Development and public health in the Himalaya

Ian Harper, Development and Public Health in the Himalaya: Reflections on healing in contemporary Nepal, New York: Routledge, 2014. Hardcover, 184 pp., $231. ISBN: 978-0-41-565998-7.

Ian Harper’s extensive work in Nepal both as a doctor and later as a medical anthropologist has produced unique insight into Nepal’s pluralistic healing practices, as evidenced in his book Development and Public Health in the Himalaya. Nongovernmental organisations have brought modern interventions to this developing country, some of which conflict with existing traditional practices. Harper’s firsthand experience in Nepal leads to a complex understanding of the local medical landscape. Through case studies of mental health, the Nepal National Vitamin A Programme, and the implementation of Directly Observed Treatment, Short-course (DOTS) in treating tuberculosis (TB), the topics of pharmaceuticalisation, biomedical stability, and medical framing of foreign aid intervention are scrutinised.

Harper opens with a visual and personal narrative of his experience travelling through Nepal during the monsoon season to understand the conditions patients are expected to endure in order to obtain medical education and treatment. This frames Harper’s focus on the issue of tradition and modernity, in particular their integration in current health care. Chapter 2 outlines the historical background of the Palpa region of Nepal, where healing constitutes a major part of local culture. Harper subsequently describes politically motivated policy responsible for the rising privatisation of health services. The implementation of such health care decision making has popularised pharmaceuticals, resulting in easy access to medication that is ‘frequently medically unjustified’ (p. 27). For instance, readers learn of unnecessary prescription of vitamins and tonics, such as vitamin B for leg pain. In addition, the monetary motivation of pharmacy health workers encourages the consumption of drugs as a healthy practice that leads to good health.

In chapter 3, Harper broadens his focus to encompass the ideological discourse between modern biomedical approaches and traditional healers. Local superstitions are discussed through accounts from medical practitioners, traditional healers, and a wide range of community members. This discussion recognises allopathic medicine’s potential to be incorporated into health policy, and in particular into mental health through ‘psychological treatment’ (p. 50), which is provided by laamaas who ground their work in traditional healing practices. In order to integrate the Nepalese belief of an ‘ill-spirit’ manifesting aches or anxieties, the author argues for recognition of the power of laamas to alleviate such symptoms, in turn improving health care efficacy.

Focusing on this shift towards the growing authority of modern health practice, chapter 4 concentrates on the experience of the vulnerable, who are ‘caught in the middle’ of Nepal’s social change. Harper uses compelling examples of people of the Palpa region to demonstrate the conflict of the unmeasurable spiritual world and the scientific taxonomy of medical diagnosis. Afflictions lead many in Nepalese society to question ‘what to believe’ (p. 59) among the range of spiritual and medical diagnostic knowledge, a dilemma that frames discussions of the ‘stabilisation of knowledge’ in subsequent chapters.

In chapter 5, Harper unpacks the epistemology of Nepal’s healing culture and introduces the United Mission to Nepal (UMN) hospital, an institution symbolic of modernised foreign aid shifting the framework of medicine. Regardless of whether foreign aid was politically or religiously driven, Harper highlights obvious health disparities in rural Nepal and the influence of pharmaceutical interests and the UMN in revolutionising and accelerating health care interventions in Nepal. Turning to mental health, chapter 6 looks at the difficulties in diagnosing mental illness. Harper reveals a mutualistic relationship between international biomedicine and local traditional healing as a pragmatic approach to stabilising medical knowledge in Nepal. When doctors introduce the phrase ‘nerve disease’ to classify psychiatric disorders in a hospital environment, the diagnosis of depression is made more socially acceptable. However, the increased diagnosis of depression may be attributed to a deeper issue. Mental illness is exacerbated by Nepal’s poor social and economic environment, which challenges a population being introduced to new and foreign medical systems. Harper also exposes the impact of the antidepressant pill amitriptyline, and his discussion of this reveals a problematic shift towards the greater ease of accessing drugs, a situation intensified by the National Vitamin A programme discussed in chapter 7.

Harper’s subtle criticism of pharmaceuticalisation reaches a climax in the largest and most politicised health programme in Nepal: the Nepal National Vitamin A Programme. The ambiguity of vitamin A as a health supplement and a lack of health education led to misinformation about the capsule’s capacity to promote good health. Despite the programme being ‘supported by a scientific humanism, buoyant on a developmentalist state’ (p. 117), Harper argues that ‘[m]edicines should not be the first line of defence’ (p. 97) when issues such as micronutrient deficiencies are grounded in a lack of education and access to resources. By demonstrating how a dominant discourse of the ‘capsular promise’ sidelines other ways of looking at health, Harper exposes a suppression of the broader political issues of poverty and malnutrition (p. 120).

Nepal’s nationally implemented DOTS strategy for TB control is discussed in chapter 8. TB pharmaceutical treatment, unlike the national Vitamin A Programme that addressed superficial issues more than underlying educational and resource disparities, is a crucial part of tackling this infectious disease. Both programmes, however, contributed to the practice of pharmaceutical consumerism in Nepal. TB thrives under conditions of poverty, and a proper diet is arguably a protective factor against the disease. Harper proposes that both the vitamin A and DOTS programmes are symptoms of the same deeper, core issues of poverty and malnutrition. His criticism, which perhaps could have been made more strongly, is that once circumstances drive people to become desperately ill with a disease like TB, there is no other option but pharmaceutical treatment. Consequently, individuals outside the pharmaceutical system susceptible to TB are forced to enter health systems, which he describes as ‘bureaucratic environments’ (p. 135), creating a cycle of biomedical imperialism.

Harper’s ethnography concludes with an overarching picture of how global attitudes towards health are changing at the microlevel. Although he focuses mainly on the Palpa district, his work presents issues of pharmaceuticalisation and medical order prevalent in many developing countries with foreign health aid. This book will appeal to health care workers; undergraduate and graduate students studying arts and science; and scholars with an interest in pluralistic medical environments or health policy. Harper’s constantly self-aware and pragmatic focus towards public health brings to light the complex impact of health on society and is a significant contribution to medical anthropology and global health. 

About the author

Amanda Wang is currently in her fourth year of a bachelor’s degree program in Law and Science at the University of Sydney. Her multidisciplinary education allows for a different perspective on areas such as public health, which she hopes to pursue in the future. Email: awan7754@uni.sydney.edu.au