State, Society and Health in Nepal by Madhusudan Subedi

Madhusudan Subedi. 2018. State, Society and Health in Nepal. Abingdon: Routledge.

Nurturing critical knowledge is important for transforming the existing situation of anomalies in Nepal’s health care system. In this context, Madhusudan Subedi’s important book provides explorative and descriptive perspectives on existing health related issues and practices, providing a broad overview of health related policies and programs in Nepal. This book presents the interplay between the causality of ill health and sociocultural processes through which people try to understand and cope with illnesses in Nepal.

The first chapter, “Traditions in Research on Society, Culture, and Health in Nepal,” throws descriptive light on different thematic areas like shamanism, health care pluralism, social suffering, pharmaceuticals, etc. The author argues that understanding the social and cultural context of health and illness is important for theoretical knowledge and for practical work to change health related behavior. In discussing shamanism, the author draws on existing research and mentions that the spiritual basis of health systems among the mountain and hill people in rural Nepal has attracted many anthropologists. However, the author limits himself to critical analysis of these earlier works on shamanism, emphasizing the influential role of shamans, their malpractices, and their role in provoking social suffering. This chapter points to some of the factors that create misunderstandings in the doctor-patient relationship, but Subedi remains silent on the orientation and nature of medical education in Nepal where medical humanism is not prioritized. Moreover, this chapter fails to reflect on the role hegemonic biomedicine has been playing in expanding health inequities and generating a new impoverished class, deprived of medical services.

In the second chapter, “Healer Choice in Medically Pluralistic Cultural Settings: The Case of Nepal,” the author insists that the presence of medical pluralism affects people’s choices and decisions in seeking different health care services in Nepal. He argues that research on illness causality sheds light on health care behavior and examinations of etiologies and folk epidemiological factors lead to better understanding of vulnerability and susceptibility. In this chapter the author displays an academic obsession to document abundant information available in the domain of medical pluralism in Nepal. However, the chapter lacks strong conceptual and methodological coherence to build core arguments. For instance, Subedi uncritically accepts the ideology from Minocha (1980), arguing that Ayurvedic practitioners have adopted methods from varied systems, incorporating the stethoscope, ophthalmoscope, and other instruments and even adopting the use of drugs and germ/virus theories in everyday practice. Still the author limits himself to questioning the trend of rapid bio-medicalization of Ayurveda and the loss of its inherent philosophy.

The third chapter basically deals with illness causation, with information derived from Kirtipur where, the author maintains, Newars perceived ill health to be caused by malfunctions within the body, linking them to changes in the diet or other bad habits. He argues that healing traditions are embedded within “cosmos-genetic” worldviews as parts of wider concepts about the origin of bodily afflictions in general, which are based on beliefs about the structure and functions of the body, and the ways it functions and malfunctions. In this chapter, the author focuses primarily on proximal determinants of disease susceptibility while ignoring distal determinants like living standards, income capacity, dietary availability, and many other factors such as the impact of modern education, mass media, and public health services in shaping the minds of many different individuals. The author is silent on the local understanding of bhåtpret, khyà and other hungry ghosts in the Newar community as a fatal causality to induce disease blaming “evil forces;” the uncritical reproduction of such values in scientific arguments normalize the existing way of thinking that conceals scientific rigor to make central arguments of this chapter more profound.

Chapter Four provides a bird’s eye viewpoint, featuring the importance of different forms of traditional healing in Nepal. Rather than providing an empirical viewpoint on any one form of traditional medicine, the author has proposed many policy provisions that should be developed by the government in order to incorporate traditional healing systems and provide a holistic model of health care. He argues that understanding indigenous knowledge is fundamental to participatory development approaches. However, in this chapter the author fails to discuss contemporary issues, given how the government has imposed many restrictions on traditional healers, creating severe ethical and legal problems, and obstructing the services that they practiced over many generations.

In Chapter Five, the author examines how local inhabitants of Kirtipur classify foods into three basic categories: garmã (hot), sardã (cold), and neither hot nor cold but intermediate. He argues that the notion of hot and cold does not usually refer only to actual temperatures, but rather to certain symbolic values and metaphorical qualities associated with each category of foodstuffs. Although the author divides his data according to educational status and gender, he does not explain the conceptual and methodological rationality for this kind of analysis, thereby failing to provide new ethnographic insights or conclusions. The author also disregards the cultural specificities and logics of Newar culinary practices, and does not cover the cycle of seasonal rituals.

Chapter Six discusses the causes, consequences, and cultural perceptions regarding uterine prolapse in Nepal. The author argues that Nepal adheres to traditional gender roles where women are not always able to make independent decisions about their reproductive health. Though the author appreciates the mobile camp approach (which includes information, education, and communication activities to deliver reproductive health service through primary health care), this chapter limits itself to the question of mobile camps’ functionality, without examining how these camps fail to attract marginalized and vulnerable social groups. In this chapter, even statements made by female Community Health Volunteers—that women have not been able to express their problems for the past thirty or forty years—are not critically acknowledged. Rather than addressing the problem, the author simply reproduces the sentence, implicitly blaming the victims, while remaining silent on the non-responsiveness of the government’s Health Service System that has compelled patients to silently cope with their sufferings for three to four decades.

Chapter Seven, entitled “Communication Aspects of Health Care Work in Nepal” (co-authored with Marit Bakke), highlights facts and findings to establish the role of communication technology and its impact on people’s health seeking behavior. In this chapter, the authors sets out to describe how communication processes must be strategically focused to cope with malnutrition and certain types of illnesses. Yet diversions into bizarre health-related issues tend to stray from the core theme of this chapter. The contents are irrelevant, focus too much on development discourse, and lose track of communication on health. This chapter is overloaded with data on demographic variables, health care situation, and elements of social development, ultimately losing sight of the chapter’s core ideas and preventing it from presenting a more substantial, profound, and nuanced picture of the relationship between mass media and public health.

In Chapter Eight, the author critically analyses causes of variations in disability rates in censuses and surveys. According to Subedi, differences in methodological approaches create different kinds of data on disability in developing countries in Asia and Africa. He argues that censuses and surveys take various approaches to defining and measuring disability, resulting in different disability rates within the same country, difficulties in statistical analysis, and problems in understanding conceptual questions relating to disability. Moreover, apart from his arguments, it would suffice to say that the proper reporting of disability is directly tied to the orientation of the actors and the commitment of the respective countries to public health as well as human rights and welfare values. Critiquing the medical model of disability, Subedi emphasizes the need for a social model of disability. Yet he is silent on the limitations of the social model of disability that may overlook individual lived experience and person-specific disabling barriers like pain and deficits as well as the psycho-emotional consequences of disability.

In Chapter Nine, Subedi maintains that pharmaceuticals reduce mortality and morbidity rates and enhance quality of life. He argues that growing Pharmaceuticalization reflects progress in medical sciences, allowing people to get medication for illnesses that were previously undiagnosed and untreated. Yet the author’s focus on pharmaceutical interventions conceals other factors shaping quality of life, such as increased living standards, growing public health awareness, and supporting social determinants. This chapter also ignores the aggressive rise of biomedicine and the marketization of health care after 1990, which is one of the most exploitative dynamics in contemporary Nepal. Subedi acknowledges how minor incentives like pens, diaries, and sample medicines have lured doctors into prescribing branded drugs. But he remains silent on more egregious factors, such as pharmaceutical companies offering expensive vehicles to popular medical doctors, sponsoring conferences and journals, and funding annual celebrations of various medical societies.

 In the last chapter, on healing and health care in Nepal, Subedi focuses mainly on topics such as safe water and sanitation, malnutrition, institutional delivery, and Nepal’s health workforce. He argues that overcoming existing health inequalities requires a sustained multi-prolonged strategy to address barriers against both demand and supply, and to build the Ministry of Health’s capacity to lead this agenda. Although the author mentions that he has traveled through more than sixty districts in Nepal, and done actual fieldwork using “casual talk methodology” to collect accurate data, these empirical experiences are not clearly reflected in these chapters as research documents. For example, in Subedi’s findings regarding the health workforce, he mentions different factors such as a top-down decision making process, mismanagement in selecting appropriate candidates, the security issue, and transfers based on political connections as some of the issues playing a direct role in weakening the health service system. But there are many other basic factors: such as rural isolation, insufficient infrastructural conditions, minimum opportunities, lesser opportunity for vertical mobility, and short sighted policy frameworks that directly play an adverse role.

Health science discourses in Nepal have been overwhelmingly dominated by the biomedical model of understanding. Madhusudan Subedi provides explanatory understandings beyond the biomedical domain, but his book’s contents lack theoretical consistency, methodological rigor, and empirically nuanced observations. His insistence on maintaining a relativist (“everything is equally valid”) position does little to amplify the voices of the sufferers. Ideological persistence and emancipatory consciousness are essential to establish an equitable and accessible health care system.

Reference
Minocha, Aneeta. 1980. Medical Pluralism and Health Services in India. Social Science and Medicine. Part B: Medical Anthropology 14(4): 217–223.

Sachin Ghimire
K and K international College