Silent Killer



Diabetes is a progressive disease that can cause blindness, heart disease, stroke, kidney failure, and death if not managed properly. It not only kills its victims but also causes avoidable pain and suffering to their family members and a huge loss to the national economy. 

According to the World Health Organisation (WHO), currently 347 million people have diabetes in the world. Of them, 80 percent live in low-and middle-income countries. In 2011, 4.6 million people died of diabetes-related complications, which constituted 2.17 percent of the total deaths. By 2030, diabetes could, WHO estimates, be the seventh leading cause of death. 

Research suggests that people from South Asia are at an elevated risk of diabetes, especially Type 2. A combination of genetic, environmental and dietary factors contributes to it. South Asian food, which is high in refined carbohydrates, is a main contributor to diabetes. Increasingly sedentary lifestyle, particularly in urban areas, has been adding fuel to the flame.

WHO statistics show that India has the highest number of diabetics in the world, followed by China and the United States. 

Around 40 million Indians are estimated to have the disease now. That number could double by 2030. In Pakistan, according to surveys, 7.7 to 11 percent of the population have diabetes. In Bangladesh, more than 12 percent people are diabetic or pre-diabetic.

In Nepal, the number of people having diabetes is estimated to be between 436,000 (WHO) and two million (Third Diabetes Conference, Kathmandu, 2013). The cause of such disparity is that there has been no reliable survey. As in other countries, Nepal’s urban areas have higher prevalence rates as compared to rural areas.

What is diabetes?
Called madhumeha in Ayurveda, diabetes is a metabolic syndrome resulting in a high sugar level in blood. It can be caused either when the pancreas, agnyasaya in Ayurveda, fails to produce enough insulin or when the body cells become resistant to it.
We need sugar, known as glucose after digestion of the food we eat, to keep us alive and moving. It is to our body what petrol is to a car. However, this sugar causes diabetes when we have more of it than necessary. 

The level of sugar increases in our bloodstream when we eat food. The pancreas, which is located behind the stomach, releases insulin to transport sugar from bloodstream to body muscles and other tissues so that it is converted to energy or stored in the liver and muscle cells for future use. However, if the pancreas does not produce enough insulin or our muscles and tissues do not respond to insulin produced by it, sugar remains unabsorbed, making a person diabetic.

Types of diabetes
Type 1, Type 2, and gestational diabetes are most common forms of diabetes. Generally, children and young adults have Type 1 diabetes. However, it can be found at any age. Type 1 diabetes generally manifests itself when our own body’s immune system destroys the ability of the pancreas to produce insulin. 

Type 2 diabetes is the most common. It is strongly associated with older age, genetic disposition, obesity, and sedentary and unhealthy lifestyle. Less prevalent among children in the past, it has surprisingly become a major problem for them now, especially in the developed world. The main culprit, it is believed, is junk or fast food.

Gestational diabetes affects women during their pregnancy. It normally disappears after childbirth. However, 40 to 60 percent women having this problem could develop Type 2 diabetes later in life. 

Apart from these, there are other types of diabetes as well. For instance, Latent Autoimmune Diabetes (LADA) has symptoms of both Type 1 and Type 2 diabetes and about 10 percent diagnosed with Type 2 diabetes suffer from it. Neonatal diabetes mellitus (NDM) and maturity onset diabetes of the young (MODY) affect children and adolescents. Often, genetic defect in insulin action, diseases of the pancreas, infections, medications, and chemicals cause such diabetes.

Symptoms and effects
Excessive passage of urine, especially at night (polyuria), excessive thirst and dry mouth, excessive hunger (polyphagia), high blood sugar (hyperglycemia), blurred vision, weight loss, abnormal skin sensation (paresthesias), sores that do not heal, and fatigue are the main symptoms of diabetes. 

Some of these symptoms could be associated with other diseases as well. Therefore, when such symptoms appear, we must have a thorough check up to determine if the patient has diabetes or some other disease. If diabetes goes undiagnosed, the patient will have to pay a high price, including disability or sudden death.

Diabetes can affect our health colossally giving us a high level of pain and distress. If not controlled, this disease can affect primarily the eyes, heart, kidneys, feet and reproductive system. 

It can affect our eyes with diabetic retinopathy damaging the retina and making us blind. It can also cause serious heart attack and stroke, affecting the heart and blood vessels. According to the International Diabetes Federation (IDF), heart attack and stroke are the major causes of diabetes-related deaths. Diabetes can result in total kidney failure which requires either dialysis or kidney transplantation. It can also create nerve diseases; damage the toes, feet and lower limbs; and may lead to ulceration and sometimes amputation. Diabetes could also cause impotency.

The national economy suffers due to the victim’s decreased productivity and untimely death and increased health costs.

Sadly, there is no cure for diabetes. However, diabetes can be controlled and managed. Diabetes management includes medication and appropriate lifestyle, including a healthy diet reasonably free of sugar and fat content, light exercise and adequate sleep. The management goal should always be to avoid or alleviate diabetes-related complications.

Medication helps control diabetes. Before prescribing medicine, the general practitioner (GP) should always carefully assess the patient’s condition and choose one or multiple medicine/s depending on the assessment. Merely prescribing conventional and most popular medicine could further aggravate the patient’s condition. If necessary, the GP, who is not a specialist, should refer the patient immediately to a diabetes specialist for urgent care and attention. Otherwise the consequences could be disastrous, even fatal. Unfortunately, in Nepal, patients are seldom referred to qualified diabetes specialists/consultants.

Medicine must be supplemented by healthy diet, some exercise, and adequate sleep. A qualified dietician can prescribe a healthy diet that goes a long way in mitigating the problems associated with diabetes and prolonging the victim’s lifespan. But in Nepal, there is shortage of properly qualified dieticians. Unqualified dieticians can only exacerbate the patient’s condition.
Likewise, the exercise and sleep regime should be tailored to the patient’s specific condition. Too much or too little exercise or sleep could lead to avoidable pain, illness, and even untimely death. But all too often, patients in Nepal do not consult qualified exercise and sleep therapists to find out what is best for them and harm themselves with the wrong type and amount of exercise and sleep. 

As diabetes is on the rise worldwide, more so in South Asia, including Nepal, it must be tackled with the urgency it deserves. The government of Nepal should, therefore,recognize diabetes as a national health issue and launch a campaign against this fast-growing scourge before it assumes catastrophic proportions. It should invest in developing a workforce of doctors, dieticians and trainers specialized in treating and managing diabetes and encourage patients, through education and awareness programs, to lead a healthy lifestyle and seek timely help. 

Timely and appropriate action by the patients and government will prevent a diabetes catastrophe, help patients lead a reasonably good and long life, minimize pain and distress for the victims’ family, and mitigate the burden of this silent killer on the national economy.

Sharma is former foreign secretary and Khadka, an expert in diabetes, currently manages an Indigenous Medical Specialist Project at the Royal Australasian College of Surgeons in Melbourne.

 Published in Republica:  
Published on 2013-05-19 01:16:05

Tattered Trust


UCPN (Maoist) Supremo Pushpa Kamal Dahal visited India soon after returning from China. He has proclaimed that both visits were meant to promote economic development of Nepal. He did talk about development, but his real mission was quite different.

High level political visits between friendly countries are common. Even when relations are not very cordial, such visits take place to help break the ice. Nepal enjoys good relations with China and India, and they routinely invite Nepali political leaders for a visit. Many a time, Nepali leaders ask for an invitation and our neighbors comply. So there is nothing remarkable about Dahal’s visits to the neighboring countries.

What is remarkable is the mission and timing. Obviously, Dahal had two missions for his sojourn to China and India: First, as his critics have said, he wanted to get the neighbors’ blessings for the forthcoming Constituent Assembly elections. Second, he wanted to augment his national and regional leadership credentials.

In small countries, external influence is an important factor in shaping internal political dynamics. So it is understandable that leaders of small countries try to obtain electoral advantage of being close to the larger neighbors. China, as the second largest economic and military power in the world, is trying to establish a wider strategic foothold in Nepal, as more arrivals of Chinese officials now suggest. Although Dahal deserves credit for extracting an invitation from Beijing to become the first Nepali leader to meet with the new leadership team there, China did not commit any new project to hand him any kind of electoral advantage.

Similarly, how Dahal’s party performs in the next CA polls in the Tarai and whether he can lead the government after the election depends much on India’s attitude, signals and support. It is, therefore, perfectly understandable if Dahal tried to accrue some electoral benefit from his visits to China and India. However, China and India usually try to steer clear of any controversy or bias just before a general election. Therefore, they are likely to invite leaders from other key parties before the polls in order to strike a balance. As these trips are likely to take place closer to the election, they would wipe out Dahal’s political edge from his visits.


What is more, neither China nor India made commitments to new projects to hand Dahal political advantage over other leaders. In a sense, his visits were ill-timed.

Dahal’s more important mission was to augment his national and regional leadership credentials. Dahal has tried to project himself at home and abroad as the undisputed leader of Nepal. He presumes, with some basis, that he is the natural candidate to fill up the national leadership void left by Girija Prasad Koirala’s death. He has claimed that before death Koirala had asked him to take the nation’s leadership, not just his party’s.

To advance this mission, Dahal gambled by integrating only a fraction of Maoist combatants into the army, changing the tactical course of his party in the recent Hetauda convention, and proposing an apolitical election government. His proposal to forge trilateral cooperation among Nepal, China and India was his latest bid to burnish his image not only as a national leader but also a regional heavyweight. Has he succeeded in his mission?

Not much. In China, Dahal, like he said, told his hosts that Nepal could maintain one-China-policy and address China’s security concerns more effectively if it were economically developed. For development, he asked Chinese leaders to construct a Nepal-China railway link and invest in hydropower and tourism in Nepal. He also said he tried to remove Chinese apprehensions about ethnic federalism.

Well, one-China policy has become a cliché that does not impress Beijing anymore. Barring a few small Central American and South Pacific countries, the whole world has embraced that policy now. Nepal has no option but to stick to it irrespective of its political orientation or development status. To hint that this policy is conditional on China’s investment in Nepal must have sounded churlish to Chinese leaders.

Similarly, to imply that Nepal’s progress could promote China’s security sounds like unwarranted arrogance. Externally, Beijing is worried about Washington’s military support for Taiwan and human rights concerns in Tibet, disputes over the Spratly Islands, and Moscow’s resurgence in the north and west. Neither Nepal nor India as such is China’s notable external security threat.

However, Beijing is deeply concerned about internal stability and security, and Nepal’s emerging ethnic federalism is related to it. Ethnic federalism in Nepal, China fears, will affect it in three ways. First, it will embolden separatists in Tibet, Xinxiang and other restive minority provinces. Second, it will create too many fragile states along the Nepal-China border that would share cultural affinity with and be sympathetic to the Tibetans opposed to Beijing. Third, a few strong states on the Nepal-India border will further skew strategic balance in Nepal in India’s favor.

China will not trust anyone until this vital security concern is addressed. If Dahal truly believes his assurances have allayed such fundamental fears of China, he either does not understand Confucian diplomacy or is delusional. Chinese, Japanese and Korean officials rarely say upfront that they disagree with the other side. Rather, they continue to display polite and pretended ignorance and raise the same issue and ask the same question repeatedly until the other side withers and compromises. This ‘diplomacy of attrition’ is different from Western and South Asian presumptive diplomacy in which officials try to put their interlocutors in the other side’s shoes.

By Dahal’s own admission, Chinese officials raised the issue of ethnic federalism at different levels and on multiple occasions. Given his mercurial character, questionable credibility, and lack of governmental backing, it would be delusional for Dahal to think that he, with his few pleasant words, could mitigate the serious Chinese apprehensions related to their vital security interest. It must have been clear to him from Beijing’s indifference to his trilateral cooperation proposal.

Dahal’s India visit was a more mixed bag. Dahal might have been able to slightly mend his frayed relations with India. He also secured some measure of sympathy for his federal agenda in which the Tarai will have one or two strong states that India wants and the Hills will have several weak states that it does not care about and China does not like.

Beyond that, nothing was accomplished. As a bad prelude, Indian External Affairs Minister Shalman Khurshid shot down Dahal’s trilateral cooperation proposal as premature before his New Delhi sojourn even started. His opaque Beijing visit also gave reason for India to distrust him. Besides, Indian officials do not trust Nepali leaders because they blow hot and cold for their petty personal interests and commit to deliver the sky at the negotiating table but do nothing afterwards.

Dahal, more than any other Nepali leader, has undermined his own credibility. He first opposed “Indian hegemony” and “expansionism”; then secretly committed to Indian intelligence agencies to safeguard Indian interests in Nepal in exchange for the freedom of movement in India for him and his comrades during the insurgency. He declared war against India and dug trenches along the border; then, in the next breath, bent over backwards to appease India to get hold of Baluwatar Durbar.

Besides, India has had no basis to believe that Dahal could deliver what it wants even if he were sincere this time. It wants to bring Nepal, like Bhutan, under its security umbrella; increase its influence vis-à-vis China, its economic and strategic competitor; weaken Kathmandu by insisting on no more than two strong states in the Tarai; and tap into Nepal’s hydropower potential.

Nepal’s national leader would be the one who can keep India, China as well as Western countries in good humor. This is difficult. More so for Dahal if he does not change his mercurial character, mend his tattered trust, and shed his penchant for fooling all the people all the time.

Published in Republica

Published on 2013-05-13 01:08:18

Fear the Ghost



Poet Laxmi Prasad Devkota has this to say about enlightenment at the end of his life: “Neither did I accumulate devotion, nor did I acquire acumen; nothing matters but Lord Krishna, as I approach the life’s end.”

We human beings are wired to mellow with advancing age. Atheists in their youth become religious in old age; the religious become devout; the greedy become generous; the fiery become gentle; the sinner become pious; and non-charitable become charitable. We worry more about legacy and afterlife, as we get closer to the eternal journey, as Devkota has so nicely said. But by the time we realize, it would usually be too late to do good deeds to build better legacy or better afterlife. 

Let me illustrate this point citing two events in April 2013. British Iron Lady Margaret Thatcher died and Pakistani Iron Man Pervez Muserraf was arrested. Both events have stoked strong passion for and against these once remarkable politicians, imparting a lesson to all others that what you do to make yourself iron man or iron lady eventually comes back to haunt and does not give you a second chance to rectify your mistakes. 


For starters, Thatcher was the first female prime minister of the United Kingdom who served from 1979 to 1990. Elected as Member of Parliament in 1959, Prime Minister Edward Heath appointed her as the secretary of state for education and science in 1970. She would earn the nickname of ‘Thatcher the milk snatcher’ for cutting funding for milk made available to children at school. After her party lost the election, she defeated her mentor and became leader of the opposition in 1975. 

As leader of the opposition, Thatcher vehemently criticized the Soviet system in 1976, and a Russian journalist gave her the nickname of Iron Lady in Krasnaya Zvezda, a Soviet government newspaper. She became prime minister in 1979 after winning the general elections and went on to win two more polls and lead the government. She was a strong opponent of welfare state and Keynesian economics. 

As a prime minister, she relentlessly denationalized public enterprises, deregulated the private sector, cut public spending, destroyed the power of trade unions, and fought the Falkland War against Argentina. Thatcher increased indirect taxes and reduced direct ones, paving the way for the biggest transfer of wealth from the poor and the middle class to the rich. The poll tax—a flat-rate tax introduced to fund local government activities—sank her popularity and forced her to resign. After resigning as prime minister, she led a mostly secluded life. 

When I met her in 2008 at a royal reception, she was suffering from severe dementia. As she came around with her daughter, she fancied my son and talked with him for half an hour in the Buckingham Palace Gardens. She asked him about his school and life in the United Kingdom. As soon as my son answered, she asked the same question again, forgetting her earlier enquiry. To us, she seemed like a warm and compassionate human being, not the milk snatching iron lady. 

When she died at the age of 87, one group of people mourned and the other celebrated. While mourning is a spontaneous and appropriate human reaction when someone dies, jubilation is not. But those who lost their jobs and whose lives were ruined by her policy as well as their children who suffered the consequences celebrated her death. Out in the streets, people carried banners that depicted her as a Satan. They burnt her effigies and chanted slogans against her. A song about her—Ding dong the witch is dead—hit number two spot in the national chart. 

General Pervez Musharraf, as chief of the army staff, deposed Prime Minister Nawaz Sharif in a coup in September 1999 and appointed himself chief executive a month later. In 2001, he became the president. Under orders from the Supreme Court, Musharraf conducted general elections and his party emerged as the largest outfit in the parliament, though it fell short of an outright majority. He ruled the country with an iron fist appointing compliant prime ministers. 

In the face of his party’s loss in the general elections of 2008, his declining popularity, corruption cases, confrontation with the judiciary, and criticism from Western countries for transferring nuclear technology to North Korea, Musharraf’s position became precarious. The court denied him another term as president and put the final nail on his ambition for reelection. As Asif Ali Zardari, the widower of the Benazir Bhutto, and Nawaz Sharif, agreed to impeach him in the parliament, Musharraf resigned and went into exile.

Pakistani officials served in fear under Musharraf. For instance, at a breakfast in Washington DC, I asked Pakistani Ambassador to the United Nations Shamsad Ahmed to go and greet Benazir Bhutto, in exile then, who was seated next to our table. But he could not muster the courage and advised me to do it alone. I greeted her and spoke for a few minutes before the breakfast.

In March 2013, Musharraf returned from exile to “save Pakistan.” However, the court disqualified him for parliamentary elections from four constituencies due to the criminal cases against him. He then fled the court and went to his villa. But two days later, the police arrested him from his villa near Islamabad. In the latest development, the Peshawar High Court has barred him from running for office for life. This is the first time such a senior army figure has faced justice in Pakistan, where the army has a country rather than the country an army. Iron Man Musharraf could land in jail for many years to come. 

Thatcher and Musharraf were at one time the most powerful people of their countries, and they ruled ruthlessly. By the time they realized that they had to mend their ways, they were unceremoniously kicked out. Now the ghost of their past has been haunting them—Thatcher after her death and Musharraf after his return to Pakistan from exile. 

The experience of these two leaders must remind leaders of Nepal and elsewhere that history could be cruel to them as well. Even if they escape justice in court, they will have to face the court of public opinion at a time when they would have no power or no life. 

Well, those leaders who have done nothing deserving to be remembered by posterity do not need to fear history. They will evoke neither accolade nor vilification after they retire or die. The challenge is for those who have wronged people and the nation or who have tried to shape history the wrong way. People might not have the guts to ridicule such leaders when they still exercise power directly or indirectly. But these leaders face public justice without fear or favor after they retire or die.

For politicians, janata is Janardan (the people are Krishna). People can bless and condemn them alive or dead. Neither power, nor money, nor relatives, nor the items of luxury they accumulate through fair or foul means can save their legacy. What can is people’s love and respect, even after they set out in the eternal journey. Life is ephemeral and may not give you a second chance to mend fences. The sooner the leaders realize this and do some good, the better for them and for Janardan janata  
Published on 2013-05-05 01:15:06