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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.

The tobacco epidemic stands as one of the most significant public health challenges the world is confronting. Annually, tobacco claims the lives of over 8m individuals, with approximately 1.2m of these fatalities attributed to second-hand smoke exposure.

In the haze of discussions surrounding the health risks of tobacco use, the environmental toll of this pervasive habit often goes unnoticed. As the global population grapples with the consequences of tobacco consumption, a shadow looms over the very Earth we inhabit. This article seeks to unveil the intricate web of environmental challenges woven by the tobacco industry and its implications for our planet.

The tobacco production cycle exhibits a notably destructive impact. From cultivation and manufacturing to consumption, tobacco inflicts widespread environmental degradation and health hazards. 

Deforestation and agriculture

One of the least acknowledged impacts of tobacco use lies in the vast swathes of land cleared for cultivation. Each year, around 600m trees are felled to produce 6trn cigarettes. Approximately five percent of the annual global deforestation is attributed to tobacco farming. This deforestation significantly amplifies carbon dioxide emissions in the environment, contributing to adverse climate change impacts. Deforestation to make way for tobacco crops eradicates biodiversity and disrupts delicate ecosystems. The use of chemical fertilizers and pesticides further compounds the environmental toll, leaving a lasting mark on the lands where tobacco takes root. The cultivation of tobacco plants necessitates substantial quantities of chemicals, many of which prove detrimental to the environment and farmers' health. This exposure to harmful substances can lead to various illnesses, such as respiratory problems, skin disorders and neurological issues among those involved in tobacco farming.

Water scarcity and pollution

The cultivation of tobacco places an extraordinary burden on water resources, intensifying water scarcity in regions where it thrives. Annually, approximately 22bn tonnes of water is utilized in global tobacco production. Notably, tobacco production demands up to eight times more water than cultivating tomatoes or potatoes. The runoff of pesticides from these tobacco fields presents a substantial risk to nearby water sources, endangering aquatic ecosystems and the well-being of both the environment and local communities.

Cigarette butts, the most visible remnants of tobacco use, are a significant source of environmental pollution. Slow to decompose and laden with toxic chemicals, they pose a threat to soil and water, leaving a long-lasting imprint on the environment. Cigarette butts contain hazardous substances such as arsenic, lead, nicotine and ethyl phenol. When these butts are discarded, these substances leach into aquatic environments and soil. While the precise environmental impact of this waste remains unquantified, the substantial volume of discarded butts raises concerns about potential leachates affecting the quality of drinking water.

A cloud of environmental cost

The journey from farm to cigarette involves energy-intensive processes and the consumption of vast resources. The paper production for cigarette packaging, often derived from deforested areas, contributes to environmental degradation. The weight of non-biodegradable packaging waste adds to the already substantial burden on the planet. They contribute to an annual production of 767,000 kg of toxic waste, while 4.5trn cigarettes scatter across our cities, parks, beaches and waterways, contaminating both land and water.

Stubbing out the planet’s health

Beyond the ecological toll of deforestation and manufacturing, the plastic pollution from tobacco wrappers exacerbates urban environmental challenges. Discarded wrappers clog drains, pile up on th streets and contribute to the global plastic crisis. Cities face blockages and increased municipal waste management challenges, further emphasizing the need for sustainable alternatives. Moreover, discarded cigarette butts stand out as the most prevalent type of plastic waste globally.

Smokeless tobacco products are usually wrapped in a plastic packet, which poses an environmental impact. In Nepal, usually during the rainy days, major cities face a similar kind of drainage blockage resulting in flooding and disrupting daily activities. 

Air pollution 

During the intricate process of curing tobacco leaves, a cascade of harmful chemicals is released into the air, becoming a significant contributor to air pollution in regions dominated by tobacco cultivation. This airborne pollution transcends the boundaries of the tobacco fields, casting a shadow over communities and posing a direct threat to the health and overall well-being of the people residing in these areas.

Tobacco cultivation contributes to air pollution. Additionally, the act of smoking cigarettes itself significantly impacts air quality. Combusting cigarettes releases over 7,000 chemicals, with at least 69 known to be carcinogenic and many possessing poisonous properties.

A study conducted in Italy revealed that cigarettes emit particulate matter into the air at a rate 10 times higher than that of a diesel engine. The combined emissions from cigarette smoke and tobacco cultivation directly contribute to climate change.

The hazards of secondhand smoke are widely recognized, emphasizing the importance of considering it not only as a public health concern but also as an environmental issue.

Global impact and social responsibility

The link between the tobacco industry and environmental degradation cannot be ignored. As consumers, it is imperative that we consider the environmental consequences of our choices. Advocacy for corporate responsibility and sustainable practices within the tobacco industry is crucial for mitigating its global impact.

Tobacco is cultivated in 125 countries, involving around 33m farmers, often receiving direct support from tobacco companies. This labor-intensive, low-yield crop demands substantial pesticide use. According to UNICEF, if the land were utilized for food production instead, it could potentially benefit 20m hungry people.

Beyond the smoke rings

In the quest for a healthier world, we must not only address the health risks associated with tobacco use but also confront the environmental consequences. It is time to unmask the hidden toll of tobacco on our planet and collectively work towards a more sustainable and responsible future. The most impactful strategy is to cease smoking altogether and, concurrently, to launch awareness campaigns discouraging the initiation of smoking.

Unveiling the concealed toll that the tobacco industry exacts on our planet, it is incumbent upon us to collaboratively forge a more sustainable and responsible future. Governments, through measures such as environmental taxes on cigarettes, can play a pivotal role, as evidenced by the positive step of enacting an environmental tax as  taken by nations like Benin, Chad and Gambia. Such proactive measures not only serve to discourage the consumption of environmentally harmful products like cigarettes but also contribute to revenue generation for the government. The imposition of environmental taxes aligns with broader global efforts to address public health concerns and mitigate the impact of climate change. By adopting such policies, governments demonstrate their commitment to creating a sustainable and healthier future for their citizens.

The recent initiatives taken by local authorities in Nepal, particularly by the Kathmandu Metropolitan City, to ban plastic-wrapped tobacco products are commendable beginnings. Nevertheless, the Supreme Court has issued a verdict to halt its implementation until the court takes a final decision. The government has the opportunity to take further steps by introducing environmental taxes on tobacco products, prohibiting the use of plastic wrappers and facilitating the transition of tobacco farms to cultivate alternative crops.

At an individual level, supporting policies banning single-use plastics, encompassing cigarette filters, smokeless tobacco pouches and disposable electronic cigarettes takes us toward a cleaner, healthier planet. In dismantling the smoke rings that shroud the environmental impact of tobacco, we embark on a collective journey toward a sustainable and responsible future. 

From Aug 1-Aug 7, the globe is uniting to make the World Breastfeeding Week (WBW) 2023 a success by bringing to light a multitude of barriers nursing parents face at the workplace. Determined by the World Alliance for Breastfeeding Action (WABA), this year’s theme, “Enabling breastfeeding: Making a difference for working parents,” serves as a clarion call for enhancing support systems for breastfeeding in professional settings.

Situation in Nepal 

The Nepal Demographic and Health Survey 2022 shows that breastfeeding practices in Nepal reflect an encouraging trend with nearly all children under the age of two having been breastfed at some point. The early initiation of breastfeeding is evident as approximately 60 percent of children are exclusively breastfed during the first two days following birth, and over half (55 percent) are breastfed within the first hour of life. This is an essential practice for establishing a strong maternal-child bond and providing vital early nutrition. The World Health Organization (WHO) guidelines recommend exclusive breastfeeding for the first six months of life. In Nepal, adherence to this guideline is not strong, with 56 percent of children under six months, who live with their mother being exclusively breastfed. Moreover, it's worth noting that about one percent of children under six months are not breastfed at all, indicating a need for continued public health efforts to promote and support breastfeeding for all infants.

Significance of breastfeeding

Breastfeeding, a natural but crucial part of early childhood development, brings enormous health advantages to both the mother and the baby. Breast milk, packed with essential nutrients, bolsters the child’s immune system, thereby reducing the risk of numerous health complications. Simultaneously, breastfeeding aids maternal recovery post-delivery and forms a unique bond between mother and the child.

However, breastfeeding is under siege from various factors, the most prevalent of which is the challenges at the workplace. It is the primary reason why many women either do not initiate breastfeeding or terminate it prematurely, undermining the recommended minimum of six months of exclusive breastfeeding.

Role of maternity leave

The duration of maternity leave is pivotal to the breastfeeding narrative. It offers mothers the necessary time to recover post-delivery, establish a breastfeeding routine, and nurture a bonding experience with their newborns. It is disconcerting that parents with less than three months of maternity leave reported truncated breastfeeding durations compared to those availing three or more months of leave. These findings shed light on the urgent need to revisit maternity leave policies worldwide. The government should provide at least 6 months of maternity leave to foster breastfeeding. 

Global support

Across the globe, a disturbingly meager number of countries mandate workplace breastfeeding facilities—only 42. A breastfeeding-friendly workplace necessitates facilities such as clean and private spaces for expressing milk, appropriate storage facilities, and flexible break times. Without these provisions, the mission to extend breastfeeding duration faces a steep uphill struggle. In Nepal, we still struggle to find a proper breastfeeding space in the workplaces, and also in public spaces such as restaurants, airports, parks and movie halls. An urgency to establish breastfeeding corners is crucial to create a conducive environment for mothers to breastfeed their children. 

Sustainable development

Breastfeeding serves as a potent tool for battling inequality and driving sustainable development. The global recognition of this fact is evidenced in the alignment of WBW themes with the United Nations' Sustainable Development Goals (SDGs) since 2016. Addressing the disparities that hinder breastfeeding contributes to an array of SDGs, such as reducing poverty, promoting good health, and achieving gender equality.

Making a difference

This year’s WBW theme underscores the urgency to enhance supportive environments for breastfeeding in workplaces. The achievement of such an environment is not a solitary task; it requires concerted efforts from all stakeholders—employers, policy-makers, health professionals, and the society as a whole.

Employers play a critical role in shaping breastfeeding-friendly workplaces by offering extended parental leave, creating private lactation rooms, and introducing flexible working hours. These measures not only boost employee satisfaction and retention but also contribute to the overall societal well-being by supporting child health and development.

Policy-makers, on their part, need to enforce comprehensive laws mandating adequate maternity leave and breastfeeding facilities at the workplace. Health professionals can foster a supportive environment by educating new parents about the importance of breastfeeding and assisting them in overcoming any challenges they may face.

Society’s role is equally vital. Breaking down the societal stigma surrounding breastfeeding, especially in public spaces, is essential. Understanding and supporting the needs of breastfeeding parents is a shared responsibility that helps to build a more inclusive community.

Legacy of WBW

The annual observance of WBW, initiated in 1992, commemorates the historic 1990 Innocenti Declaration. Through diverse themes—healthcare systems, women and work, the International Code of Marketing of Breastmilk Substitutes, community support, ecology, economy, science, education, and human rights—it fosters awareness and champions policies to encourage breastfeeding.

In 2018, a World Health Assembly resolution endorsed WBW as a pivotal strategy for breastfeeding promotion, further cementing the global consensus on the importance of breastfeeding and the pressing need to bolster support for nursing parents, particularly within the workplace.

Conclusion

As we step into World Breastfeeding Week 2023, the challenge to support nursing parents at the workplaces is ever-present and ever-daunting. But it's a challenge we must face head-on. It’s time to normalize breastfeeding in every sphere of life, particularly in professional settings, and to make the dialogue about breastfeeding an integral part of our societal conversation. This week, let us renew our commitment to making workplaces truly supportive for all parents, nurturing a healthier and more equal world for future generations.

The author is a public health expert at Nepal Development Research Institute

The tobacco epidemic is one of the biggest public health threats, responsible for more than eight million deaths per year around the world. It’s estimated there were 37,529 tobacco-related deaths in Nepal in 2019—19.4 percent of total deaths that year. Despite various efforts to reduce tobacco use in Nepal, the prevalence of tobacco has been consistently high in the last decade. According to the STEPS survey, the prevalence of tobacco use was 30.8% in 2012/13 and 28.9% in 2019. Recently, a survey conducted by Nepal Development Research Institute in December 2019 found that these prevalence rates are even higher, at 31.7 percent. The reason for the increasing consumption may be attributed to the numerous tobacco companies’ innovative and focused marketing methods and tactics as well as lax regulation on tobacco use. Numerous tobacco products are made, tobacco control regulations are not strictly enforced, and these products are readily available and reasonably priced, all of which contribute to the rising tobacco use among young people. The use of newer tobacco products, such as hookah and e-cigarettes, is rapidly increasing among youths. Young people are consuming new forms of tobacco products without realizing that they contain tobacco. Since almost all tobacco product use starts in adolescence or early adulthood, it’s crucial to prevent juvenile tobacco product use in order to reduce mortality. All forms of tobacco are toxic to human health. There is no safe level of tobacco exposure. Hookah, also known as a water pipe, narghile, and shisha, is a common form of tobacco in many countries. Around the world, hookah smoking has increased recently, particularly among young people. Newer evidence suggests that children are experimenting with this form of tobacco as well. There are concerns that young people in Nepal are also imitating this trend. Hookah comes in a variety of flavors (such as apple, mango, peach, lemon, mint, cherry, chocolate, coconut, watermelon, etc.) that are likely to appeal to young people. Nowadays, hookah smoking is frequently done in groups and is considered a part of socialization among youths. The expanding hookah market and its popularity among young people are serious concerns as hookah poses numerous health risks. Various studies have shown that hookah smoke contains at least 82 harmful substances and carcinogens. Carcinogenic poly hydrocarbons (PAH), carbon monoxide (CO), ultrafine particles, formaldehyde, nitrogen, nitric acid, nicotine, phenols, and phenol derivatives have all been found in shockingly high concentrations in water pipe tobacco smoke. Despite the smoke passing through water, the harmful, addictive compounds generated by tobacco are not eliminated. The burning of charcoal, which produces poisonous substances including carbon monoxide (CO) and polyaromatic hydrocarbons, is another source of one of the worst emissions (PAH) which possess additional health risks. Nicotine is a highly addictive chemical that has been related to a number of negative health consequences for the growing fetus if consumed during pregnancy and can have long-lasting negative impacts on adolescent brain development. Also, studies conducted around the world reveal that hookah contains considerable amounts of nicotine, tar, and heavy metals, and smoking has cumulative effects on cardiovascular disease that can be both acute and long-lasting. Increased heart rate, blood pressure, the prevalence of coronary artery disease, heart failure, myocardial ischemia, and worse outcomes, including mortality linked to these disorders are only a few of these impacts. It’s documented in some research that smoking tobacco with a water pipe for an hour emits the same amount of smoke as 100–200 cigarettes. Hookah smokers are 2.2 times more likely than non-smokers to experience long-term cardiovascular consequences. It has also been shown that hookah smokers are more likely to develop esophageal cancer than non-smokers. Because hookahs are shared by several smokers and come in direct contact with the mouth, infectious diseases related to the lungs, mouth, lips, and gums can be transmitted easily to other persons during a session. Contagious diseases such as flu and oral herpes, as well as more severe conditions like tuberculosis and hepatitis, can spread from hookah smoking. Also, second-hand smokers, such as employees at hookah restaurants and people who cohabit with hookah smokers, are at considerable risk of major health problems due to the smoke from hookahs and their hazardous compounds, some of which are present in higher concentrations than in cigarette emissions. In Nepal, Hookah flavors and accessories are easily accessible and available through online shopping. Hookah pipes are sold without age restrictions, and are available at coffee shops, public places, and households. The fact that it’s also quite cheap has contributed to increased hookah consumption among youth. Hookah establishments are targeted at adolescents and youth and have opened near educational institutes. It’s often considered that a restaurant without a hookah bar cannot attract people, so most restaurants and lounges in the city area have made arrangements to have a hookah bar. The directive on Printing Warning Messages and Pictures on Tobacco Product Boxes, Packets, Cartons, Parcels, and Packaging Materials, 2014 has made provision that health warnings on tobacco packs should cover 90 percent of the front and back of the pack. The message should include: ‘Cigarette smoke contains carcinogenic chemicals, including Benzopyrene and Nitrosamine’, ‘Stop smoking’ and ‘Nicotine, tar, and carbon monoxide in cigarette smoke can cause heart and lung problems’ in the left- and right-side panels. But the provision has not been made compulsory for hookah products in Nepal. The prevention and control of tobacco use have never been a priority among political parties in Nepal. There haven’t been any debates or on tobacco use in the lead-up to the federal election. Governments are willing to tolerate disease and death brought on by tobacco use just because tobacco products generate a substantial amount of revenue each year. Tobacco smoking has no benefit at all. All political parties in Nepal should look into curbing tobacco use. Tools such as taxing tobacco, and the implementation of tobacco control acts, policies, and regulations should be the priority of all political parties. The new government to be formed after this federal election must give special emphasis on saving Nepalis from the tobacco epidemic.