Modern Medicine and International Aid: Khunde Hospital, Nepal, 1966–1998
Book review – by Vivek Neelakantan
Does the implementation of foreign aid follow theory? Although there is a burgeoning historiography of international aid and its impact on the developing world, little is known about how international development translates from policy to practice. Susan Heydon’s Modern Medicine and International Aid is a pioneering case study that focuses on the Khunde hospital in the Khumbu (Everest area) the intersection of mountaineering of Nepal. It examines philanthropy led by Sir Edmund Hillary, the Sherpa perception of illness, Western medicine and international aid to assess the wider role of the hospital in the provision of community health services. Configuring the medical history of Nepal within the dominant discourse of postcolonial international aid poses a historiographical dilemma as the country was never formally colonised, although Western medicine was a part of the modernisation discourse. Neither a discourse on the diffusion of international aid to Nepal from the West nor a subaltern Sherpa perspective would fully unearth the complexities inherent in the implementation of international medical aid, which was characterised by an ongoing interaction between different people with different ideas, needs and considerations.
Expedition medical practice in Nepal during the 1950s began as a response to the shortage of biomedical facilities in rural areas. Initially, expedition teams treated patients on a short-term basis. The Khunde hospital began as Hillary’s private aid programme in 1966 as part of his efforts to assist the Sherpa population of Nepal after scaling Mount Everest in 1953.
Sherpa beliefs and practices of sickness identify the cause of an illness rather than treating its symptoms. Therefore, identifying external agents of disease, such as pem (witch spirits), determined whether a person would consult the lhawa (spirit medium), the amchi (practitioner who ascribes disease to a derangement of bodily humours), the lama (Buddhist religious teacher) or the Khunde hospital. Although the Khunde hospital became an agent of change by introducing Western medicine, the use of the hospital was affected by the Sherpa cosmology of illness and wellness, and providing health services at Khunde hospital has thus involved a negotiation of the Sherpa medical cosmology with Western medicine.
Aid programmes in the 1950s and 1960s operated within a framework that contained specific ideas and practices regarding what was appropriate for a low-income country such as Nepal. Ideas about aid in the 1950s focused on providing technical assistance to low-income countries. New Zealand was an active participant in the Colombo Plan for Economic Development in South and Southeast Asia, which was a Cold War response to check the spread of communism in Asia through programmes of technical assistance for low-income nations. New Zealand aid to Nepal prioritised the sharing of expertise in dairying and pasture development. Although New Zealand rejected Hillary’s request for funding for the Khunde hospital in 1963, Hillary used New Zealand diplomatic channels to overcome Nepalese bureaucratic hurdles.
The Nepalese government had an ambivalent position towards international aid in the 1950s and 1960s because the aid donors had diverse agendas that were sometimes at odds with Nepal’s sovereignty. The Nepalese government was aware of the complex relationship between international aid and the geopolitics of the Cold War; therefore, it preferred to deal with Western governments rather than dealing with private aid donors on a one-to-one basis. From the 1970s, the ‘primary healthcare’ model – which prioritised community participation and emphasised preventative rather than curative health services – became the dominant leitmotif of international health initiatives. ‘Community participation’ was a slippery term in a Nepalese context as international health initiatives failed to achieve desired social change for the poor and marginalised groups. In the Khunde hospital, Hillary initiated the Hospital Advisory Committee to familiarise the Sherpas with hospital administration, without any result as Sherpas deferred hospital administration to the doctor. Tuberculosis was an important issue in Khunde, and overseas health volunteers attempted to use the Hospital Advisory Committee to ensure the compliance of the people in treatment but were unsuccessful.
The Khunde case study illustrates that the implementation of foreign aid does not follow theory. Susan Heydon forces us to rethink one of the fundamental postulates of international medical aid, which states that people will use Western medical services once they are convinced of their efficacy through health education programmes. This assumption proved wrong. Despite the multiple therapeutic options available for the Sherpas, the poor utilisation of biomedical facilities in Nepal’s Khumbu region continued. However, social determinants (such as class, gender, ethnicity and education) affect the utilisation of health services; this deserves further attention in the monograph.
Heydon S. Modern Medicine and International Aid: Khunde Hospital, Nepal, 1966–1998. Orient BlackSwan; 2009.
Vivek Neelakantan is a doctoral student at the Unit for the History and Philosophy of Science, The University of Sydney, and is working on the development of Indonesian social medicine in the 1950s.