Ian Harper, Professor of Anthropology, Health, and Development at the University of Edinburgh, talks to Alice Street about his book Development and Public Health in the Himalaya: Reflections on Healing in Contemporary Nepal.
AS: Ian, maybe you can tell us a little bit about your history as a medical practitioner, and how you came to work in Nepal.
IH: Well, I had been practising as a physician for about five or six years in the UK, both in hospitals and as a GP. I’d known about the job of working in Nepal with an International Non-Governmental Organisation (INGO), the Britain-Nepal Medical Trust (BNMT), with the grand title of Hill Doctor for a number of years, and I applied and got the post. That started in 1990. The job involved living in rural parts of east Nepal and running TB clinics—two of them, one in Dhankuta District, one in Sankhuwasabha District. I was working with the government and public health workers to think about how to control tuberculosis. I did that for nearly four years. Two years as a Hill Doctor and then a year and a half in a more managerial role, running, or being responsible for running, services and HR stuff for the INGO I was working for in the eastern parts. The area had a population of about two and a half million.
AS: And what made you give that up to become an anthropologist?
IH: Did I give it up? I suppose I did. I developed a number of questions around the practice of medicine in a highly pluralistic healing environment on the one hand. And on the other hand, [it] was a more self-reflective attempt to understand the political and economic conditions that allowed me to be there in the first place—so the conditions under which myself as a foreigner, practising medicine within the context of development, was able to work in this particular environment. I thought that when I finished that I’d either do a masters in public health, or anthropology would be a way of understanding these issues in more detail. Of course, I hadn’t fully appreciated that anthropology was even more reflexively anxious than public health. Public health didn’t have any anxieties or qualms about what it was doing, whereas anthropologists were nervous about all sort of things—the right to speak and so on and so forth.
AS: Can you think of any experience that you had in Nepal that made you feel that there were problems to be addressed, and that you weren’t able to address through your position as a hill doctor?
IH: One issue can be reflected in cultural differences, reflected for example with groups like the Gurung (Tamu), who are a tribal group, to use an old parlance. And I remember an elderly man who was diagnosed with TB, and it was treatable, it was drugs-susceptible. But he, after a conversation with his family, refused to live in, to stay in the kind of restroom that we had, in order to have his streptomycin injections. And it was more important for him and his family to control the manner of his dying, such that the local healers, the shamanic practitioners, could lead his soul to the land with the dead, so he wouldn’t become a hungry ghost. So in that sense, wellbeing involved a good death as well. So there were questions that arose about what does health mean, and what does being instructed by medicine mean, in a context where there are other forms of practices, which define healthy wellbeing in a totally different way. So that’s one example.
AS: The introduction of biomedicine into a pluralistic medical environment is very much what your book is about. Maybe you can tell us a little bit more IH: Well, one of the things that struck me was the ubiquitous and ever expanding availability of pharmaceuticals. So on the one hand you’re introducing alien diagnostic principles, if you like, into an environment where those forms are unstable and aren’t necessarily accepted by people. On the other hand you have increasing material availability of drugs, which are taken in increasing numbers. So that’s one kind of facet that interested me. And that led not only to this book, but also to further research looking at the expansion of pharmaceuticals and their production and distribution, So that’s one issue. Another issue was the relationship between development funding, resources, and medicine. And the resource availability, I suppose, and the availability of practitioners. So you have a situation where you have a whole new tier of health workers, whose understanding of health has changed radically within a generation. So from understanding health to be related to witchcraft and human imbalance and so on, to an understanding that it’s more biomedical. So these transformations had happened rapidly, and it was trying to grapple with that and gain a sense of this and that drove me to write this book.
AS: Medical pluralism is something that has fallen off the medical anthropology agenda a little bit in recent years, perhaps alongside an increase in the focus on global health. Do you think that your book puts it back on the agenda, or that it needs to be put back on the agenda in some way?
IH: Well, I think so. Because the practices do fall into an extraordinary range of other practices. And so, on a very pragmatic level, that’s what you’re dealing with—people’s different understandings of health, different access to different healers, and so on. And the relationships that they develop between themselves, and how their own practices themselves change in relationship to the introduction of biomedicine, and how biomedical practices move in relationship to the understanding that they have with these other practitioners. So that’s the environment within which you’re working. So it is a shame that it’s fallen off the agenda really, and I think it should come back.
AS: One of the things I found really refreshing about your book was exactly this focus on the practicalities involved. The kind of theoretical framework you provide us with is one in which biomedicine as a particular kind of discursive formation of knowledge is able to travel and be stabilised in these complex and difficult environments, through certain kinds of technologies and programmes and strategies. But what came across to me ultimately was how fragile biomedicine was—not biomedicine as a domineering form of power and knowledge in this space, but actually people were desperately trying to find a place for it and embed it and entrench it in these other complex arenas. And often weren’t making that much headway.
IH: Yes, to some extent, that’s true. As people from the social studies of science have pointed out, the introduction of protocols has been central to the attempted stabilisation of biomedical forms. So diagnostic algorithms, particular ways of diagnosing things in these particular circumstances, all lead towards a form of stabilisation. But yes, it is fragile.
AS: It seemed to me that the hospital appears in this story as a particularly powerful means of stabilising biomedical knowledge. Would you say that’s true?
IH: Yes, I think that is true. It had been there for a very long time. I mean the history of the mission hospital in Palpa District is interesting. It certainly had a very fragile political history and tenuous support. It was a form that introduced antibiotics and introduced diagnostic capabilities that had never been seen before. So people got better, for example, from infections. And its reputation increased, and the reputation of foreign doctors, as a particular kind of force, a magical force, if you like, became very powerful, which drew people from far and wide to come and seek out its services. One of the interesting things about the mission hospital was that within the mission hospital…this was an area where there was a lot of witchcraft, you know, lots of people who don’t necessarily know each other coming into contact and so on. So there was also a lot of alternative and other healers hanging around outside the wards, and sneaking in and chanting, and doing other things. And it makes it a particularly interesting site, I think, for attempts to understand these particular stabilisations.
But the very structure of the hospital itself, the very architecture, leans towards the generation of particular knowledge forms. So, as an ill person you come in with a mass of symptoms, you get characterised in a particular way, you end up in an outpatient, say for psychiatry or mental health, and you get diagnosed, and there you go. So the stabilisation, the diagnostic stabilisation, is solid there, and there are the antibiotics and other drugs that are available that can be taken. But it’s a very fragile form of stability, in that, you know, the moment you’re outside of the walls again, there are all these other multiple interpretations for understanding how you’re ill, so it can shift again. And the stories that the shamans and the herbalists and others hand out, the powers and the failures of medicine, that was a particularly interesting part of the fieldwork…talking to people about what worked and what didn’t, and what it was good for and what it wasn’t good for. And that’s when you came across this distinction between diseases of the body that hospitals were particularly good for dealing with, and other diseases that fall on you from the outside, more spiritual forces, for which [the shamans and herbalists] were better arrayed to deal with.
AS: That’s interesting, because in Papua New Guinea, traditional healers make very similar kinds of distinctions, but they’re actually encouraged to do so by medical practitioners, who say, ‘okay everything that we can deal with we will classify as biomedical problems that should be referred to us. And anything else that we actually can’t deal with, and is all airy fairy and intangible anyway, we’ll let the traditional practitioners continue to deal with those problems, because they don’t concern us and they don’t impinge on us.’
IH: That’s true to some extent, and indeed the mission hospitals set up trainings for traditional healers to deal with just that. They wanted them to become sites for referral, basically. Of course, the healers themselves had other ideas; they wanted to increase their power and influence by being able to tap into biomedical forms of knowledge. So you have use, for example, of stethoscopes by healers, who will use it to sweep out spiritual forces, or the use of a certificate, showing the power of the state, that legitimates their practices. And it’s put them in a very ambiguous space with state functionaries and the doctors, who saw all this stuff as superstitious nonsense, really, and forms of impoverishment. So that dynamic was interesting.
I witnessed a practitioner using the stethoscope for sweeping out the forces. It was due to soul loss, so he was sweeping out various forces and chanting and calling back the soul of this little kid. And at the same time, he was giving electrolyte replacement therapy because the child had diarrhoea. So they were not necessarily incompatible in the minds of the practitioners or the people themselves. It’s the doctors who can’t cope with it; they see it as this form of impoverishment and so on, and superstition.
AS: You elaborate more on the opposition between local culture and biomedicine in a case study of Vitamin A programmes. And there, you talk about the kinds of assumptions that are made about culture being the obstacle to eliminating Vitamin A deficiency. You draw on Paul Farmer’s work, and others’, to talk about the structural obstacles to people being able to eat the kinds of diets that would prevent that problem. But I was confused sometimes as to where the place of culture in your account was…
IH: Well, I suppose it depends where… let’s think about culture in various ways. One is, it’s the realm that needs to be purified, so culture is a barrier—you know, the barrier logic we find in so many medical journals. Culture is a barrier to the implementation of proper medical forms. So in that sense, you get this distinction between what is superstition and what is good practice and what isn’t. And the health workers will purify that, through thinking, using ideas of science, what is good practice and what isn’t.
AS: This is the view from the clinic.
That’s the view from the clinic, so that’s one area. But then of course, the clinic itself, or culture… at least this is the way I started to think about it, you can challenge me on this if you like. But when you become ill, it’s precisely culture that breaks down. So when you’re really ill, say you’ve got TB, that’s the point that people will do anything in order to get better. So you see the kind of dissolution of culture. And so that creates a moment of vulnerability. And it’s that vulnerability that can be exploited, that’s what missionaries exploit. And they exploit it by… well, they exploit [it], I think, rather crassly by trying to introduce the idea of the Lord, and God, and redemption.
I’ve drawn on Homi Bhabha and others here… I think he phrased it as ‘it brings a moment of doubt in the native space of enunciation.’ By which he means that it’s precisely that point where local understandings break down that you can introduce new ideas. And that’s how power works and functions. And I think that’s very true. And of course, I was as complicit in that as anyone else. So take my neighbour, whose daughter was constantly ill, constantly hot, constantly being told she’s being overheated, and on antibiotics. I teased away at the possibility of another way of thinking about it, and that allowed a space to do something about it. And that’s also what some of the health workers I worked with said they wanted to achieve… let’s introduce doubt into the way that people think about things, and then you create a fertile land for new ideas.
AS: So the view from the clinic, in that sense, isn’t always wrong.
IH: No, I don’t think so. And I don’t think my book sets up a dichotomy between right and wrong. The idea of being sceptical towards the proposed impacts and aims of particular programmes, to show that actually, often it’s other things that are happening. And we might think we know what we are doing, but what we don’t know is what we do actually does.
AS: I was really interested in the Vitamin A programme case study of… on the one hand you’ve got civil war, you’ve got out migration, and you’ve got potential famine in some areas, and extreme poverty. Which are obviously all going to impinge on the kinds of foods that you can grow and eat, and how much food they can grow and eat. On the other hand, you do also have ideas about hot and cold, which actually mean that women don’t think that you should eat green, leafy vegetables after pregnancy.
IH: With the political and economic issues around access to eating, what you can eat, what poor people can eat and can’t eat—[it] is an issue. So it’s all very well and fine, you can say, ‘well you’ve got to eat liver and eggs and stuff,’ but if you can’t afford it, you’re not gonna be able to eat it. And the other thing that struck me was that the health workers themselves often were telling people to do certain things that they themselves would never have dreamed of doing. So there was almost an internal cognitive dissonance between what they were telling others to do and what they would have done themselves. And having a child in the field was very interesting because Tara, our daughter, was a constant focus of moral discourses around how to keep children well. So how can you possibly eat green, leafy vegetables if you’re breastfeeding? And this would come from the same people who were giving out instructions to other women to eat green, leafy vegetables. So there’s this disjuncture there between science’s understanding and cultural understandings around heat and cold and so on.
AS: You also have this wonderful phrase in your account of Vitamin A, about the capsule of promise.
IH: My interviews with people on the Vitamin A programme allowed people to reflect on the past and the future in interesting ways. So they’d say, ‘oh well in the past we were a lot healthier, and there were no insecticides in the food, and so therefore we need these capsules in order to be well, even though we live longer.’ So there’s this sort of ambiguity articulated around the capsule form itself.
AS: What was really interesting in that narrative was the fact that these capsules are also associated with an outside…
IH: Indeed, with this idea of science.
AS: So our lives have changed, and they’ve changed in all these ways, which means there’s uncertainty—uncertainty about the safety of the food, about the qualities of the food, about what it’s going to do to our bodies. But in order to deal with that, we have to go even further toward this outside…
IH: One of the reasons why the mission hospital was so popular was because they had access to the drugs that people had greater faith in. Now, Nepali drugs and other drugs, we don’t trust them… but the missionary drugs, they come from foreign places, and we know them and we trust them. So there is this paradox, if you like, it’s the outside forces that cause the problem, but can also solve them.
AS: The last chapter in your book is about the TB dots programme. And this is really the aspect of that early work that you’ve taken forward, and you now have a Wellcome Trust grant specifically to study the TB dots programme. What is it do you think about TB and what you saw in the 1990s and early 2000s, about the way the TB dots programme was being implemented, that has kept you interested for so long?
IH: Well one of the reasons is that it’s the biggest public health problems in adults in Nepal, so there’s a very practical desire to remain engaged in public health work. So there’s that. And I’ve developed close ties with the TB programme and other NGOs working there. So there’s been this constant desire to try to improve the availability and access to TB services, so that’s one reason. The second reason is that the way that the TB programme was introduced through the dots programme is extremely hierarchal and not very patient centred and patient friendly. So there was a need, I thought, and had long felt, to ease up on that and to trust people and their understanding of the disease more. So it’s a very hierarchical, very disciplinary form of public health intervention.
AS: And do you think that’s changed at all since you first started working there?
IH: A little… the WHO have eased up a bit on the idea that there’s a magic bullet approach that has to be observed, so there has been some change there. Also, and sensibly, a lot of the health workers just ignore it and have other ways of supporting patients, so that’s always encouraging, it’s nice to gain a better understanding of that. Although attempts to explain that to those in positions of power in the NDP is often met with degrees of frustration that they’re not doing their jobs properly.
AS: One of the things I really liked about that last chapter was this idea that, in a way, one of the key ways in which biomedical knowledge is stabilised, is actually through it’s destabilisation, that it’s actually all the little ways in which these health workers work around the protocols and systems and categories, that they’re being asked to use that actually they make it work, and increase people’s trust and willingness to be enrolled in that programme.
IH: Yes, I think that’s right, it’s the very flexibilities that they’re able to introduce, rather than the rigid ideas, that allow those programmes to travel.
AS: What would you see as the key contribution of your book?
IH: In my PhD I purified myself of all the medicine in it, and later I thought, well that’s not playing to the strengths I had, being a dual practitioner. So I reintroduced it. I wrote it for three audiences, which is why it’s not overly theoretical and why I hope the language is accessible. I wrote it for medics working in these situations, for development workers, and for anthropologists. And so there’s a narrative arc in it, which is very much, this is what I did, this is what I thought was happening, but actually, you know, here as anthropologist I can reflect on it in a different way. That’s where the idea of scepticism came in, to be sceptical towards the intended impact of what we thought we were doing.
AS: One of your key criticisms of the ways in which, for example, shamanistic practices are represented in medical discourse in Nepal is that they present the extreme, and the extraordinary, as the norm.
IH: Yes, that’s absolutely right. And that’s modern medical power at work as well. So when you talk to doctors about these practices, they’ll always give you the one example of something horrendous that had happened. All the hundreds of thousands of contacts between traditional practitioners and people… and that strikes me as illogical and slightly daft, to not appreciate that as a form of power. It would be like me… and I saw several cases of thiacetazone, reactions to thiacetazone, where people died. But you’ve got tens of thousands of these tablets being given out… if I was to represent that as being representative of normal, that’s just wrong, it’s wrong headed, it just doesn’t make sense.
AS: I thought, ironically, that one of the messages that I, after reading this book, I would give to development workers, or medical workers, is to be a bit more pragmatic. You as the anthropologist seem more pragmatic than the practitioners. They seem so focused on a utopian ideal of development, of national development, that it often actually precludes the acceptance of and working with the conditions in which they find themselves.
IH: Yes, I think that’s right. And I have noticed that working in other contexts as well. The ideological drive does tend to drive out certain pragmatic interventions. There is the big policy stuff, and then there are the simple little pragmatic interventions. So yes, be more pragmatic, think about what little things can be achieved within the complex context within which you find yourself. Rather than thinking about sweeping changes. So I would definitely agree with you.
AS: And what would be the key message that you would want medical anthropologists to take home from reading your book?
IH: Don’t overdo the Foucault, and let’s…
AS: What do you mean—it’s full of Foucault!
IH: It is actually! No, do as much Foucault as you like! No, well, first of all, I think often the materiality of things like pharmaceuticals get overlooked in understanding pluralistic practices. I’m an empiricist really so if you get back to the empirical grounding, the areas where we work, there’s lots of practices going on, it’s trying to understand them and their relationships more. Let’s not over determine theory, apart from Foucault [laughs].
AS: I suppose one of the things I took from the book was to take seriously the real problems of public health. There’s a lot of real good that biomedicine can do, but it’s complicated because people are trying to make it travel to spaces where it has no pre-established home.
IH: Well if you think of the medical anthropological canon, it’s very anti-medicine. And probably anti-humanistic. Prior to this there were very few books actually that would reflect on medicine in a positive light. Which is ironic because Foucault, of course, quite rightly pointed out that modern forms of power work because things work. Medicine works as a modern form of power because medical interventions help people.
Medics and public health workers who I talk to have no problem with Foucault at all. They say ‘Absolutely. He’s spot on, it’s exactly what we’re trying to do.’ Whereas, peculiarly, from a medical anthropological perspective, it’s often seen as a very negative force. And I think that’s a bit of a shame. Indeed, medics and public health workers who study medical anthropology notice very quickly this very strong negative trend towards health and medical intervention. So it causes constant distress to students who come from a health background into medical anthropology. So I hope this is a counterpoint to that, with the Foucault still in it.
Ian Harper is Professor of Anthropology, Health and Development at the University of Edinburgh. He has published widely on medical anthropology in relation to public health programmes in Nepal. Between August and December 2008, at the invitation of the Director, he worked in the Nepal National Tuberculosis Programme (NTP) assisting with the implementation of Global Fund funded programmes. From 2012 he is the recipient of a Wellcome Trust Senior Investigator Grant for the project: Understanding TB Control: Technologies, Ethics and Programmes and he is PI on a grant from Phase 3 of the ESRC / DfID Joint Programme for the project “New Norms and Forms of Development: Brokerage in Maternal and Child Health Service Development and Delivery in Nepal and Malawi.” His book, Development and Public Health in the Himalaya: Reflections on healing in contemporary Nepal, is published with Routledge.
Alice Street is a Chancellors Fellow in Social Anthropology and Director of the MSc Programme in Medical Anthropology at the University of Edinburgh. Her book, Biomedicine in an Unstable Place: Infrastructure and Personhood in a Papua New Guinean Hospital, is published with Duke University Press.