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Embracing the theme ‘Close the Care Gap’, humanity marked World Cancer Day on Feb 4, sending a grim reminder to Nepal, which finds itself at a critical juncture in the fight against cancer. Cancer stands as a main cause of mortality worldwide, contributing to almost 10m deaths in the year 2020, equating to nearly one in six fatalities. The latest statistics reveal a sobering reality, emphasizing the need for heightened awareness, improved healthcare infrastructure and collaborative efforts to combat this stubborn disease.

Nepal’s cancer landscape

Nepal, which has a population of around 30m, reported 22,008 new cancer cases in 2022. Among these, 9,792 cases affected males, while 12,216 cases impacted females. This alarming figure highlights the widespread impact of cancer on individuals and communities. The age-standardized incidence rate of 81.6 underscores the urgency of addressing the factors contributing to the rising incidence of cancer.

Top cancers and their impact

The top three leading cancers in Nepal, categorized by gender, reveal distinct patterns in the prevalence of the disease. Among males, lung cancer takes the forefront, followed by stomach and lip, oral cavity cancers. In contrast, females grapple predominantly with breast cancer, followed by cervix uteri and lung cancers. When considering both sexes collectively, lung cancer maintains its prominence, with breast and cervix uteri cancers following closely. These statistics highlight the need for gender-specific awareness campaigns, early detection initiatives and targeted healthcare interventions to address the unique challenges posed by different types of cancer in both men and women. These cancers not only affect the physical well-being of individuals but also carry a substantial emotional and economic burden for individual families and the society.

Losses and lessons: 14,704 lives lost

Tragically, 14,704 lives were lost to cancer in 2022, with lung cancer claiming the top spot. The breakdown by gender reveals that 6,936 males and 7,768 females succumbed to the devastating impact of cancer. Among males, lung cancer stands as the leading cause of cancer-related deaths, accounting for a significant 15.6 percent of the mortality rate, whereas lung cancer holds the third position among females, contributing to 7.4 percent of cancer-related deaths. The age-standardized mortality rate of 55.3 signals the urgent need for comprehensive strategies to improve cancer care, early detection and treatment outcomes.

A complex tapestry

The risk factors for cancer and other non-communicable diseases encompass tobacco use, alcohol consumption, an unhealthy diet, physical inactivity and exposure to air pollution. A study on the burden and risk factors of cancer suggests that roughly 50 percent of global cancer deaths can potentially be prevented. It is crucial to distinguish risk factors such as smoking and alcohol use from others. Various research studies indicate that a significant 90 percent of lung cancers worldwide are attributable to smoking and tobacco consumption. Cigarette and tobacco smoke emit over seven thousand chemicals, including nicotine, tar, carbon monoxide, lead, benzopyrene, hydrogen cyanide, ammonia and nitrosamines. Among these compounds, a minimum of 250 are identified as harmful, with at least 69 of them having the potential to cause cancer. Studies have shown that smoking as well as smokeless tobacco causes mouth, lip, throat, lung and esophagus cancer apart from more than 25 fatal diseases like heart disease, chronic respiratory obstruction and asthma. Research has shown that tobacco causes 20 types of cancer. Smoking can cause cancer in any part of the body. Tobacco use causes cancer of the mouth and throat, esophagus, stomach, bowel, rectum, liver, pancreas, voicebox (throat), trachea, bronchus, kidney, bladder and uterus.

A cancer-free future

In the pursuit of a cancer-free future for Nepal, a multifaceted approach is essential, encompassing key initiatives that address prevention, early detection, treatment, and palliative care forming integral components. Acknowledging that 30-50 percent of cancers are preventable, emphasis is placed on lifestyle choices, including avoiding tobacco and alcohol, maintaining a healthy weight, regular physical activity and a balanced diet. Vaccination against viruses such as HPV and hepatitis B, especially for high-risk groups, adds a crucial layer to preventive measures. 

Early detection, facilitated through awareness, clinical evaluation and timely referrals, significantly enhances the chances of successful treatment and lower morbidity. Screening programs, though effective, require substantial resources. Tailored treatment incorporating surgery, radiotherapy and systemic therapy is pivotal in achieving therapeutic goals, including cure and prolonged life. However, the global availability of comprehensive treatment remains uneven, with disparities between high- and low-income countries. In advanced stages, palliative care becomes essential, emphasizing community-based strategies for pain relief. Access to oral morphine is emphasized to address moderate to severe cancer pain, impacting over 80 percent of terminal-phase patients. The integration of vaccination into this comprehensive framework underscores its role in reducing cancer risk, particularly for virus-related cancers.

As we observe World Cancer Day, the global community must heed Nepal’s call to action. Beyond the statistics lie human stories, families affected, and communities in need. It is imperative to unite in the fight against cancer, offering support, resources and expertise to strengthen Nepal’s healthcare system.

Not so long ago, Yuval Noah Harari, a well-known historian, warned, “Once Artificial Intelligence (AI) makes better decisions than us about careers and perhaps even relationships, our concept of humanity and of life will have to change.” 

In his book, one of the most read in modern times, ‘21 Lessons for the 21st Century,’ published in 2018, Harari cautioned future generations vis-a-vis different topics, among which the threat of AI is one. A number of researchers, sociologists, computer scientists, development practitioners, tech optimists and pessimists have been making similar predictions about AI.

Undoubtedly, the emergence of AI created euphoria as the internet and printing press had done in the past. The printing press and the internet brought about disruption in the information ecosystem, breach of hierarchy and assault on power dynamics; AI has intensified this process at an unimaginable scale and speed. 

With accelerated generation of data, application of algorithms and competitive race on AI across the globe, a new world order is emerging with tech giants on top. Already enslaved, a huge section of humanity is at the receiving end, while those playing with AI are spreading optimism and enjoying the ‘winner-take-all’ model of tech business.

Amidst all this, the warning of Harari counts much. With the hijacking of the brain, machines fed with AI have begun giving more precise results than the humans. As such, is it simply ease, please and convenience to humans or grave threats to human brain and cognition? It warrants serious debate and discussion.

When OpenAI launched ChatGPT in Nov 2022, it quickly triggered shock waves globally. The content generation in no time dazzled the human. Give a command, and it serves you instantly. Google was evidently dwarfed by ChatGPT. From a student’s homework to university research, it dominated the landscapes of modern information, knowledge, innovation and technology. Co-authoring with ChatGPT became a new fad, but the app has courted its share of criticism as well. Many launched astute analysis and several journals banned this app as the co-author. 

Despite this, OpenAI continued advancements, advancing to ChatGPT-4 from ChatGPT-3 in March 2023. It has undoubtedly marveled the creation of diverse contents—text, image, video. 

Isn’t it a better decision than humans as Harari viewed?

Vanishing jobs 

Some months back, with the onset of winter, Facebook and Twitter in Nepal were rife with AI-generated images showing some people ready to eat hot steamed dumplings (momo) while some ready to grab cups of steaming tea and coffee. Now, the media have begun using relevant images as well. 

There are not simply the cases of AI benefits, but also of the assault on humanity. With AI creating the content (text-story, poem, play, photo, video), a large number of jobs are likely to vanish, posing a serious threat to humans. Even in Nepal, many content writers, translators and editors have lost jobs, thereby facing a dent in their incomes and financial sustainability.

In this wake, a research report released recently by the International Monetary Fund (IMF) must have taken many by surprise. The IMF report, named ‘Gen-AI: Artificial Intelligence and the Future of Work’, states, “Almost 40 percent of global employment is exposed to AI, with advanced economies at greater risk, but also better poised to exploit AI benefits than emerging markets and developing economies. In advanced economies, about 60 percent of jobs are exposed to AI, due to the prevalence of cognitive-task-oriented jobs.”

Moreover, the report warned that ‘a new measure of potential AI complementarity suggests that, of these, about half may be negatively affected by AI’. “Overall exposure is 40 percent in emerging market economies and 26 percent in low-income countries,” per the report.

AI-powered justice 

Meanwhile, a news story on the positive side of AI has been hogging the headlines worldwide. Per the report, UK judges can use AI in writing legal notes/opinion, with caution. The Nepali media also covered the Associated Press news, which states: “The Courts and Tribunals Judiciary last month said AI could help write opinions but stressed it should not be used for research or legal analyses because the technology can fabricate information and provide misleading, inaccurate and biased information.”

The above cases are indeed examples of ‘creative disruption’ of AI. As the story suggests, caution is required with regard to the fabrication of information, the spread of misinformation, disinformation, mal-information and deep-fake with the use of AI. 

The year 2024 is an election year, with polls taking place in India, the US, and the UK. Whether AI will influence electoral integrity has been a cause for concern and researchers are conducting serious research on the topic. The super-speed of disinformation and deep fakes with AI is a headache for many professionals and governments.

Tech giants draw flak

Moreover, the UN Secretary-General, Antonio Guterres, recently lambasted tech companies at the World Economic Forum in Davos, Switzerland. The Guardian wrote, “Big technology companies are recklessly pursuing profits from artificial intelligence and urgent action is needed to mitigate the risks from the rapidly growing sector, the head of the United Nations has warned.”

When it comes to the regulation of AI, the US, the EU and China are large players. The US has fostered a liberal competitive digital atmosphere, thereby contributing to a cut-throat AI race among tech companies, while China is focused on cyber sovereignty and advancing AI accordingly. Equally important is the role of EU countries in advancing research and seeking ethical and responsible use of AI. The EU seems engrossed in emerging as a global leader of tech regulation. 

It is time to ponder over the spurt of AI, which is gripping us at scale. We are at a watershed moment where non-humans are sprawling and stalking the sacrosanct terrain of humans—the cognition—and rendering the humans irrelevant. 

Informed debate a must

As the yawning digital divide has already crippled poor and marginalized countries and communities, the tech empires that dominate the global AI race are likely to further afflict the vulnerable ones. Networking, collaboration, knowledge and information creation and sharing without jeopardizing national interest is essential for countries like Nepal to reap benefit from AI. In this regard, the Ministry of Communications and Information Technology is learnt to be preparing an AI policy. The ministry must facilitate and forward the debate and discussions on AI under the leadership of informed, educated and intellect milieu rather than mediocre rallying.

In recent years, an increasing number of Nepali students have chosen to pursue higher education abroad, significantly impacting the educational landscape of Nepal. Approximately 80,000 students were granted permission to study abroad last year, contributing to a substantial expenditure of
Rs 67.7bn. This phenomenon raises questions about the factors influencing Nepali students to seek education abroad and the repercussions for educational institutions in Nepal.

Our educational institutions face several challenges that drive students to seek opportunities abroad. One significant issue is the prevalence of outdated courses within many institutions, where curricula may not align with the rapidly evolving demands of the global job market. Additionally, the availability of specialized programs, particularly in fields such as technology and science, is often restricted, posing challenges for students with specific career aspirations.

The educational landscape in Nepal exhibits a notable emphasis on theoretical instruction at the expense of practical knowledge. Graduates may find themselves lacking hands-on experience and practical skills that are increasingly sought after by employers in the professional realm. Compounding these challenges is the persistently high student-to-teacher ratio in Nepal’s educational institutions, hindering personalized attention, mentorship, and interactive learning experiences for students.

The system’s inefficiencies are further compounded by delays in conducting examinations, publishing results, and offering courses within stipulated time frames. These delays, attributed to administrative challenges and political disruptions, introduce uncertainties for students. Moreover, the influence of political activities, including those of student and teacher unions, contributes to an environment of disruptions, violence, and opposition within our educational institutions, negatively impacting the overall learning experience.

Inadequate infrastructure and a lack of investment in modern facilities, laboratories, and research spaces also plague Nepali educational institutions. Insufficient resources limit students’ opportunities to engage in cutting-edge research and apply their knowledge practically. Additionally, the dearth of support for academic research, including limited opportunities and funding, further hampers students’ academic and professional growth. Addressing these challenges is crucial for enhancing the overall quality and competitiveness of Nepali higher education.

A significant number of students leaving a country to study abroad has ramifications for overall national development. One notable consequence is brain drain, where the departure of talented and educated individuals seeking higher education and career opportunities abroad results in a loss of skilled workforce for the home country. This, in turn, negatively affects productivity, innovation and technological advancement, as the skilled professionals who could contribute to these areas are now working and settling abroad.

Economically, the outflow of funds for tuition, living expenses, and associated costs related to studying abroad can lead to a depletion of the country’s foreign exchange reserves, causing currency depreciation. Moreover, the money spent by students abroad contributes to the economies of host countries rather than benefiting the home country, potentially resulting in trade imbalances and economic dependence.

The impact extends to the education system itself, with the departure of a significant number of students potentially causing decreased enrollment in domestic educational institutions. This may lead to financial challenges for educational institutions and a decline in the overall quality of education.

A skill gap may emerge as a consequence, with the home country facing shortages of skilled professionals in various fields. This shortage can impede the country's ability to compete globally, attract investments and foster technological advancements.

At a social and cultural level, the migration of a substantial portion of the youth population can lead to a loss of diversity in the home country. This may impact cultural exchange, social dynamics and the overall vibrancy of the community. Additionally, there is a dependency on remittances, as students who settle abroad may continue to work there and send remittances back home. While this provides financial support to families, it may result in a long-term dependency that is not a sustainable source of economic growth.

The impact also extends to research and development, as the country may experience a loss of research talent if students pursuing advanced degrees and research opportunities choose to stay abroad. Over time, the cumulative effect of brain drain and economic outflow can lead to long-term consequences for the country's economic growth, development and global competitiveness.

Educational institutions in Nepal can attract students by taking proactive measures to enhance the quality of education. One crucial step is to address the perceived stagnancy in curricula by actively engaging in curricular reforms. This involves updating and diversifying course offerings, introducing specialized programs and incorporating practical knowledge to align education with the evolving demands of the global job market.

Moreover, recognizing the importance of infrastructure and research opportunities, educational institutions should invest in modern facilities, laboratories and research infrastructure. State-of-the-art resources create an environment conducive to research and innovation, appealing to students with a keen interest in practical applications of their knowledge.

Additionally, fostering international collaborations is essential. Establishing partnerships with renowned international institutions can lead to collaborative programs, student exchanges and joint research initiatives. Such initiatives contribute to elevating the educational standards and global recognition of Nepali educational institutions.

In parallel, the government has a crucial role in shaping the education landscape. It should focus on comprehensive policy reforms, addressing concerns such as outdated courses and delayed administrative processes. Education policies should be revised to meet international standards, promoting innovation in teaching methods and ensuring a more globally competitive education system.

Furthermore, the government should allocate funds for research initiatives, promoting a culture of research and development. Scholarship programs can be introduced and expanded to incentivize meritorious students to pursue higher education locally. These scholarships could be based on academic excellence, innovation and contributions to community development.

In conclusion, a comprehensive approach involving both educational institutions and the government is necessary to address the challenges facing Nepali universities. By implementing these measures, Nepal can create an educational ecosystem that not only retains local talent but also attracts students globally, contributing to the overall growth and development of the country.

Recent research indicates that zoonotic diseases will continue to grow and become a leading cause of animal and human casualties. Thus, healthcare workers, including animal health workers, will increasingly face substantial challenges in controlling such diseases, as these zoonotic diseases will continue to evolve and develop into new strains of pathogens or completely new pathogens along with complex disease dynamics. This complex nature of diseases underpins the importance of an integrated One-Health Approach (OHA) to address zoonotic diseases. Thus, this approach has emerged as a specified field of disease prevention and control that aims to promote the overall well-being of humans, animals and the environment.  

Although OHA has got a boost in many countries, it is rarely institutionalized. The lack of translation of scientific studies for the benefit of local communities has made people reluctant to follow OHA. It received greater attention from prominent organizations such as WHO, OIE, FAO, CDC and EU, leading to the development of a joint plan of action for the integration of OHA into national disease prevention and control strategies, giving rise to one-health organizations and integrated disease control models. Furthermore, many developed and developing countries have started to work on a one-health approach and developed legislations and laws to guide OH actions. Now, the gradual integration of the OHA is occurring across the various areas of prevention and control of diseases. 

Despite the acknowledged importance of the one-health approach for effective prevention and control of diseases, the barriers to the implementation of OHA persist in many Low and Middle Income Countries (LMICs). These barriers include a lack of qualified one-health professionals, funding constraints, a silo mentality among all concerned stakeholders, lack of intersectoral collaboration and political will, absence of collaboration among all stakeholders and inadequate investment by the government to promote OHA. Furthermore, there exists a dearth of research that involves the cost-effectiveness of OHA. This absence of information is a serious limitation for assessing the usefulness of OHA, whose application in the field condition is extremely poor. This paucity of data might be due to several factors, including wildlife professionals being excluded from multidisciplinary one-health action committees or lacking resources/measures to effectively account for sociocultural systems. However, despite having such challenges, these challenges represent opportunities for better integration and implementation of OHA involving all stakeholders, ranging from policymakers to wildlife and environmental professionals.

The OH activities have historically been disregarded in many developed and developing countries. In addition, factors that affect the implementation of OHA are poorly understood. Lack of collaboration and communication among all concerned stakeholders are pervasive, and wildlife and environmental professionals are neglected in OH action policies. Furthermore, due to a limited understanding of OHA among ground-level stakeholders, implementation of OHA has not yielded intended results. Lack of qualified one-health professionals in the field conditions, coupled with inadequate infrastructure, has prevented instant action in the field conditions. Lack of awareness among the public regarding the OHA has led to a low level of public acceptance of OHA.

Effective prevention and control of diseases needs a comprehensive and systematic approach involving all stakeholders with multidisciplinary interventions. A growing body of knowledge has shown that an integrated OHA is a cost-effective way to prevent and control diseases. Thus, integration of OHA across all disciplines of governance in all three tiers of government as well as research in institutions is essential for effective OH action.

Long-term investments in awareness campaigns for stakeholder behavioral change, research on the cost-effectiveness of OHA, and collaborative partnerships are necessary if OHA is to be effective.  A constant effort should be made to promote better knowledge and understanding of one-health issues in society either through awareness campaigns, rallies, seminars, and dissertation groups or through social media platforms. As there is an acute lack of one-health experts in many developing countries, the training of non-specialists under the supervision of one-health experts and strengthening their capacity in prevention and control of zoonotic diseases, disaster response, and risk reduction, data collection, and communication would be an effective approach. To raise awareness among public, school and university curricula should be updated with the inclusion of OHA. 

Those students in school and university then can teach their parents about one-health issues through lessons learned in school. And, the parents by being aware of OH issues, can apply preventive and control measures to prevent disease occurrences. Therefore, students should be educated and supported to facilitate the implementation of one-health activities. Using education platforms could be a cost-effective method involving little or no financial resources, raising awareness to convey a message about one-health systems.

Healthcare professionals working in field conditions should be trained on OHA. Now, it is time for all countries to act together to achieve the goal of disease control and elimination as envisioned by One-Health policy documents by building a strong intersectoral collaboration, funding allocation, infrastructures, human resources as well as political commitments.

This OHA should be spearheaded by professional OH actors and/or societies to provide needed expertise to address OH issues. Furthermore, WHO, OIE and FAO should provide support for regional cooperation among countries to build a robust system of OHA plans for better preparedness in dealing with epidemics and preventing as well as controlling zoonotic diseases. Thus, it is high time to implement OHA to tackle infectious diseases.

The author is a Veterinary officer at the Department of Livestock Services (DLS)