State, Society and Health in Nepal
This collection of essays is a welcome addition to the literature about the health sector in Nepal. Its author, Madhusudan Subedi, is a professor at the Department of Sociology, Tribhuvan University, Nepal. From its front cover the theme of the book is clear as the title encapsulates that health - and ill health - is a complex interplay between health issues, the state and society. This slim, well produced book (although unfortunately Mary Cameron appears in the index and reference as Marry) is part of Routledge’s Nepal and Himalayan Studies series with its aim of bringing the wider Nepal and Himalayan region to the forefront of scholarly attention and exploring critically important issues facing the region. The essays in this collection which form chapters two to nine have been published previously and separately over a number of years but in harder to access publications.
They cover a range of both familiar and newer topics – medical traditions, indigenous knowledge, gender and health, disability, pharmaceutical business – but for this edition the essays have been revised and updated. Chapter one is an introduction to different research traditions about health and society in Nepal, while chapter 10 – the final chapter – provides an overview of current health policies and politics with suggestions for the ongoing development of the health system. The book has a foreword by Marit Bakke, emerita professor, University of Bergen, Norway who is also a co-author of the chapter on communication and health and with whom Subedi has collaborated for many years.
The strength of this book is the author’s considerable knowledge and wide experience of the Nepalese health environment. While the study to date of disease, medicine and public health in Nepal has been conceived largely in terms of development and anthropological perspectives, it has often been written by outsiders – as is the author of this review.[i] This situation is, however, changing. While several of the contributors to The Dynamics of Health in Nepal are Nepali, many are now based outside the country.[ii] Subedi lives and works in Nepal. As he has written at the start of his final chapter – ‘During the last 15 years, I have travelled in more than 60 districts, ranging from very remote mountain districts to hills, and to relatively easily accessible areas in the Tarai districts. Visiting different places and interacting with people with different cultural and economic backgrounds, and hearing their experiences, have helped me to understand the ground reality of Nepal’s health system, its services and management’ (p. 168). Over this time Subedi has carried out a wide range of research and has also taught medical, public health and social science students.
The aim of the book is to focus on the social and cultural aspects of health to deepen the understanding of Nepal’s health sector. Subedi uses his knowledge and experience to make insightful points. For example, he comments that the government will distribute resources at the time of an epidemic yet does not consider the relevance of sociocultural understanding to better respond to different people’s specific needs at the time (p. 13). Such context matters whether thinking about health in the past, present or future. Much of the research in his initial overview reflects the historical interest of researchers at the time, but many of these older topics remain relevant today. Medical pluralism, for example, is still an important theme in Nepal’s health environment and is returned to throughout the book. Disability is of more recent interest. Here Subedi’s approach is to highlight the importance of definition and asking the right questions. His interviews in a mobile camp for women with uterine prolapse highlight the ongoing challenges surrounding this sensitive topic. Nepal, however, is experiencing rapid social change that needs further investigation. The interviews that form the basis of his chapter on the pharmaceutical industry are revealing. As neo-liberal ideas and policies take hold, Subedi notes dismantling in the public health sector and the rise of an unregulated private sector where financial interests take precedence over those of patients. Much has been achieved in the health sector but much remains to be done. Further research is needed to inform policy that can respond to current health challenges in Nepal but, as Subedi argues throughout the book, the policy issues that emerge need to consider health within a broader context of people’s values and relationships.
The book, however, has an inherent weakness as each chapter has already appeared as a stand-alone article. One of Subedi’s aims is to show the development of medical anthropology as a discipline and its relevance for Nepal but there is a tendency that collectively this is too prominent in the book. The richness of Subedi’s data can get lost in the theoretical underpinning of each essay. When Subedi started medical anthropology in Nepal the topic was relatively new and so an introduction was understandable. That said, health professional students still often lack an appreciation of the wider factors that influence health in Nepal that are the heart of this book.
[i] See for example: Ian Harper, Development and Public Health in the Himalaya: Reflection on Healing in Contemporary Nepal, Chennai: Routledge, 2014; Susan Heydon, Modern Medicine and International Aid: Khunde Hospital, Nepal (1966-1998), New Delhi: Orient BlackSwan, 2009.
[ii] Sharada Prasad Wasti, Padam Simkhada and Edwin van Teijlingen (eds), The Dynamics of Health in Nepal, Kathmandu: Himal Books, 2015.