Researching and comprehending the complexities of health and health care systems provide us interesting insights into society, especially when studied through the lens of an interdisciplinary social science perspective. This is what the two books being reviewed here attempt to do and do so, competently. The authors approach their topics from their disciplines in medical anthropology and sociology respectively, but give an interdisciplinary perspective to the themes. Subedi covers a wide range of issues relating to health research, health services, health status, ill-health and healthcare policies in Nepal by putting together ten essays, weaving in the socio-cultural and political milieu of Nepal. They form an interesting canvas of topics that give the reader a sense of the socio-economic, cultural and political determinants that impinge on the various sub-systems of health and healthcare. Jafree, on the other hand, focuses on women practitioners in healthcare and the regular violence they confront at their workplace. She too locates the women within the socio-cultural and political context and this gives us immense insights into the society where the women personnel come from.
Even though the themes of the books are diverse, the convergences lie in the fact that both books are located in South Asian societies; and the approach to understanding and analysing health seeking behaviour, healing practices and healthcare systems in these societies is through perceptions of people within communities; their experiences and negotiations with ill-health and healthcare systems in daily lives; and perceptions of those who are active actors, forming an integral part of the healthcare system. The socio-cultural construction of well-being, of the community in one instance and the women healthcare providers in the other, pervades both the books. The audience for these books are public health scholars, practitioners, social scientists studying health, healthcare systems and South Asian society and policy makers.
Essays on Pakistan’s healthcare systems are rare to come by, and being a scholar of public health, I realized there is so little research conducted on healthcare practitioners. Research mostly focuses on practitioners in the context of their work responsibilities within a public health framework or patient-doctor relations. This research was conducted over a period of five-years and methodologically rigorous, with an extensive review of literature, from global literature to studies specifically from Pakistan, followed by quantitative and qualitative methods of enquiry. The author notes that since domestic violence is at the forefront of all violence, there is negligible data on workplace violence but the highest rates of workplace violence faced by women is in the health sector.
Although we are aware that violence on healthcare practitioners is prevalent, these are mostly gender neutral insights, highlighting this violence as an occupational hazard which mostly include retaliation from angry patients and their kin in the form of verbal and physical abuse. Violence against women healthcare providers has a broader connotation—verbal, physical, emotional and societal. Jaffri’s book situates this violence within the larger determinants of poverty; class; culture and religious perceptions of women and working women; patriarchy; poor policies for women’s safety; politics and violence; organizational structures and governance of public healthcare systems, and the ways in which these perpetuate a culture of violence. Women healthcare providers are oppressed, lack autonomy and are restricted to certain disciplines, specializations and type of work. The book resonates the Indian scenario of violence that engulfs women health workers here too. Women practitioners in South Asia have historically been subservient to men, whether as mid-wives, helpers, traditional healers in the past to nurses and doctors in the present; but surprisingly in religious texts and mythology, women healers are important, recognized and hold a higher status. This comes through in Jafree’s book when she describes women healers mentioned in the religious texts.
Personal and institutional violence that women face as healthcare workers reflects their plight in the larger society and where they come from—a microcosm of regressive cultural norms and legitimacy of violence that exists in all other institutions of the society. Jaffri locates her analysis in the structural violence that exists along with theories that focus on the individuals involved in the violence—perpetrator and victim. Jaffri focuses not just on women doctors but also nurses and lady health workers (LHW) and hence the intensity of violence and the silence surrounding it across classes is something that has been well analysed. Class plays a major role in victimization of women health practitioners with those at the lower classes suffering neglect, abuse and violence. At the same time the women practitioners from the lower classes and in the lower hierarchy were open to talking about the violence as compared to the women doctors who felt they would be targeted further.
Subedi’s book is a collection of essays on health and covers a range of topics that provides insights from extensive primary fieldwork over the years in different locations and areas but the book in its entirety provides the reader with the larger picture knit together.
The first chapter sets the tone for the rest of the essays to follow, by spelling out the ‘traditions in research’ on health in Nepal as mostly seen through the eyes of western scholars and earlier anthropologists who have studied Shamanism, local healing practices and magical practices in the context of culture. Most of this work has focused on cultural and social context of communities but the weaving of complex processes for a comprehensive understanding is missing.
The chapters delve into different therapeutic traditions and pluralism in knowledge and practice, and faith-based healing and local health traditions, central to communities’ lives; perceptions of illness by the community that include linking of nature, environment and behaviour with illness, and this determines the health-seeking behaviour of people and the multiple traditions that they negotiate. The highly heterogeneous category of traditional practitioners has a significant presence in Nepal. Subedi suggests that there must be policies with regard to traditional health care or the indigenous pharmacopoeia that might be lost. This resonates with the Indian case of traditional medicines as well as local health traditions. The practitioners need to be brought under some regulatory framework from education, training to absorb the practitioners in the public health system and mainstreaming their practice.
Another chapter focuses on a systematic relationship between food categories and people’s health seeking behaviour during illnesses. The underlying conception is that food determines people’s moods and actions–cold, hot and stale food–health is thought to depend on maintaining balance of body temperature. A chapter on disability delves into the methodological concerns of defining disability and the inclusive and exclusive criteria. The story of pharmaceuticals in the chapter on ‘trade in health services’, is similar to what we hear in most developing countries, but a significant issue nevertheless since it does affect accessibility and affordability. The concluding chapter summarizes the policies on health in relation to the politics and spells out the challenges and what the possible agenda could be for change.
The chapter that is indeed significant and does not get much focus or emphasis in public health literature is that of the communication aspects in health care work. What has generally been in common discourse of practitioners in the last few decades have been ‘Behaviour Change Communication’ and ‘Information Education and Communication’ as preventive and promotive healthcare services. Most literature has covered these aspects from programme and provider perspective with the assumption that a certain kind of communication will lead to a desired change in behaviour. Communication is a two-sided process, where it is critical to understand the language of the community in describing illness, diseases, health seeking behaviour and appropriate culturally sensitive ways of communicating. Subedi rightly concludes the chapter by saying that communication cannot address systemic issues related to health like poverty or lack of access to health care but a comprehensive health communication programme should include systemic exploration of all factors that contribute to the health of the population. Communication is also critical to provider-community relation and building trust. Healthcare services must accommodate the cultural constructions of well-being and, agency of the community and individuals should be understood with respect to culture. Gaining the trust of the community towards healthcare and its various sub-systems should be prioritized and aligned to the cultural meanings which is a value that a public health service system must seriously build.
The two books are extremely important readings for social scientists. Policies need to embrace such insights in order to formulate effective programmes that incorporate views and voices of community and providers who are part of the system but, sadly most of the times policies take the easier path of being techno-managerial and not addressing the human component effectively.
Madhurima Nundy is Associate Fellow, Institute of Chinese Studies, Delhi.