Ian Harper

Navigating Diagnoses: Understanding Mind–Body Relations, Mental Health, and Stigma in Nepal

Anthropologists and psychiatrists traditionally have used the salience of a mind–body dichotomy to distinguish Western from non-Western ethnopsychologies. However, despite claims of mind–body holism in non-Western cultures, mind–body divisions are prominent in non-Western groups. In this article, we discuss three issues: the ethnopsychology of mind–body dichotomies in Nepal, the relationship between mind–body dichotomies and the hierarchy of resort in a medical pluralistic context, and, finally, the role of mind–body dichotomies in public health interventions (biomedical and psychosocial) aimed toward decreasing the stigmatization of mental illness. We assert that, by understanding mind–body relations in non-Western settings, their implications, and ways in which to reconstitute these relations in a less stigmatizing manner, medical anthropologists and mental health workers can contribute to the reduction of stigma in global mental health care.

The anthropology of public health

The Journal of Biosocial Science regularly publishes papers addressing the social and cultural aspects of disease, sickness and well-being. Most of these papers attempt to understand the prevalence and distribution of disease and sickness within and between populations as well as local responses to biomedical interventions and public health policy more generally. They fall broadly within the remit of human ecology; and they embrace a ‘factorial’ model of disease in which social and cultural factors are deemed to be just one of a number of factors to be considered alongside a range of other factors. These include biological features of the infecting organism; nutritional factors; environmental factors; psychological factors; and genetic factors influencing susceptibility to disease at an individual and population level.

Extreme condition, extreme measures? Compliance, drug resistance, and the control of tuberculosis

This paper explores the issue of compliance by focusing on the control of tuberculosis. In the last ten years, patient compliance in tuberculosis control has discursively shifted from ‘direct observation’ of therapy to more patient-centred focus and support drawing on rights-based approaches in dealing with health care provision. At the same time, there has been an increased international concern with the rise of drug resistant forms of tuberculosis, and how to manage this. This paper looks at these issues and the tensions between them, by discussing the shift in discourses around the two and how they relate. Drawing on experience from work in Nepal, and its successful tuberculosis control programme, it looks at debates around this and how these two arenas have been addressed. The rise of increasingly drug resistant forms of tuberculosis has stimulated the development of new WHO and other guidelines addressing how to deal with this problem. The links between public health, ethics and legal mandate are presented, and the implications of this for controlling transmission of drug resistant disease, on the one hand, and the drive for greater patient support mechanisms on the other. Looking forwards to uncertain ethical and public health futures, these issues will be mediated by emergent WHO and international frameworks.

The Politics and Anti-Politics of the Global Fund Experiment: Understanding Partnership and Bureaucratic Expansion in Uganda

After a decade of operations, the Global Fund is an institutional form in flux. Forced to cancel its eleventh round of funding due to a shortfall in donor pledges, the Fund is currently in firefighting mode, overhauling its leadership, governance structures, and operations. Drawing on a case study of Uganda, we look at how the original Global Fund vision to be a simple financial instrument has played out at the country level. Even prior to the cancellation of round 11, the proliferation of partners required to sustain the Global Fund to Fight AIDS, Tuberculosis and Malaria experiment led to increasing bureaucratization and an undermining of the Fund’s own intentions to award life-saving grants according to need. Understanding these effects through the ethnographic material presented here may be one way of reflecting on the Fund’s structure and practices as it struggles to reinvent itself in the face of criticism that it has impeded resource distribution.

The Politics and Anti-Politics of Infectious Disease Control

Walking from the courtyard, out of the monsoon rains, into the cool offices of a large and prosperous nongovernmental organization (NGO) in one of Nepal’s sprawling urban cities was a relief. It was the summer of 2013 and research into the politics and expansion of the NGO sector under direct influence of funding from the Global Fund to fight AIDS, Tuberculosis, and Malaria (GFATM) was underway. We had arranged to meet the director and senior members of the organization to talk about their work on HIV treatment and prevention with intravenous drug users (IDUs). The director was one of a number of high-profile human rights advocates, demanding access to antiretroviral drugs and better services, and the work of these advocates reflected a shift toward a rights-based approach characteristic of the HIV sector in health development work. We were told that the organization had started initially as a loose network of individuals supporting each other in their recovery from drug addiction. Then came the HIV epidemic, and the aid money. IDUs became a risk group, and the target of interventions to prevent the further spread of the HIV virus. ARVs followed, as did a new form of identity politics associated with these transformations. Each member of the team introduced him or herself as a ‘recovering IDU.’ After

Aid conditionalities, international Good Manufacturing Practice standards and local production rights: a case study of local production in Nepal

BackgroundLocal pharmaceutical production has been endorsed by the WHO as a means of addressing health priorities of developing countries. However, local producers of essential medicines must comply with international pharmaceutical standards in order to be eligible to compete in donor tenders. These standards determine production rights for on-patent and off-patent medicines, and guide international procurement of medicines. We reviewed the literature on the impact of Good Manufacturing Practice (GMP) on local production; a gap analysis from the literature review indicated a need for further research. Over sixty interviews were conducted with people involved in the Nepali pharmaceutical production and distribution chain from 2006 to 2009 on the GMP areas of relevance: regulatory capacity, staffing, funding and training, resourcing of GMP, inspectors’ interpretation of the rules and compliance.ResultsAlthough Nepal producers have increased their overall share of the domestic market, only the public manufacturer, Royal Drugs, focuses on medicines for public health programmes; private producers engage mainly in brand competition for private markets, not essential medicines. Nepali regulators and producers state that implementation of GMP standards is hindered by low regulatory capacity, insufficient training of staff in the industry, financial constraints and lack of investment for upgrading capital. The transition period to mandatory compliance with WHO GMP rules is lengthy. Less than half of private producers had WHO GMP in 2013. Producers are not directly affected by international harmonisation of standards as they do not export medicines and the Nepali regulator does not enforce the WHO standards strictly. Without an international GMP certificate they cannot tender for donor dependent health programmes.ConclusionsIn Nepal, local private manufacturers focus mainly on brand competition for private consumption not essential medicines, the government preferentially procures essential medicines from the only public producer while donor funded programmes rely on international manufacturers compliant with international GMP standards. We also found evidence of private hospitals bypassing national medicines approvals process.Policies in support of local pharmaceutical production in developing countries as a source of essential medicines need to examine carefully how GMP regulations impact on regulators, local industry and production of essential medicines in practice.

The Clinic and the Court: Law, Medicine and Anthropology

Law and medicine can be caught in a tight embrace. They both play a central role in the politics of harm, making decisions regarding what counts as injury and what might be the most suitable forms of redress or remedy. But where do law and medicine converge and diverge in their responses to, and understandings of, harm and suffering? Using empirical case studies from Europe, the Americas and Africa, The Clinic and the Court brings together leading medical and legal anthropologists to explore this question.

Accountability and Generating Evidence for Global Health: Misoprostol in Nepal

Postpartum haemorrhage (PPH) is a major cause of maternal morbidity and mortality in Nepal. Compounded by the remote terrain, endemic poverty, and a lack of access to health facilities, the use of misoprostol has advantages over the standard use of oxytocin for PPH management. Drawing on our qualitative study of a pilot intervention managed by the Nepal Family Health Programme, we map the institutional relationships involved in the design, implementation, and practices for bringing misoprostol into national policy. In the intense and competitive global and national policy arena, sustained lobbying and getting the ‘right people’ on board were as powerful drivers as the quality of the intervention itself. The case study takes us to the heart of the debate around the politics of generation of evidence for interventions in global health programmes, and ultimately the question of accountability for health policy and practice.

Comment — WHO outsourcing dilemma: For whose benefit, at whose expense?

In recent years, global development and humanitarian organisations have come under intense scrutiny for failure to provide to people in need. Critiques are wide ranging, and are driven by a range of issues: from ideological and political differences—the recognition of ultimate authority to intervene; critiques of western imperialism; to the practical—the failure of the system to ‘recognise’ the real issues on the ground, to more recent critiques that focus on lack of effective and efficient response in the face of global crises. The commentary ‘Outsourcing: how to reform WHO for the 21st century’ argues that the WHO has underperformed and is in need of reforms. Established in 1948, at a particular juncture in world history, the WHO is not considered to be fit for purpose in the context …

Understanding Health Research Ethics in Nepal.

Abstract Unlike other countries in South Asia, in Nepal research in the health sector has a relatively recent history. Most health research activities in the country are sponsored by international collaborative assemblages of aid agencies and universities. Data from Nepal Health Research Council shows that, officially, 1,212 health research activities have been carried out between 1991 and 2014. These range from addressing immediate health problems at the country level through operational research, to evaluations and programmatic interventions that are aimed at generating evidence, to more systematic research activities that inform global scientific and policy debates. Established in 1991, the Ethical Review Board of the Nepal Health Research Council (NHRC) is the central body that has the formal regulating authority of all the health research activities in country, granted through an act of parliament. Based on research conducted between 2010 and 2013, and a workshop on research ethics that the authors conducted in July 2012 in Nepal as a part of the on‐going research, this article highlights the emerging regulatory and ethical fields in this low‐income country that has witnessed these increased health research activities. Issues arising reflect this particular political economy of research (what constitutes health research, where resources come from, who defines the research agenda, culture of contract research, costs of review, developing Nepals research capacity, through to the politics of publication of data/findings) and includes questions to emerging regulatory and ethical frameworks.