Medicines and primary healthcare in the Himalayan region
By Susan Heydon
Almost one-third of the world’s population still lacks regular access to medicines, especially in much of Africa and South Asia, but programmes to improve global health to a large extent rely on people having access to and using medicines. The World Health Organization guidelines frame official policies in the Himalayan region, but their implementation presents many challenges. The aim of my project is to examine how medicines have influenced people’s use and non-use of health services, particularly in primary healthcare, which from the late 1970s became the main focus of international and global health programmes.
Medicines are an integral part of treating sickness, not only in biomedicine but also in other medical systems. Their central role in the introduction and spread of what the Nepal Ministry of Health and Population website refers to as the “modern system of medicine”, however, has received inadequate attention in histories of medicine. Such accounts have looked at knowledge, disease, institutions and people, but their consideration of medicines is mostly an implicit assumption of their presence or lack rather than an explicit examination of their importance in health programmes and people’s experiences of sickness. A much richer source of literature for the role of medicines is the many anthropological studies that have been undertaken, especially from the 1980s.
The project is at an early stage, starting with a return to my doctoral case study of Khunde Hospital in the Mount Everest area of Nepal. While references to medicines are scattered throughout my recently published book, Modern Medicine and International Aid: Khunde Hospital, Nepal, 1966–1998, I did not explore their centrality to medical encounters. Although it has always been called a hospital, Khunde Hospital operates primarily as an outpatient clinic with facilities for a small number of inpatients. The hospital was built in 1966 by New Zealander Sir Edmund Hillary and administered as part of his ongoing aid programme to the mainly Sherpa inhabitants of this rugged region. I principally saw medicines from the perspective of the hospital staff, whose aim was to ensure that the hospital had sufficient, appropriate medicines for treating patients. Medicines, if implicitly an integral part of medical practice, were explicitly a supply issue.
Similarly, when I looked at people’s use and non-use of services between the 1960s and the late 1990s I did not focus on the medicines, yet they were central to perceptions of efficacy that underlay people’s pragmatic and selective use of the hospital and modern medicine. The many new medicines, particularly antibiotics, were revolutionising medical treatment, especially for infectious disease. Nevertheless, staff had to adapt their practice to the way people used or did not use the hospital. Short courses of medicines were best. People came for pills that could free a person from pain, but injections received a mixed response. The hospital soon became the main provider of biomedical services, but even in the late 1990s a family declined an injection of pain relief for a terminally ill patient because they believed other people would blame the hospital when he died.
Since the 1950s, mountaineering expeditions and tourists have played a major role in the introduction of modern medicine into the Everest area. Visitors (medical and non-medical) carried medicines when they travelled for their own use, for expedition employees and for treating local people who approached them when they passed through an area. The handing over of some medicine remains a key part of the medical encounter. New Zealand mountaineer Norman Hardie, in his book about his stay among the Sherpas in 1955, wrote how an expedition could train a local employee about “the uses of the appropriate pills”, which he could then use to treat various diseases and so help to “slowly diminish the deep-rooted superstitions that exist in the home villages”. The rise of tourism has underpinned the economic development of the region. While tourists remain a source of medicine donations for the hospital, the medicines tourists carry have had an influence on medical practice there. In the case of diarrhoea, which is common, local people know tourists carry antibiotics that are effective and, unsurprisingly, they also want them.
Change remains ongoing in the Everest area. Until recently, medicines were obtained from the hospital or village clinics, either free or at minimal cost, but the first pharmacy shop has opened. This has economic implications and will also affect the way medicines are obtained and circulate in the community. It also raises issues about quality and use. In another example, the hospital’s 2008/09 annual report mentions that a group of patients are on anti-hypertensive medication, which they are taking regularly.
In the past, compliance with taking medicines over long periods, such as for treating tuberculosis, has been a major challenge for hospital staff. A further issue that remains important is that Khunde Hospital continues to provide health services within the area’s plural medical environment. Sherpas originally came from Tibet and a new Tibetan medicine clinic has been established in the main centre, Namche Bazar, and this is aimed at both tourists and local inhabitants.
Medicines, therefore, have a key role in prevention and treatment, and this will continue with the expansion and development of new medicines. Increasing costs also have important implications for individuals, national governments and, in countries such as Nepal, aid organisations and international and global agencies.
One of the conclusions from my earlier work was that, even when services were offered and adequately resourced, implementing health programmes did not necessarily work out as successfully as hoped for. Beginning in the Everest area of Nepal, but with the intention of broadening the study area, this project looks to better understand the role of medicines in people’s use of healthcare services.
Dr Susan Heydon is Lecturer in Social Pharmacy at the School of Pharmacy, University of Otago, New Zealand.