submitted as coursework towards my Masters in Global Public Health at the University of Manchester)


Charles Rosenberg’s 1992 essay “What Is An Epidemic” characterises an epidemic into four Acts, and utilises Albert Camus’s 1948 novel “The Plague” to describe these Acts of “Progressive Revelation”, “Managing Randomness”, “Negotiating Public Response”, and “Subsidence and Retrospection” (Rosenberg, 1992). Whilst this “Four Acts” model cannot fit all mass disease events, it is a useful lens which will be used here to explore the cultural impacts of population-scale diseases. This essay focuses on one historic epidemic: Spanish Flu during 1918-1919, drawing on parallels with other historic pandemics such as HIV/AIDS in the 1980s, and Ebola in West Africa during 2014, and critically addresses how those lessons were later applied to the Covid-19 pandemic of 2020. 


Culture is the manifestation of the history, knowledge, values, and beliefs of people, and plays a significant role in the spread of disease by influencing how often and the manner in which people interact, and the scale of interactions, alongside rituals, ceremonies and traditions. These include everything from purchasing groceries to attending large concerts. Culture is fundamental to epidemiology: it is a contributing factor in how rapidly a disease spreads, to whom, and to how people who are diagnosed are treated, or if they are treated at all (Bristow, 2010). 


Spanish Flu constitutes a prime example of a post-germ theory, pre-influenza vaccine, epidemic in developed urban centres. Pharmaceuticals to effectively treat influenza were not widely available, and as such non-pharmaceutical interventions, including behavioural changes, were the primary response. The US rather than European context of Spanish Flu is more pertinent to cultural change, as World War I and its impacts obscures much of the impact of the disease and its effect on culture in Europe. The virus did not originate in Spain, and was termed Spanish Flu because Spain did not censor its press during the war, unlike many other countries, so those first Spanish cases, including the King of Spain, made for a highly visible disease that became known as Spanish Flu (Whiting, 2020). The epidemic lasted for two years from the first recorded case in March 1918 to the last in March 1920, killing an estimated 50million people, though the true death toll may be up to twice that number (Johnson and Mueller, 2002). The Covid-19 death toll at time of writing is 4.1million people (Dong et al, 2021). 


Act I, Progressive Revelation.


“Progressive Revelation” is the slow acceptance and acknowledgement of the problem, a slowness which may be explained by the suggestion that acknowledging it can threaten existing economic and institutional interests and power structures (Sajtos et al, 2021). At the time of the Spanish Flu epidemic, people and information travelled more slowly than they do today. There were no commercial aeroplanes, and cars and telephones were the preserve of the rich: although the 1918 influenza virus spread slower than Covid-19 (Terry, 2020), the spread of information about the dangers, precautions and treatments was equally slow. 


The history of medicine is incomplete without the stories of the patients, their experiences, beliefs and behaviours (Porter, 1985), and it is this narrative backdrop that provides us with the greatest understanding of the epidemic itself. In post-germ theory USA at the time, life expectancy was on the rise and it was perceived by some at least that infectious diseases may be a thing of the past (Karlen, 1996). Influenza, however, was a familiar visitor, bringing sickness every year, which made the public complacent, a fact which even prior to 1918 caused concern for public health officials who recognised the need for public vigilance (Anderson, 1894). Public complacency was similarly a worry early in the Covid-19 pandemic as the previous SARS-CoV epidemic of 2002, and the H1N1 epidemic of 2009 were remembered as diseases that were significantly less transmissible or deadly than initially feared (Rogers, 2020). Health authorities in 2020, conscious that public complacency could hamper measures to control the pandemic if they were not adhered to, ensured that messaging was as clear and commanding as possible, whilst trying to avoid hysteria or spectacle (Krpan and Dolan, 2021).


Early behaviour change is an essential strategy in the management of an epidemic. For example, the rapid spread of the 2014 Ebola epidemic in West Africa was partly related to cultural practices of washing the dead to help them transition to the afterlife (Manguvo and Mafuvadze, 2015). Even once it was recognised that Ebola spreads through physical contact with an infected person’s bodily fluids, the value placed on these rituals, as with many cultural practices, meant that behaviour change was difficult to engender. Some families were so motivated to continue their funeral rites that they bribed corpse collectors to provide false cause of death reports (Dixon, 2014). Like Ebola, Spanish Flu also delayed or prevented funerals, and meant many were buried in mass graves, all of which deprived families of their traditional mourning process. This experience, along with a fear of infecting loved ones with an invisible disease, is believed to have inspired many of the zombie-like figures in the works of H. P. Lovecraft and the 1919 silent film “J’accuse” by Abel Gance, through a desire to visualise an invisible monster (Outka, 2019). Learning this lesson, visually engaging the public as early as possible particularly in order to convey the human impact of the disease, has proven powerful in encouraging behaviour change during the Covid-19 pandemic (Wilson and Frey, 2020).


During the early phases of the 1918 pandemic, many governments attempted to impose “maritime quarantine” in order to prevent the spread of the disease from elsewhere, but it was often imposed too late or was breached by people not yet symptomatic (Crosby, 1976). Australia was the notable exception, successfully delaying the second wave of the pandemic (Crosby, 2003), and indirectly protecting many Pacific islands from the worst of the disease (Shanks et al, 2018). This cultural lesson was only learned by a handful of governments responding to Covid-19. Some governments such as New Zealand, which suffered 5 deaths per million people, implemented full border controls very early on, in contrast to the UK, which kept borders open and suffered 1,900 deaths per million (Our World In Data, 2021). Most Western governments attempted to implement a modern-day equivalent of maritime quarantine using border testing and quarantine. However, the 2009 H1N1 epidemic experience showed that only 6.67% of cases were accurately detected through border testing (Gunaratnam et al, 2014), and education programmes to encourage people to only make essential travel, and get tested prior to travelling, were proven to be more effective (Grépin et al, 2021). 


Act II, Managing Randomness.


In Rosenberg’s second Act, “Managing Randomness”, a recurring epidemic theme is the scapegoating of groups already seen as undesirable or undeserving. Rosenberg suggests this is an effort to create order and meaning out of chaos, and has been recorded in many epidemics, including impoverished Jews who were blamed for the cholera pandemic of 1892 (Markel, 1999), Chinese immigrants for the bubonic plague outbreak in San Franscico in 1900 (Kraut, 1994), and the stigmatisation of gay men and Haitians in the HIV/AIDS epidemic in the 1980’s (Grmek, 1990). Even amongst some medical professionals in 1982, HIV became known as “GRID”: Gay-Related Immune Deficiency (Epstein, 1996). In general, immigrants were not blamed for Spanish Flu, possibly because it struck individuals of all groups and classes (Kraut, 2010). In 2020 however, President Trump’s “Chinese virus” statements led to a rise in Asian hate crime (Kurtzman, 2021), and naming Covid-19 variants as originating from a particular country, align with this leitmotiv of pandemics (Markel, 2007). Scapegoating and stigmatising certain groups makes it more difficult for those people to get treatment, and distracts from the true causes of the disease. This is clearly a lesson yet to be learned.


Just as “big pharma” conspiracy theories grew during the Covid-19 pandemic, during 1919, rumours emerged that Spanish Flu was linked to the German pharmaceutical firm Bayer intentionally spreading disease, and was compounded by the start of the epidemic coinciding with the end of WW1 (Cohut and Guildford, 2020). Physicians of the time were unaware of the side effects of high doses of aspirin, which can result in hyperventilation and pulmonary oedema – symptoms often seen in early deaths from Spanish Flu. Many victims were treated with high dose aspirin, and as a result, a significant proportion of Spanish Flu deaths may in fact be attributable to aspirin toxicity (Starko, 2009), a correlation which emboldened the conspiracy theorists. In the face of uncertainty, governments and healthcare organisations during Covid-19 attempted to provide as much clear and accessible information as early as possible, to enable people to spot conspiracy theories before they fell for them (Douglas, 2021).  


The economic impact of the 1918 epidemic was greater for developing countries than developed countries (Murray et al, 2006). Learning from this lesson, the Indian government prioritised healthcare, supply chains and employment opportunities during the Covid-19 crisis in order to avoid deeper economic harm (Sharma et al, 2021). However, not all economic lessons have been so clearly learned. The impact of Spanish Flu exacerbated the increasingly protectionist approaches of governments after World War I, restricting the free movement of people and goods (Boberg-Fazlic, et al, 2021). Similar nationalistic and protectionist approaches are already being seen as a result of Covid-19, highlighting “the downsides of extensive international integration while fanning fears of foreigners and providing legitimacy for national restrictions on global trade and flows of people” (Legrain, 2020). 


Economically and sociologically, Spanish Flu provided a stimulus to socialised healthcare through a realisation that treating disease at an individual level was insufficient for managing pandemics that affected entire populations. Prior to 1918, there persisted a eugenics-based belief that disease was a particular problem of the lower classes due to their inherent inferiority (Lombardo and Dorr, 2006). After the 1918 pandemic, it was clear that treating individuals in isolation or blaming people for becoming infected was an ineffective strategy, and subsequently many governments embraced socialised medicine; Russia first, via a state-run health insurance programme, followed by other European countries. The USA followed suit in their own way by consolidating healthcare into employer-based insurance schemes (Spinney, 2017). 


Act III, Negotiating Public Response.


Public response must be negotiated in order to build collective, sustained, and consistent action against epidemics. Rosenberg’s third Act, “Negotiating Public Response”, describes how prophylactic measures were strictly enforced in slums and poor areas of the city, but less so in affluent areas, despite affluent areas generating many cases (Rosenberg, 1992). Although public adoption of facemasks was relatively high in the US during the Spanish Flu epidemic, due to a consensus that influenza was airborne (Crosby, 1976), the surgical masks adopted by the public at the time were made of gauze, which was insufficient to prevent the spread of virus particles (Nakayama, 2020). Cities where masks were compulsory suffered as much as cities where masks were optional (MacDougall, 2007) and there was significant opposition on some fronts to the wearing of masks (The Seattle Star, 1918). During the Covid-19 pandemic, effective mask materials such as N95 have been widely available and largely adopted in countries where wearing masks in public was previously rare, but has been accompanied by vocal opposition from some (Barceló & Sheen, 2020). The same tension between individual liberty and collective responsibility arose in the HIV/AIDS epidemic in the 1980s, where there was initially strong resistance to the percieved oppression of gay people and their rights, including wearing of condoms. This is understandable response, given the wider context of gay freedom that had been so hard-won (Berridge, 1996; Shilts, 1987), and illustrates a key cultural barrier to proactive public engagement.


Schools have an ability to engage with and influence the public response. In 1918, American schooling was in the process of transformation; by 1920, almost 65% of the eligible population had attended school, with attendance rates consistently over 90%, a significant increase in uptake (Ross, 1924). Children in public schools were subject to regular health inspections and believed to be better protected from the threat of infectious disease than those out of school (Doty, 1911). Many schools had full-time nurses, smallpox vaccination programs, and contingency plans for serious disease outbreaks (Stern et al, 2010). Most schools in the USA closed during Spanish Flu, but some schools such as those in New York, Chicago and New Haven, opted for a successful strategy of remaining open during the epidemic under a rationale which recognised the role that schools could play in monitoring the spread of disease, communicating health and hygiene information to parents, and providing more hygienic school environments than many children had at home (Robertson, 1919). The lessons from this success were perhaps overlooked during the Covid-19 pandemic, when many schools in the USA were closed in efforts to hinder the spread of the virus, which has resulted in an increased attainment gap between higher- and lower-income families, exacerbated food insecurity, and increased the risk of childhood abuse or trauma (Van Lancker and Parolin, 2020, UNICEF, 2021). 


Act IV, subsidence and retrospection


“The most vexing phase of an epidemic” (Markel, 2007, p. 47): the eventual decline in cases and the opportunity to reflect, learn and adapt. After 1919, enthusiasm for the scientific method in the USA waned, in part due to the significant blow to the prevailing consensus at the time that all diseases were caused by bacteria (Tognotti, 2003); if science was wrong about this, what else was science wrong about? Conversely, Chinese culture, which has typically embraced Traditional Medicine and suffered less from the impact of Spanish Flu (Cheng and Leung, 2007), learned valuable lessons and became more scientific after 1919, including improved public health surveillance and better data collection (Whiting, 2020).


Economically, Spanish Flu had a devastating impact and reduced the average GDP by 6% (Maas, 2020). The largest adverse macroeconomic events of modern times were World War II, the Great Depression of the 1930s, and WW1, followed by Spanish Flu (Barro and Ursúa, 2008). Such a devastating economic impact would surely leave significant scars on society, yet the cultural memory of Spanish Flu feels faint (Onion, 2020) and American culture in particular failed in some respects to acknowledge the impact of the epidemic (Bristow, 2010). It can be difficult for people to contextualise disease, particularly population-scale diseases (Outka, 2019). After a war, it may be possible to reconcile death with a sacrifice that was necessary for the war to end, and people who died in wars may be memorialised as heroic, but rarely are those who died in epidemics memorialised: instead, they are seen as only tragic (Bristow, 2010). Learning lessons from pandemics is much more difficult because the acute visual reminder of the scale of the deaths is not present, unlike deaths caused by conflict, which may leave scars on the land as well as the memory. As a result of this faint epidemic memory, many of the lessons that could have been learned from such a devastating pandemic have been lost, or painfully learned again during the Covid-19 pandemic.




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