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DRAFT COPY : NOT TO BE QUOTEDDecision is to: To be Published for June 2017 in Health, Culture and Society. http://hcs.pitt.edu

Decision : To be Published for June 2017 in Health, Culture and Society. http://hcs.pitt.edu

Philosophical foundations of health research under neoliberalism and the case of the epistemic well.

Abstract

Philosophical foundations are the core of each individual researcher and all research questions, hypothesis, methodologies, recommendations are shaped by it. Particular modes of governance instil particular modes of philosophies. Under neoliberalism the prevailing philosophical foundations have been identified as, detached, decontextualized, depoliticized, dehistoricized, dissocialized, deproblematized, reductionist/individualist, instrumentalization, separation, marketisation, positivist and objectivist. The combination of these attributes builds the epistemic well. The epistemic well of research is not absolute and is not meant to provide quantification data. The epistemic well is a reflexive tool that can be used to evaluate a research especially for a nation like Nepal. The research funds or the benefits that ensues a researcher are important criteria for research. When thinking of a research topic, the primary determining factor becomes the amount of fund available the gaze of a native researcher can overlook various conditions and processes. The epistemic community that is formed by these researchers maintain and sustain particular epistemes. The NCD’s were selected primarily to stick to a cohort but this does not limit the scope and purpose of the epistemic well.

1. Introduction The rational, objectives, methodological, methods, results and recommendations are the most visible aspects of any research. But behind these lay the philosophical foundation that is mostly invisible and that builds up the visible part of the research. Philosophical foundations about the nature of reality are crucial to understanding the overall perspective from which any study is designed and carried out. Methodology and methods are determined by researcher bias1, researcher positionality2, ontological positions 34 and axiological positions5. A fundamental part of deciding on a methodology is the philosophical

1Phil Brown, ‘Qualitative Methods in Environmental Health Research’, Environmental Health Perspectives 111, no. 14 (2003): 1789–98, doi:10.1289/ehp.6196.2Gill Walt et al., ‘“ Doing ” Health Policy Analysis  : Methodological and Conceptual Reflections and Challenges’, Health Policy and Planning 23, no. 2000 (2008): 308–17, doi:10.1093/heapol/czn024.3P Lynne Johnstone, ‘Mixed Methods, Mixed Methodology Health Services Research in Practice’, Qualitative Health Research 14, no. 2 (2004): 259–71, doi:10.1177/1049732303260610.4Douglas L Weed, ‘Towards a Philosophy of Public Health’, Journal of Epidemiology & Community Health 53, no. 2 (1999): 99–104, doi:10.1136/jech.53.2.99.5Paulo Freire, PEDAGOGY of the OPPRESSED, ed. Continuum, 30th ed. (E W YORK • LONDON: The Continuum International Publishing Group Inc, 1970).

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foundation one possesses regarding beliefs, values, ontology, epistemology and relationality67. Over the years a range of philosophical perspectives have emerged such as methodological individualism, empiricism, positivism, Cartesianism, reductionism, methodological holism, political economy, Marxism, pragmatism, existentialism, constructionism and in contemporary era philosophy, post-modernism, post-colonialism, post-positivism, post-foundationalism, post-neoliberalism. These different philosophies sometimes contradicting and sometimes overlapping have been providing the foundations of researches in different sectors.

The scope of this article is not to discuss about these varied philosophies and its strengths and weakness and neither is the scope to discuss which philosophical perspective is better. The attempt here is to explore the philosophical foundations and the assumptions that inform researchers (epistemic community of researchers) under neoliberalism. Research is an outcome of prevailing epistemes. Epistemes are crucial in maintaining, establishing and sustaining the prevailing knowledge. An episteme is the accepted and leading method of gaining and organizing knowledge in a given historical epoch. Epistemes are ‘manners of justifying, explaining, solving problems, conducting enquiries, and designing and validating various kinds of products or outcomes’89. An episteme tells our ways of seeing; our Weltanschauung or ‘world view’10. Episteme is the historical a priori that grounds knowledge and its discourses and thus represents the condition of its possibility within a particular, historical context11. Dominating epistemes or world views are articulated in part through institutions, such as healthcare settings, and through specific scientific disciplines such as public health, psychiatry, endocrinology, engineering etc.12. Epistemes are established and sustained by epistemic communities.

Epistemic communities are groups of professionals or, networks of technical professionals who are usually from diverse and different disciplines who gather, synthesize and interpret technical bodies of knowledge and as such play a strong role in shaping which policies are selected in highly specialized policy arenas, and they also produce policy-relevant

6Elizabeth Jackson, ‘Choosing a Methodology: Philosophical Underpinning’, Practitioner Research in Higher Education Journal 7, no. 71 (2013): 49–62.7 ‘Akinyoade - Ontology and Epistemology of Peace and Conflict Studies - 2012 - The Security Sector and Conflict Manageme.pdf’, n.d.8Jan H F Meyer and Ray Land, ‘Editors’ Preface’, in Overcoming Barriers to Student Understanding Threshold Concepts and Troublesome Knowledge (Glasgow and Durham: Routledge Publishers, 2006), xvi.9Geneviève Rail Murray, Stuart J, Dave Holmes, ‘On the Constitution and Status of “ Evidence ” in the Health Sciences’, Journal of Research in Nursing 13, no. JULY (2008): 11, doi:10.1177/1744987108093529.10Hazel Squires, ‘A Framework for Developing the Structure of Public Health Economic Models’, Value in Health (The University of Sheffield, 2016), doi:10.1016/j.jval.2016.02.011.11Jean-Pierre Unger et al., ‘The Production of Critical Theories in Health Systems Research and Education. An Epistemological Approach to Emancipating Public Research and Education from Private Interests’, Health, Culture and Society 1 (2011): 0–28, doi:10.5195/hcs.2011.50.12Murray, Stuart J, Dave Holmes, ‘On the Constitution and Status of “ Evidence ” in the Health Sciences’.



knowledge about intricate technical issues and combine various characteristics, political initiative and scientific objectivity 1314 Epistemic communities lay the groundwork for a broader acceptance of the community’s beliefs and ideas about the proper construction of social reality15 and is tightly integrated, limited in number, with high continuity and members having roughly equal status and power16. Epistemic communities broadly display the following three characteristics, 1) Transnational networks of scientists and of other knowledge-based professionals. Scientific associations have features of epistemic communities; subgroups within them may act as epistemic communities. 2) Networks of experts who define for policy makers what the problems they face are and what they should do about them and 3) a group of people who do not have any specific history together but share ideas. Those who accept one version of a story that is particularly meaningful for their communities17.

Based on available literature on epistemic communities and the features that characterise an epistemic community as mentioned in the above paragraph the National Health Research Council (NHRC) can be identified as an epistemic community. The Second National Summit of Health and Population Scientists in Nepal which was held from April 11-12, 2016, with the theme, “Health and Population Research for Achieving Sustainable Development Goals in Nepal” provides the background and the data needed for the study. One hundred and sixty five papers were presented. The research papers were classified into nine different themes. The summit was attended by a rich diversity of participants from academia, research institutes, government, I/NGOs and external developmental partners18. This diversity of views available in one event presents an excellent opportunity to build the objective of this article which is to explore the philosophical foundations and the assumptions of health research regarding non communicable diseases by the native epistemic community of researchers in an era of neoliberalism.

13Marianna Y Smirnova and Sergey Y Yachin, ‘Epistemic Communities and Epistemic Operating Mode’, International Journal of Social Science and Humanity 5, no. 7 (2015), doi:10.7763/IJSSH.2015.V5.533.14Sarah L. Dalglish et al., ‘Epistemic Communities in Global Health and the Development of Child Survival Policy: A Case Study of iCCM’, Health Policy and Planning 30 (December 2015): ii12-ii25, doi:10.1093/heapol/czv043.15Peter M Haas, ‘Epistemic Communities and International Policy Coordination’, International Organization 46, no. 1 (1992): 1–35, doi:10.2307/2706951.16Melissa Pearson, Zwi B Anthony, and Nicholas A Buckley, ‘Prospective Policy Analysis: How an Epistemic Community Informed Policymaking on Intentional Self Poisoning in Sri Lanka.’, Health Research Policy and Systems / BioMed Central 8 (2010): 19, doi:10.1186/1478-4505-8-19.17International Epidemiological Association, A Dictionary of Epidemiology, Oxford University Press, vol. 53, 2008, doi:10.1017/CBO9781107415324.004.18Nepal Health Research Council and NHRC, ‘Health and Population Scientists Abstract Book’, 2016.



2 -Rationale

The indiscriminate and uncritical use of questionnaire surveys to gather information was raised more than three decades ago in 1979 in the first edition of the book Use and misuse of social science research in Nepal (2nd edition)19. Recently others have also expressed the fact that the overwhelming majority of articles reported on quantitative20 and calls for making health a public health agenda have also been made21. Others have discussed issues that reflect a particular political economy of research - where funding comes from, who defines the research agenda, the costs of review, developing Nepal’s research capacity, through to the politics of publication of research findings - and includes questions relevant to emerging regulatory and ethical frameworks22. Studies of philosophical nature in dealing with ontological and epistemological issues on Nepal have been few and those that do deal with caste, religion, semantics and forestry23242526. Working with an epistemic community to generate a range of options for further analysis may itself yield important insights into policy, as well as into how the epistemic community operates, perceives the problem(s) and proposed solutions. The rationale of the study to explore the philosophical foundations of research arises due to three primary reasons.

The first is the historical process that has conditioned contemporary Nepal. The second reason is the influence of neoliberal values and principles which has been in practise since late 1980 and the third reason is the empirical experiences in ten years of academic activities the author has garnered. A very brief history of Nepal is discussed since; a historicized understanding of the present condition has been deemed an important approach27. Nepal though never colonized has been substantially affected by colonialism in ways which are different from other past colonial nations. The Rana period from 1848 to 1950 pushed Nepal towards isolation by deliberately keeping the population away from the modern ideas of development such as education. Literacy rate in 1950 was approximately two percent28. The

19J. Gabriel Campbell, Ramesh Shrestha Linda, and Linda Stone, The Use and Misuse of Social Science Research in Nepal, Second (Mandala Book Point, 2010).20Biraj Man Karmacharya, ‘Shifting the Paradigm: Nepal as a Potential Leader in the Field of Medical Education’, Kathmandu University Medical Journal 9, no. 33 (2011): 1–2.21Madhusudan Sharma Subedi, ‘Making Health a Public Agenda in Nepal’, Journal of SASS (Society of Anthropology/Sociology …, 2006, 1–8.22Jeevan R A J Sharma, Rekha Khatri, and I A N Harper, ‘UNDERSTANDING HEALTH RESEARCH ETHICS IN NEPAL’ 8731 (2016), doi:10.1111/dewb.12109.23Helene Ahlborg and Andrea J. Nightingale, ‘Mismatch between Scales of Knowledge in Nepalese Forestry: Epistemology, Power, and Policy Implications’, Ecology and Society 17, no. 4 (2012), doi:10.5751/ES-05171-170416. 24(Schulz & Siriwardane, 2015)25(Ojha et al., 2015)26J Campbell, R Shrestha, and L Stone, ‘The Use and Misuse of Social Science Research in Nepal’, 2010.27Charles E Rosenberg, ‘What Is Disease ? In Memory of Owsei Temkin’, Bull. Hist. Med 77, no. October 2002 (2003): 491–505.28Sarah Kernot, ‘Nepal : A Development Challenge’, South Asia: Journal of South Asian Studies 29, no. 731635008 (2006): 293–307, doi:10.1080/00856400600849167.



year 1956 marks the end of oligarchy, the beginning of an egalitarian political system, introduction of universal access to education, introduction of the General Health Plan, becoming an aid-recipient country and the launch of the First Five- year Plan (1956–1961) 293031. The late advent of modern liberal democratic ideas, the poor living conditions, and the implementation of the banking model of education with its emphasis on accumulation of knowledge demobilized the people within the existing establishment of power by conditioning them to accept the cultural, social, political status quo of the dominant culture which also led to increased dependency on others for its development3233343536.

Nepal began neoliberalising from the late eighties onwards. In the early 1990’s Nepal was subjected to structural adjustment policies (SAP) in line with neo-liberal principles373839. As a process, neoliberalization is variegated, unfinished, and contingent40. It is a slippery concept to theorize41, let alone study empirically42. Most scholars tend to agree that neoliberalism is broadly defined as the extension of competitive markets into all areas of life, including the economy, politics, and society4344. Key to this process is an attempt to instil a series of values

29Tejendra Pherali, Alan Smith, and Tony Vaux, ‘A Political Economy Analysis of Education in’, 2011.30WHO, WHO Country Cooperation Strategy Nepal, 2013–2017, 2013.31Shiba K Rai et al., ‘The Health System in Nepal—An Introduction’, Environmental Health and Preventive Medicine 6, no. 1 (2001): 1–8, doi:10.1007/BF02897302.32Catherine Campbell and Sandra Jovchelovitch, ‘Health, Community and Development : Towards a Social Psychology of Participation’, Journal of Community and Applied Social Psychology 10, no. 4 (2007): 255–70, doi:10.1002/1099-1298(200007/08)10.33Ghanashyam Sharma, ‘Criticalizing the Pedagogy of English Studies  : A Nepalese Perspective’, Bodhi: An Interdisciplinary Journal 4, no. 1 (2010): 111–35.34Sarah Kernot, ‘Nepal: A Development Challenge’, South Asia: Journal of South Asian Studies 29, no. 2 (2006): 293–307, doi:10.1080/00856400600849167.35E van Teijlingen et al., ‘Learning from Health Care in Other Countries: The Prospect of Comparative Research’, Health Prospect Journal of Public Health 14, no. I (2015): 8–12.36Madhusudan Subedi and Devendra Uprety, The State of Sociology and Anthropology Teaching and Research in Nepal, Martin Chautari, 2014, doi:10.1017/CBO9781107415324.004.37Anil Bhattarai, ‘Nature of Nepali State and Hegemony of Technocentrism and Behaviorism in Health Practices in Nepal Under the Direction of’ (Chapel Hill, 2008).38Dilli Raj Khanal et al., Understanding Reforms in Nepal: Political Economy and Institutional Perspective. (Institute for Policy Research and Development (IPRAD), 2005).39Fraser Sugden, ‘Geoforum Neo-Liberalism , Markets and Class Structures on the Nepali Lowlands  : The Political Economy of Agrarian Change’, Geoforum 40, no. 4 (2009): 634–44, doi:10.1016/j.geoforum.2009.03.010.40Helga Leitner, Jamie Peck, and Eric S Sheppard, Contesting Neoliberalism (New York: The Guilford Press, 2007).41Simon Springer, Kean Birch, and Julie Macleavy, ‘An Introduction to Neoliberalism’, The Handbook of Neoliberalism, 2016.42Ibid.43David Harvey, ‘Freedom’s Just Another Word...’, A Brief History of Neoliberalism, 2005, 1–38, doi:10.1111/j.1541-1338.1983.tb00804.x.44Dorothy Porter, Health, Civilization and the State A History of Public Health from Ancient to Modern Times (London: Routledge, 1999).



and social practices in subjects 4546 and by virtue of being embedded in practices of governance at the local level often leads to a sense of neoliberalism being everywhere47.

Depending upon the social, economic and political condition of a nation, the pursuit of free-market and neoliberalism can have varied affects and consequences. Neoliberal values survivor of the fittest philosophy has taken hold in all sectors including academic, research and education. In academics and research the ‘publish or perish’ philosophy prevails as a result of which hundreds of researches are being done every year in Nepal. Research is done to know about a particular condition that we do not know much about by using methods that are scientifically based. But how do we know what needs research? And what are the reasons for doing a research? Even before identifying the research topic, subject or object they are cognitive processes that influences us to decide on a particular research topic, research questions and the research hypothesis.

Figure -1 Research process

In figure one the research process has been shown the researcher is at one end of the process and the results, recommendations and the knowledge generation that the research provides is at the other end. In between these two, lay the other determining factors that affect the research output. The researcher is at the bottom as shown in the figure one. Varied range of classifications have been done on the different factors that affect and guide our research at different stages such as the, ontology, axiology, epistemology in totality our philosophy or paradigm. Though ontology and epistemology has been shown separately, there have been claims that these cannot be considered separable as axiology, epistemology and ontology co-

45Springer, Birch, and Macleavy, ‘An Introduction to Neoliberalism’.46E V A Bendix Petersen and Bronwyn Davies, ‘In / Difference in the Neoliberalised University’, Learning and Teaching 3, no. 2 (2010): 92–109, doi:10.3167/latiss.2010.030206.47Noel Castree, ‘Neoliberalism and the Biophysical Environment: A Synthesis and Evaluation of the Research’, Environment and Society: Advances in Research 1, no. 1 (2010): 5–45, doi:10.3167/ares.2010.010102.



evolve48. Theoretically the research process flows within the framework of research process as shown in figure one.The sections highlighted in bold are the most visible outcomes of research. The philosophical aspects of research are usually invisible (ontological epistemological and axiological conditions). The focus of this article is on factors that guide us to choose a particular methodology and through which the results are generated, findings are made and recommentions done.

Since the neoliberal environment condition our ideas that is generated, it is imperative that neoliberalism and its ideology, its assumptions and its processes be discussed and understood. The central presuppositions of neoliberalism include the rational self-interested individual, free market economics, a commitment to laissez-faire and a commitment to free trade49. Neoliberalism has shaped our cognition and it espouses neoliberal ideologies that emphasize individual-level decision making about economics and healthcare50. Neoliberal view and practise has directly implicated in shaping the way health is promoted51 and thoughts are shaped52. The neoliberal ontological project presumes homo economicus53 as dominant model for individual behaviour which arises from subject’s economic rationality operating in a world of perfect information and static notions of equilibrium54. Neoliberalism touches all aspects of life and research is no different.

Under a neo-liberal influence research is predominantly positivist by nature and the recommendations, findings; interventions are predominantly individualist in nature5556. This knowledge of interventions stems from the ontological and epistemological assumptions one has and under neoliberalism it has been predominantly guided by a positivist ontology which suggests that all things exist in some sort of objective universe and this includes human beings57. A positivist ontological approach assumes the existence of a ‘‘real,’’ apprehendable reality driven by immutable natural laws and mechanisms and that researchers are capable of

48 Peter M Allen and Liz Varga, ‘Complexity: The Co-Evolution of Epistemology, Axiology and Ontology.’, Nonlinear Dynamics, Psychology, and Life Sciences 11, no. 1 (2007): 19–50.49Mark Olssen and Michael A. Peters, ‘Neoliberalism , Higher Education and the Knowledge Economy : From the Free Market to Knowledge Capitalism’, Journal of Education Policy 20, no. September 2010 (2005): 313–45, doi:10.1080/02680930500108718.50Catherine L Sanders and Kimber H McKay, ‘The Search for “Strong Medicine”: Pathways to Healthcare Development in Remote Nepal Using GIS’, Technology & Innovation 15, no. 2 (2013): 109–24.51Nike Ayo, ‘Understanding Health Promotion in a Neoliberal Climate and the Making of Health Conscious Citizens’, Critical Public Health 22, no. April 2015 (2012): 37–41, doi:10.1080/09581596.2010.520692.52N. Rose, ‘The Politics of Life Itself’, Theory, Culture & Society 18, no. 6 (2001): 1–30, doi:10.1177/02632760122052020.53Peter Roberts and Michael A Peters, Neoliberalism , Higher Education and Research (ROTTERDAM: Sense Publishers, 2008).54Yahya M. Madra and Fikret Adaman, ‘Neoliberal Reason and Its Forms: De-Politicisation through Economisation’, in Antipode, vol. 46, 2014, 691–716, doi:10.1111/anti.12065.55Christy a Rentmeester and Rajib Dasgupta, ‘Good Epidemiology, Good Ethics: Empirical and Ethical Dimensions of Global Public Health.’, Indian Journal of Medical Ethics 9, no. 4 (2012): 235–41.56Paul Farmer and Nicole Gastineau Campos, ‘Rethinking Medical Ethics: A View From Below’, Developing World Bioethics 4, no. 1 (2004): 17–41, doi:10.1111/j.1471-8731.2004.00065.x.57Bernd Carsten Stahl, ‘Positivism or Non-Positivism - Tertium Non Datur A Critique of Ontological Syncretism in IS Research’, in Ontologies, 2007, 115–42, doi:9780387370224.



studying objects without influencing them or being influenced by them58. Positivism relies on a reductionist view in its search for universal mechanistic rules that are not contextually bounded and seeks to verify hypotheses59. Positivists view the individual as an essentially biophysiological and neurophysiological system, a reductionist view6061. An offshoot of the positivist school of thought is methodological individualism which emphasises; homo economicus, based on assumptions of individuality, rationality, self-interest; and the doctrine of spontaneous order62.

Methodological Individualism as a position consists of several assumptions. Some of the assumptions inherent in a methodological individualist approach have been identified as, ontological assumptions6364, epistemological assumptions656667, fundamentalist assumptions6869, atomistic assumptions7071, observability assumptions7273, methodological assumptions 747576 and

58R M Carpiano and Dorothy M Daley, ‘A Guide and Glossary on Post-Positivist Theory Building for Population Health.’, Journal of Epidemiology and Community Health 60, no. 7 (2006): 564–70, doi:10.1136/jech.2004.031534.59Ibid.60George Khushf and Dan Brock, ‘Handbook of Bioethics’, in HANDBOOK OF BIOETHICS Philosophy and Medicine, ed. George Khushf, Kluwer Aca, vol. 78 (New York, 2004), 353-380–380, doi:10.1007/1-4020-2127-5.61Vijay Kumar Yadavendu, Shifting Paradigms in Public Health: From Holism to Individualism, Shifting Paradigms in Public Health: From Holism to Individualism, vol. 9788132216 (Springer, 2013), doi:10.1007/978-81-322-1644-5.62Roberts and Peters, Neoliberalism , Higher Education and Research.63Tejas Patil and James Giordano, ‘On the Ontological Assumptions of the Medical Model of Psychiatry: Philosophical Considerations and Pragmatic Tasks.’, Philosophy, Ethics, and Humanities in Medicine : PEHM 5 (2010): 3, doi:10.1186/1747-5341-5-3.64Thor Eirik Eriksen et al., ‘At the Borders of Medical Reasoning: Aetiological and Ontological Challenges of Medically Unexplained Symptoms.’, Philosophy, Ethics, and Humanities in Medicine : PEHM 8, no. 1 (2013): 11, doi:10.1186/1747-5341-8-11.65Jeremy Briell et al., ‘Personal Epistemology : Nomenclature , Conceptualizations , and Measurement’, in Links Between Beliefs and Cognitive Flexibility: Lessons Learned, ed. J. Elen, L. Verschaffel, and G. Clarebout (Springer Science+Business Media, 2002), doi:10.1007/978-94-007-1793-0.66Suzanne Bunniss and Diane R. Kelly, ‘Research Paradigms in Medical Education Research’, Medical Education 44, no. 4 (2010): 358–66, doi:10.1111/j.1365-2923.2009.03611.x.67Begna Dugassa, ‘Knowledge Construction: Untapped Perspective in Pursuit for Health Equity’, Sociology Mind 2, no. 4 (2012): 362–72, doi:10.4236/sm.2012.24048.68A Reutlinger and H Koch, ‘Methodological Individualism and the Epistemic Value of Macro-Explanations’, Percipi 2 (2008): 1–14.69Philip Musgrove, Health Economics in Development, 2004.70Reutlinger and Koch, ‘Methodological Individualism and the Epistemic Value of Macro-Explanations’.71Dennis Wendt, ‘Evidence-Based Practice Movements in Psychology: Empirically Supported Treatments, Common Factors, and Objective Methodological Pluralism’, Journal of Psychology 2 (2006): 49–62.72 ‘Critical Thinking about Psychology : Hidden Assumptions and Plausible Alternatives / Edited by Brent D. Slife, Jeffrey S. Reber, Frank C. Richardson. - Version Details’, Trove, accessed 3 August 2016, http://trove.nla.gov.au/version/42167291.73Wendt, ‘Evidence-Based Practice Movements in Psychology: Empirically Supported Treatments, Common Factors, and Objective Methodological Pluralism’.74Katherine L Frohlich, Ellen Corin, and Louise Potvin, ‘A Theoretical Proposal for the Relationship between Context and Disease’, Sociology of Health & Illness 23, no. 6 (2001): 776–97.75Johnstone, ‘Mixed Methods, Mixed Methodology Health Services Research in Practice’.76Reutlinger and Koch, ‘Methodological Individualism and the Epistemic Value of Macro-Explanations’.



axiological assumptions777879. A positivist ontological approach combined with methodological individualism can create a disposition to treat humans as objects80. Treating humans as objects means that one can treat them as means rather than ends, thus violating Kant’s famous version of the categorical Imperative 81 according to which humans should never be treated as means or to put it in more contemporary words: "Such research may end up by recommending most people to be handled like billiard balls”82.

This combination of methodological individualism and positivism has been incorporated in epidemiology, the discipline most actively involved in the study of health problems83. Claims that mainstream/traditional epidemiology was too blunt to dissect the complexities of today’s health problems was made in 1994. The Leeds declaration emphasized the need to refocus upstream and to use research methods that are appropriate to the level at which intervention will take place. Epidemiologic techniques can be used in other settings (e.g., clinical epidemiology) and for other purposes (e.g., studies of disease progression and prognosis), but the key contribution of epidemiology to public health is its population focus84. Citing the Leeds declaration in 1994, the Lancet editors concluded that common epidemiological research has always been based on simplistic notions of causality85. The Research Unit in Health and Behavioural Chance at Edinburgh University concluded that mainstream epidemiology has little to offer in modernising public health, that its positivistic orientation underscores a principal weakness in its understanding of the social dynamics of health and disease, therefore undermining its ability to effect change in public health 86

The dominant risk factor epidemiology which is prevalent has several limitations 8788 and operates under an atomistic metaphysics and hence it is individualistic8990. The principal approach of epidemiological explanation takes place entirely within the confines of a scientific 77Johnstone, ‘Mixed Methods, Mixed Methodology Health Services Research in Practice’.78Neil. McKeganey, ‘Quantitative and Qualitative’, in Addiction, ed. J. W. Creswell, vol. 90 (Culbertson: Thousand Oaks, CA: Sage Publications, 1995), 0–14.79Mariachiara Tallacchini, ‘Before and beyond the Precautionary Principle: Epistemology of Uncertainty in Science and Law’, Toxicology and Applied Pharmacology 207, no. 2 SUPPL. (2005), doi:10.1016/j.taap.2004.12.029.80Stahl, ‘Positivism or Non-Positivism - Tertium Non Datur A Critique of Ontological Syncretism in IS Research’.81Mark R. Amstutz, International Ethics: Concepts, Theories, and Cases in Global Politics (Rowman & Littlefield Publishers, 2013).82Hans-Erik Nissen, ‘Acquiring Knowledge of Information Systems: Research in a Methodological Quagmire’, Research Methods in Information Systems (Sweden, 1985).83Jaime Breilh et al., ‘LATIN AMERICAN HEALTH WATCH Alternative Latin American Health Report’, Global Health Watch, 2005.84Neil Pearce, ‘Traditional Epidemiology , Modern Epidemiology , and Public Health’ 86, no. 5 (1996).85L. J. G. Nijhuis, H. G. J., & Van der Maesen, ‘The Philosophical Foundations of Public Health: An Invitation to Debate”’, Journal of Epidemiology and Community Health 48, no. 2 (1994): 1–3, doi:10.1136/jech.54.2.134.86Ibid.87Neil Pearce, ‘Traditional Epidemiology, Modern Epidemiology, and Public Health’, American Journal of Public Health 86, no. 5 (1996): 678–83, doi:10.2105/AJPH.86.5.678.88Daniel Goldberg, ‘The Preparation of a Syllabus in Social Medicine  : McKeown Revisited’, Social Medicine 7, no. 3 (2013): 147–56.



way that has been termed Cartesian reductionism, an analytical advance categorized by a focus on factors measured in seclusion from their context9192. The dominant theoretical developments in epidemiology have effectively ignored the true dialectic that exists between people’s actual chances and their real possibility of making choices93.

The hallmark trait of contemporary public health has been dominated by behavioralism 94 and the individualization of risk95969798. This individualization along with the belief in positivist ontology and epistemology has resulted in the much acclaimed evidence-based medicine or to put it more broadly evidence-based practise. The materialization of Evidence-based medicine (EBM) as the gold-standard practice was followed by Evidence-based public health (EBPH) which resulted in significant ontological and epistemological shift which resulted in proactive use of evidence conducted within a realist ontology using positivistic empirical strategies99. The emergence of evidence-based practice must be appreciated within the context of neo-liberalism100. The EBPH like EBM tries to ground health policies and interventions on ‘sound facts’ and this uncritical adoption of evidence-based medicine by the public health field has been seen to validate blaming individual patients for health problems resulting from social conditions101. Both EBM and EBHP assume universal biological response 102 and hence do not take into account the social and historical grounds of the researched sample, and thus they assume that conclusions of a specific set of researches can be generalized to any population103.

89Maria Wemrell et al., ‘Contemporary Epidemiology : A Review of Critical Discussions Within the Discipline and A Call for Further Dialogue with Social Theory’, Sociology Compass 2, no. 10 (2016): 153–71.90Dominique Pareja Béhague, Helen Gonçalves, and Cesar Gomes Victora, ‘Anthropology and Epidemiology  : Learning Epistemological Lessons through a Collaborative Venture’, Cien Saude Colet 13, no. 6 (2009): 1701–10.91Anthony C. Gatrell, ‘Complexity Theory and Geographies of Health: A Critical Assessment’, Social Science and Medicine 60, no. 12 (2005): 2661–71, doi:10.1016/j.socscimed.2004.11.002.92Steve Wing, ‘The Limits of Epidemiology.’, Medicine & Global Survival 1, no. 2 (1994): 74–86, doi:http://dx.doi.org/10.1088/0952-4746/19/1/001.93Klim McPherson, ‘Wider “causal Thinking in the Health Sciences”’, Health, J Epidemiol Community 52, no. 1 (1998): 612–18.94J. E. R. Staddon, ‘Scientific Imperialism and Behaviorist Epistemology’, Behavior and Philosophy 32, no. 1 (2004): 231–42, doi:10.2307/27759479.95Henry A Giroux, ‘Beyond Neoliberal Common Sense: Cultural Politics and Public Pedagogy in Dark Times’, Jac 27, no. 1–2 (2007): 11–61.96Bruce Braun, ‘Biopolitics and the Molecularization of Life’, Cultural Geographies 14 (2007): 6–28.97Sara Shostak, ‘Locating Gene-Environment Interaction: At the Intersections of Genetics and Public Health’, Social Science and Medicine 56, no. 11 (2003): 2327–42, doi:10.1016/S0277-9536(02)00231-9.98International Social Science Council, ‘World Science Social Report’ (Paris, 2010).99M. Gray, ‘Pursuing Good Practice?: The Limits of Evidence-Based Practice’, Journal of Social Work 6, no. 1 (2006): 7–20, doi:10.1177/1468017306062209.100Ibid.101Dani Filc, ‘Reconstructing Data : Evidence-Based Medicine and Evidence-Based Public Health in Context’, 2006, 287–306.102Cesar G. Victora, Jean Pierre Habicht, and Jennifer Bryce, ‘Evidence-Based Public Health: Moving Beyond Randomized Trials’, American Journal of Public Health 94, no. 3 (2004): 400–405, doi:10.2105/AJPH.94.3.400.103Filc, ‘Reconstructing Data : Evidence-Based Medicine and Evidence-Based Public Health in Context’.



The critics of EBP warn that the concept of ‘what works’ evidence is parochial, because it defines ‘evidence’ scientifically and mechanically that is too limited from public health perspective104. The evidence-based approach has been claimed to have led to the commodification of health care and public health, the polarization between a medical elite which strengthened its professional status, and a rank and file which experienced a process of de-professionalization105. The model’s limitations are especially salient in the field of public health, where conditions considering problems to be the result of simple, one-directional, causal relationship, is even more reductionist 106107108109110111 . Commonly ignored, yet seriously health-damaging, contextual factors include: being a second-class citizen, or being made to feel like a second-class citizen. Epidemiologically informed ‘lifestyle’ approaches thus obscure how health is an embodied multi-dimensional construct. As a social construct, health also comprises different meanings to different people112 . Most theoretical debates about the pros and cons of public health approaches are confined to the methodological scientific level. Philosophical foundations such as underlying ontological notions are rarely part of public health discussions, but these are always implicit and lie behind the arguments and reasoning of different viewpoints or traditions113. In empiricist science, pre-eminent in modern epidemiology, exposure and risk assessment, the almost unchallenged philosophical approach is that of the positivist paradigm —unprejudiced observation; the separation of ‘‘facts’’ from ‘‘values’’; and the emphasis on verification to develop general laws114.

The empirical experiences in day to day experiences in my academic career of more than ten years such as classroom interactions, seminars and research activities have also considerably prompted me to explore the research philosophy. Experiences such as when teaching public health and community medicine at the post-graduate level in the first semester

104Samiul Parvez.Nafeesa Ahmed and Nafeesa Tabassum, ‘In the Light of Epistemological Debates about Knowledge , Is “ Evidence-Based ” Policy Making ( in the Britain ) Anything More than Political Rhetoric ?’, Public Policy and Administration Research 4, no. 4 (2014): 111–19.105Filc, ‘Reconstructing Data : Evidence-Based Medicine and Evidence-Based Public Health in Context’.106Ibid.107Paul Aveyard, ‘Evidence-Based Medicine and Public Health’, Journal of Evaluation in Clinical Practice 3, no. 2 (April 1997): 139–44, doi:10.1046/j.1365-2753.1997.00095.x.108Wendy L McGuire, ‘Beyond EBM: New Directions for Evidence-Based Public Health.’, Perspectives in Biology and Medicine 48, no. 4 (2005): 557–69, doi:10.1353/pbm.2005.0081.109Nadav Davidovitch and Dani Filc, ‘Reconstructing Data : Evidence-Based Medicine and Evidence-Based Public Health in Context’, DYNAMIS. Acta Hisp. Med. Sci. Hist. Illus. 26 (2006): 287–306.110Gray, ‘Pursuing Good Practice?: The Limits of Evidence-Based Practice’.111Patricia A L Cochran et al., ‘Indigenous Ways of Knowing : Implications for Indigenous Ways of Knowing  : Implications for Participatory Research and Community’, AMERICAN JOURNAL OF PUBLIC HEALTH 98, no. April 2016 (2008): 22–27, doi:10.2105/AJPH.2006.093641.112Emma Rich, Lee F Monaghan, and Lucy Aphramor, ‘Debating Obesity Critical Perspectives’, in Debating Obesity : Critical Perspectives (Palgrave Macmillan, 2011).113 Nijhuis, H. G. J., & Van der Maesen, ‘The Philosophical Foundations of Public Health: An Invitation to Debate”’.114David John Briggs, Clive E Sabel, and Kayoung Lee, ‘Uncertainty in Epidemiology and Health Risk and Impact Assessment and Impact Assessment’, Environ Geochem Health, no. NOVEMBER (2008): 16, doi:10.1007/s10653-008-9214-5.



when asked what causes an individual to have ischemic heart disease or any other diseases that have been historically linked to social, economic and environmental conditions? The answers received comply with the dominant paradigm of proliferating blame the victim ‘life-style’ theories which emphasize individual’s responsibility to choose so called healthy life-styles and to cope better with stress, illiteracy, ignorance, superstition and other individual attributes. The principal causes of ill-health. The lack of historically informed analysis is absent and this lacuna manifests itself when doing health research.

3 - Methodological approach

The methodological approach to explore the philosophical foundations of health research largely rested on a dialectic reflexive analysis of empirical practices that exist. The first step in the methodological process was to identify the characteristics that have been associated with health research under neoliberalism. Under neoliberalism, the dominant research philosophy has been characterized as detached115116117118119,

115W.J. Orlikowski and J.J. Baroudi, ‘Studying Information Technology in Organizations: Research Approaches and Assumptions’, Information Systems Research 2, no. 1 (1991): 1–28, doi:10.1287/isre.2.1.1.116Massimiliano Tarozzi, ‘How Does My Research Question Come About ? The Impact of Funding Agencies in Formulating Research Questions’, The Qualitative Report 18, no. 102 (2013): 1–11.117Petra Brhlikova et al., ‘Trust and the Regulation of Pharmaceuticals: South Asia in a Globalised World’, Globalization and Health 7, no. 1 (2011): 10, doi:10.1186/1744-8603-7-10.118Karen Henwood et al., ‘Risk , Framing and Everyday Life : Epistemological and Methodological Reflections from Three Socio-Cultural Projects’, Health, Risk & Society 10, no. 5 (2008): 421–38, doi:10.1080/13698570802381451.119Martin Carrier, ‘Scientific Knowledge and Scientific Expertise: Epistemic and Social Conditions of Their Trustworthiness’, Analyse & Kritik 32, no. 2 (2010): 195–212.



decontextualized120121122123124125126127128129130131132133134135136137138139, depoliticized140141142143144145146147148149, dehistoricized150151152153154155156157158159, dissocialized160161162163164165166167, deproblematized168169170171, reductionist/individualist172173174175, instrumentalization176177178179180181, separation182183, marketisation184185186187188, positivist189190191192 and objectivist193194195196197198. These features when viewing health does not question the social and political structures, it takes them as given and deals with issues within these pre-existing structures.

120Dennis Raphael and E Sara Farrell, ‘Beyond Medicine and Lifestyle : Addressing the North America’, 2002, 208, doi:10.1108/1366075021045214.121Kelly Ichitani Koide, ‘A Militant Rationality : Epistemic Values , Scientific Ethos , and Methodological Pluralism in Epidemiology’, Scientiæ Zudia v, no. 10 (2012): 141–50.122Majid Ezzati et al., ‘Selected Major Risk Factors and Global and Regional Burden of Disease’, Lancet 360, no. 9343 (2002): 1347–60, doi:10.1016/S0140-6736(02)11403-6.123Pearce, ‘Traditional Epidemiology , Modern Epidemiology , and Public Health’.124Genevieve Rail, ‘The Birth of the Obesity Clinic: Confessions of the Flesh, Biopedagogies and Physical Culture’, Sociology of Sport Journal 29 (2012): 227–53.125Laurence J. Kirmayer, ‘Cultural Competence and Evidence-Based Practice in Mental Health: Epistemic Communities and the Politics of Pluralism’, Social Science and Medicine 75, no. 2 (2012): 249–56, doi:10.1016/j.socscimed.2012.03.018.126Marc Edelman and Angelique Haugerud, The Anthropology of Development and Globalization: From Classical Political Economy to Contemporary Neoliberalism, Blackwell Anthologies in Social and Cultural Anthropology ; 6., 2005, doi:10.1525/aa.2006.108.1.240.127Lauren Wentworth and Tim Dornan, ‘Human Molecular Biology: An Introduction to the Molecular Basis of Health and Disease’, Journal of the Royal Society of Medicine 96, no. 5 (2003): 248–49.128Louise Potvin et al., ‘Integrating Social Theory into Public Health Practice’, American Journal of Public Health 95, no. 4 (2005): 591–95, doi:10.2105/AJPH.2004.048017.129J Brassolotto, D Raphael, and N Baldeo, ‘Epistemological Barriers to Addressing the Social Determinants of Health among Public Health Professionals in Ontario, Canada: A Qualitative Inquiry’, Critical Public Health 1596, no. June (2013): 37–41, doi:10.1080/09581596.2013.820256.130Vincanne Adams, Nancy J Burke, and Ian Whitmarsh, ‘Slow Research  : Thoughts for a Movement in Global Health Slow Research : Thoughts for a Movement in Global Health’, Medical Anthropology Cross-Cultural Studies in Health and Illness 9740, no. March 2016 (2014): 20, doi:10.1080/01459740.2013.858335.131Walt et al., ‘“ Doing ” Health Policy Analysis : Methodological and Conceptual Reflections and Challenges’.132N Emmerich, ‘Sociological Perspectives on Medical Education’, in Medical Ethics Education: An Interdisciplinary and Social Theoretical Perspective (SpringerBriefs in Ethics, 2013), doi:10.1007/978-3-319-00485-3.133E Perdiguero, ‘History of Health, a Valuable Tool in Public Health.’, J Epidemiol Community Health 55, no. 9 (2001): 667, doi:10.1136/jech.55.9.667.134Glenn Mclaren, ‘The Obesity Crisis and Semiotic Corruption : Towards a Unifying Biosemiotic Understanding of Obesity’, Cosmos and History: The Journal of Natural and Social Philosophy 11, no. 1 (2015): 181–220.135Pearce, ‘Traditional Epidemiology, Modern Epidemiology, and Public Health’.136Laurence J. Kirmayer, ‘Cultural Competence and Evidence-Based Practice in Mental Health: Epistemic Communities and the Politics of Pluralism’, Social Science and Medicine 75 (2012): 249–56.137John W Lynch et al., ‘Income Inequality and Mortality  : Importance to Health of Individual Income , Psychosocial Environment , or Material Conditions’, BMJ: British Medical Journal 320, no. April (2000): 1200.138Emma Rich, Lee F. Monaghan, and Lucy Aphramor, ‘Introduction: Contesting Obesity Discourse and Presenting an Alternative’, in Debating Obesity Critical Perspectives, 1993, 288.139Boaventura De Sousa Santos and César A. Rodríguez-Garavito, Law and Globalization from Below Towards a Cosmopolitan Legality, CAMBRIDGE UNIVERSITY PRESS, vol. 102, 1996, doi:10.1086/231034.140Guljit K Arora and Anil Gumber, ‘Globalization and Health Effects in SAARC Region Evolving a Framework of Analysis’, International Journal of Economic Development 6, no. 3 (2004): 55–88.



These dozen features identified in the study can be said to make an imaginary well, which the author tries to develop as epistemic well of research (see figure two)199. The epistemic well is not absolute in nature and not all researches will display all the twelve characteristics of the epistemic well. The concept of epistemic well has been influenced by concepts such as epistemological obstacles or barriers, epistemological violence, epistemological dependency, epistemological racism, epistemologies of ignorance, epistemic pollution, epistemic dominance, epistemic fallibility, epistemic fallacy, epistemic uncertainty and epistemic indolence.

141Paul Stephen Brierley Jackson, ‘Cholera and Crisis: State Health and the Geographies of Future Epidemics’, ProQuest Dissertations and Theses 2011.142Ilona Kickbusch, ‘Editorial The Imperative of Public Health : Opportunity or Trap ?’, Health Promotion International, 2015, 1–4, doi:10.1093/heapro/dav025.143Paul Starr, ‘Professionalization and Public Health: Historical Legacies, Continuing Dilemmas.’, Journal of Public Health Management and Practice : JPHMP 15, no. 6 Suppl (2009): S26–30, doi:10.1097/PHH.0b013e3181af0a95.144World Health Organization (WHO), ‘A Conceptual Framework for Action on the Social Determinants of Health’ (Geneva, Switzerland, 2010).145Porter, Health, Civilization and the State A History of Public Health from Ancient to Modern Times.146Melissa Parker and Tim Allen, ‘De-Politicizing Parasites : Reflections on Attempts to Control the Control of Neglected Tropical Diseases’, Medical Anthropology 33, no. 3 (2014): 223–39, doi:10.1080/01459740.2013.831414.147Dennis Raphael and E Sara Farrell, Beyond Medicine and Lifestyle : Addressing the Societal Determinants of Cardiovascular Disease in North America (Emerald, 2002), doi:10.1108/1366075021045214.148Olivier Jutel, ‘Neo-Liberal Discourse and the Food Crisis’ (University of Otago, 2009).149Jose Gabriel Palma, ‘The Revenge of the Market on the Rentiers. Why Neo-Liberal Reports of the End of History Turned out to Be Premature’, Cambridge Journal of Economics 33, no. 4 SPEC. ISS. (2009): 829–69, doi:10.1093/cje/bep037.150AA Stagnaro, ‘Social and Political Reverberations in the Social Study of a Disease’, Salud Colectiva (English Edition) 8, no. S1 (2012): S25–27, doi:10.1590/S1851-82652012000300004.151Abdullah M Al-dagamseh, ‘Adiga’s The White Tiger as World Bank Literature’, Comparative Literature and Culture 15, no. 6 (2013).152M. a. Peters and T. Besley, Academic Entrepreneurship and the Creative Economy, Thesis Eleven, vol. 94 (New York,: Routledge, 2008), doi:10.1177/0725513608093278.153Jamie Peck and Adam Tickell, ‘Neoliberalizing Space’, Antipode., no. May (2002), doi:10.1111/1467-8330.00247.154Stagnaro, ‘Social and Political Reverberations in the Social Study of a Disease’.155Ivan Illich, ‘Limits to Medicine’, Journal of Current Cultural Research 4 (2012): 425–42, doi:10.3384/cu.2000.1525.124425.156Samuel Dunn, ‘Narratives and Newscomers: Rethinking Culturally Appropriate Health Care’, Nexus 14 (2000): 21–30.157Leslie Butt, ‘The Suffering Stranger: Medical Anthropology and International Morality.’, Medical Anthropology 21, no. 1 (2002): 1-24-33, doi:10.1080/01459740210619.158N. B. King, ‘Security, Disease, Commerce: Ideologies of Postcolonial Global Health’, Social Studies of Science 32, no. 5–6 (2002): 763–89, doi:10.1177/030631270203200507.159Mylène Botbol-Baum, ‘Epistemology of Bioethics in the Making: From Historical Context to Conceptual Plurality and Anticipation’, Bioethics Update 1, no. 2 (2015): 79–95, doi:10.1016/j.bioet.2015.12.002.160Illich, ‘Limits to Medicine’.161Timothy H Holtz et al., ‘Health Is Still Social : Contemporary Examples in the Age of the Genome’ 3, no. 10 (2006), doi:10.1371/journal.pmed.0030419.162Merrill Singer, ‘The Coming of Age of Critical Medical Anthropology’, Social Science and Medicine 28, no. 11 (1989): 1193–1203, doi:10.1016/0277-9536(89)90012-9.163Peck and Tickell, ‘Neoliberalizing Space’.164Wendy Larner, ‘Neo-Liberalism: Policy, Ideology, Governmentality’, 2000, 5–25.165SP Alemanno and B Cabedoche, ‘As the Ultimate Response to the Effects of Globalisation? France Télécom, Psychosocial Risks, and Communicational Implementation of the Global Workplace’, Intercultural Communication Studies 2 (2011): 24–40.166Jonathan Matusitz and Gerald-Mark Breen, ‘Telemedicine: Its Effects on Health Communication.’, Health Communication 21, no. 1 (2007): 73–83, doi:10.1080/10410230701283439.



From the depths of the epistemic well when researches are done, health issues are assumed to be self-evident problems200. The process of naturalisation of socially produced risk201, normalisation of social division’s 202 neutralization of negative health impacts 203 takes place in researches formed under neoliberalism. Wayne Brekhus (1998) referred to this as the process of “unmarking” problems so that what was marked as clear and evident becomes virtually unnoticed and, by virtue of that, “unremarkable”. The prevailing discourse in the health profession is biomedical, micro level, individualized and depoliticized and this tradition treats health as the absence of illness or disease in individuals and pursues to improve

167Edward Alan Miller, ‘Telemedicine and the Provider-Patient Relationship: What We Know So Far’, The Importance of the Provider-Patient Relationship in Telemedicine (Boston, Massachusett, 2010).168Illich, ‘Limits to Medicine’.169Fernando Domínguez Rubio, ‘Unfolding the Political Capacities of Design’, What Is Cosmopolitical Design?, no. January 2015 (2015): 143–60.170Alan P Rudy and Bruno Latour, ‘On ANT and Relational Materialisms An Introduction to Actor-Network Theory More towards Politics , Political Ecology , and Sociology . 1 Perhaps Agreeing Too Much with Seen Technoscience as Politics by Other Means . 3 His Primary Position Has Been That Te’, 2005.171Jaber F Gubrium and Margaretha Järvinen, ‘Troubles, Problems, and Clientization’, in Turning Troubles into Problems (Routledge, 2014).172C D Bryant and D L Peck, 21st Century Sociology: A Reference Handbook, 21st Century Sociology: A Reference Handbook (Sage Publications India Pvt. Ltd., 2007), doi:10.4135/9781412939645.173Daniel S Goldberg, ‘The Errors of Individualistic Public Health Interventions : Denial of Treatment to Obese Persons’, Health Policy and Management 1, no. 3 (2013): 237–38, doi:10.15171/ijhpm.2013.47.174Jocalyn Clark, ‘Medicalization of Global Health 1: Has the Global Health Agenda Become Too Medicalized?’, Global Health Action 7, no. SUPP.1 (2014): 10.3402/gha.v7.23998, doi:10.3402/gha.v7.23998.175Elizabeth Fee and Nancy Krieger, ‘Health Then and Now Understanding AIDS : Historical Interpretations and the Limits of Biomedical Individualism’, 1993, 1477–86.176Koen Vermeir, ‘Scientific Research : Commodities or Commons ?’, Sci & Educ 22, no. August 2012 (2013): 2485–2510, doi:10.1007/s11191-012-9524-y.177Marcos Barbosa De Oliveira, ‘On the Commodification of Science: The Programmatic Dimension’, Science & Education 10 (2012): 23, doi:10.1007/s11191-012-9455-7.178Jesper Christiansen, ‘The Irrealities of Public Innovation’, Ph.d 2013.179Dev Raj Dahal, ‘Contextualizing Social Science in’, Dhaulagiri Journal of Sociology and Anthropology 2 (2005).180Ricardo Pereira, ‘Processes of Securitization of Infectious Diseases and Western Hegemonic Power : A Historical-Political Analysis’, Public Health 2, no. 1 (2003): 1–15.181Sonia París, Albert Irene, and Comins Mingol, ‘Epistemological and Anthropological Thoughts on Neurophilosophy ’:, RECERCA 13 (2013): 63–83.182Vivienne Bozalek, James Garraway, and Sioux Mckenna, Case Studies of EPISTEMOLOGICAL Access in Foundation/Extended Curriculum Programme Studies in South Africa, 2011.183Rebecca Lave, ‘Neoliberalism and the Production of Environmental Knowledge’, Environment and Society: Advances in Research 3 (2012): 19–38, doi:10.3167/ares.2012.030103.184Dave Hill, ‘Critical Education’, Critical Education 4, no. 10 (2013): 22.185Bronwyn Davies and Peter Bansel, Neoliberalism and Education, Globalisation, Societies and Education, vol. 20 (CRESSKILL, NEW JERSEY: HAMPTON PRESS, INC., 2007), doi:10.1080/14767720802506821.186Paddy Rawlinson and Vijay Kumar Yadavendu, ‘Foreign Bodies: The New Victims of Unethical Experimentation’, Howard Journal of Criminal Justice 54, no. 1 (2015): 8–24, doi:10.1111/hojo.12111.187Lee F Monaghan, ‘Extending the Obesity Debate, Repudiating Misrecognition: Politicising Fatness and Health (Practice)’, Social Theory & Health 11, no. 1 (2012): 81–105, doi:10.1057/sth.2012.10.188Lave, ‘Neoliberalism and the Production of Environmental Knowledge’.189Wing, ‘The Limits of Epidemiology.’190Stephen Bezruchka, ‘Epidemiological Approaches to Population Health’, in Staying Alive: Critical Perspectives on Health, Illness, and Health Care, ed. T. Bryant Raphael and M. Rioux, 2010, 13–40.



quantifiable aspects of their lives through the lessening of risk factors via indicators of morbidity and mortality204. Those espousing this world view typically accept that work against disease is empirically desirable. Necessitating no additional rationalization: the epidemiology (the evidence) is normally believed to "speak for itself" 205206

Figure 2 Epistemic well of research

In order to explore the philosophical foundations that guide the philosophical foundations of health research of native researches an analysis of the health researches on noncommunicable diseases presented in the NHRC conference in 2016 was conducted. The book of abstracts for the year 2016 was available on the NHRC website for public use. In total

191Unger et al., ‘The Production of Critical Theories in Health Systems Research and Education. An Epistemological Approach to Emancipating Public Research and Education from Private Interests’.192Briggs, Sabel, and Lee, ‘Uncertainty in Epidemiology and Health Risk and Impact Assessment and Impact Assessment’.193Josiane Bonnefoy et al., Constructing the Evidence Base on the Social Determinants of Health : A Guide Authors  : (World Health Organization (WHO) ;, 2007).194Matthias Steup, An Introduction to Contemporary Epistemology (Prentice-Hall, 1998).195Harold Kincaid and Jennifer McKitrick, ‘Establishing Medical Reality. Essays in the Metaphysics and Epistemology of Biomedical Science’, Faculty Publications, no. 9 (2007): 236.196Dennis Raphael, Ann Curry-Stevens, and Toba Bryant, ‘Barriers to Addressing the Social Determinants of Health: Insights from the Canadian Experience.’, Health Policy (Amsterdam, Netherlands) 88, no. 2–3 (2008): 222–35, doi:10.1016/j.healthpol.2008.03.015.197Louise Cummings, ‘Public Health Reasoning : A Logical View of Trust’, COGENCY 6, no. JANUARY 2014 (2015).198Svein Barene, ‘PUBLIC HEALTH RESEARCH FROM A THEORETICAL SCIENTIFIC PERSPECTIVE’, International Journal of Research In Social Scienc 4, no. 9 (2015): 119–25.199 The list is not exhaustive 200Nancy Krieger, ‘Workers Are People Too: Societal Aspects of Occupational Health Disparities-an Ecosocial Perspective’, American Journal of Industrial Medicine 53, no. 2 (2010): 104–15, doi:10.1002/ajim.20759.201Schulz and Siriwardane, ‘Depoliticised and Technocratic? Normativity and the Politics of Transformative Adaptation’.202Simon J Williams, Jonathan Gabe, and Michael Calnan, Health , Medicine and Society (London: Routledge, 2000).203Therese Nilsson, Inequality , Globalization and Health, vol. 156 (Lund Economic Studies, 2009).204Brassolotto, Raphael, and Baldeo, ‘Epistemological Barriers to Addressing the Social Determinants of Health among Public Health Professionals in Ontario, Canada: A Qualitative Inquiry’.205Mark Battersbby, ‘Applied Epistemology and Argumentation in Epidemiology 1’, Informal Logic 26, no. 1 (2006): 41–62.206David Seedhouse, Philosophy , Prejudice and Practice Second Edition (JohnWiley&Sons Ltd, 2004).



twenty two researches were presented under the theme of NCD in the conference. Amongst these two were excluded one was on a clinical study of Maxillary Anterior Teeth and the other was on gender-based study of pattern reversal visual evoked potential.

Based on pragmatism this study holds that the most important determinant of the research philosophy adopted is the research question. It is the research questions that guide the other aspects of the research. The ontological nature of reality, the epistemological nature of knowledge that sets boundaries around knowledge and establishes its scope 207 and the axiological position of the researchers guide the research questions and hence forth the methodologies, methods, results and recommendations (Encyclopaedia of Medical Concept, 2012)208. A research question or a hypothesis, (hypothesis serves as an extension of the research question209) can be looked at from different angles and using different methods to provide different types of answers. Research methods can be traced back, through methodology and epistemology, to an ontological position. It is impossible to engage in any form of research without committing (often implicitly) to ontological and epistemological positions. Researchers’ differing ontological and epistemological positions often lead to different research approaches towards the same phenomenon210.

The selected twenty researches were analysed of their a) research objectives, aims or goals b) methodology and methods used and c) conclusions, discussions and recommendations made (see figure3). Each research was approached with the following questions.

What are the stated objectives, justification, rational, aim or purpose of the research?

What or who are the subjects of study of the research?

What are the methodologies and methods followed in the research?

What type of data does the methodology aim to generate?

What are the findings of the research?

What are the recommendations of the research?

After obtaining the answers to the above mentioned questions these components were then subjected to questions philosophical in nature. These questions were framed by keeping in

207Joy Higgs and Nita Cherry, Doing Qualitative Research on Practice, Writing Qualitative Research on Practice, 2009.208Suleiman Ismail Onoruoiza et al., ‘Using Health Beliefs Model as an Intervention to Non Compliance with Hypertension Information among Hypertensive Patient’, Journal Of Humanities And Social Science 20, no. 9 (2015): 11–16, doi:10.9790/0837-20951116.209Carpiano and Daley, ‘A Guide and Glossary on Post-Positivist Theory Building for Population Health.’210Jonathan Grix, ‘Introducing Students to the Generic Terminology of Social Research’, Politics 22, no. 3 (2002): 175–86, doi:10.1111/1467-9256.00173.



mind the different stages of research. Since assumptions are inherently present in any research here too the primary question asked was, what are the assumptions in the research?

1. What are the ontological assumptions? What is the nature and constitution of objects in the external world? What is the form and nature of reality and, therefore, what is there that can be known about it?211

2. What are the epistemological assumptions? How can we as researchers gain knowledge about the external world? What is the nature of the relationship between the knower or would-be knower and what can be known?212

3. What are the methodological assumptions? How research should or ought to proceed given the nature of the issue it seeks to address? How can the inquirer (would-be knower) go about finding out whatever he or she believes can be known?213

4. What are the axiological assumptions? How has ethics been maintained and what are the values of the research? Whether research should be “neutral” or valued-oriented?214

The first question deals with ontology and involves the philosophy of reality215. Ontology is the study of being 216 and the ontological understanding shapes our views and affects our sight. The researcher’s view of reality is the corner stone to all other assumptions, that is, what is assumed here predicates the researcher’s other assumptions217. As applied to healthcare research, ontology is about the nature of reality that is worth investigation218. For instance, one could view poverty as the result of individual attributes like laziness, drunkenness, ignorance or one could view poverty as the result of the development model followed.

The second question deals with epistemological beliefs that the researcher has about the nature of knowledge what counts as educational knowledge and how is it obtained’ or ‘how can we as researchers gain knowledge about the external world?’ 219 Epistemology addresses

211E. G. Guba and Y. S Lincoln, ‘Competing Paradigms in Qualitative Research’, in Handbook of Qualitative Research (Thousand Oaks, CA: Sage Publications, 1994), 105–17, doi:http://www.uncg.edu/hdf/facultystaff/Tudge/Guba%20&%20Lincoln%201994.pdf.212Ibid.213Ibid.214Kenneth Rochel de Camargo, Francisco Ortega, and Claudia Medina Coeli, ‘Modern Epidemiology and Its Discontents O Mal-Estar Na Epidemiologia Moderna’, Revista de Saude Publica 47, no. 5 (2013): 984–91, doi:10.1590/S0034-8910.2013047004777.215Steven Eric Krauss, ‘The Qualitative Report Research Paradigms and Meaning Making: A Primer’, The Qualitative Report 10, no. 4 (2005): 758–70, doi:10.1176/appi.ajp.162.10.1985.216Everest Turyahikayo, ‘Resolving the Qualitative-Quantitative Debate in Healthcare Research’, Medical Practice and Reviews 5, no. 1 (2014): 6–15, doi:10.5897/MPR.2013.0107.217Guba and Lincoln, ‘Competing Paradigms in Qualitative Research’.218Turyahikayo, ‘Resolving the Qualitative-Quantitative Debate in Healthcare Research’.219Adrian Haddock, Alan Millar, and Duncan Pritchard, ‘SOCIAL EPISTEMOLOGY’, in SOCIAL EPISTEMOLOGY, vol. 53, 1989, 160, doi:10.1017/CBO9781107415324.004.



how we come to know the reality. Researcher’s differing ontological and epistemological positions lead to different research approaches towards the same phenomenon. For instance the differing ontological views on poverty as mentioned in the above paragraph leads to different epistemic beliefs. The first view on poverty can lead the researcher to believe that knowledge about proper counselling and knowledge that can bring about behavioural change is desired. The second view on poverty can lead the researcher to believe that the limitations of the particular developmental model be identified and acted upon so as to reduce poverty.

The third question deals with the methodological approaches, the researcher pursues. Methodology can be individualist, holist, quantitative, qualitative, inductive, deductive and mixed. Continuing with the example on poverty, the differing positions will pursue different methodology. The first view that poverty is the result of individual attributes can employ methods such as in-depth interviews and study the life style practices that act as hindrances to lessening poverty. The second view can look at the reasons why a particular developmental model is followed and in the process could interview policy makers and development experts. The chosen methodology and methods can be traced back, through methodology and epistemology, to an ontological position; the researcher’s ontological and epistemological perspective affects the topic selection of the research. Researchers’ ontological and epistemological assumptions are evident in the questions and methodological approaches that they select220. If one’s answer to the ontological question is that a knowable reality exists, then his or her research will differ considerably from a researcher who holds the belief that reality is individually or socially constructed221.

The fourth question deals with the axiological nature of the researcher and focuses on values in the research process or morals and ethics. Axiology is the theory of values, and values are aspects of human behaviour that emerged during evolution and gave us aims, goals and opinions which through our knowledge direct our actions. The axiological nature of the research is inherently present during all stages of a research. In (See figure 1) the process of research has been shown.

The characteristics of the epistemic well can affect a research at different levels. The research could be giving us the true nature of the problem in quantitative measure but the understanding of the problems could be decontextualized, deproblematized and detached. For example if a research was done to study the breast feeding practices of mothers with children up to six months in an industrial/manufacturing region. I do house hold visits and collect data on breast feeding practices and I conclude that breast feeding is low since mothers are ignorant and need to be motivated through health literacy and health promotion programs. Also I 220Scott C. Marley and Joel R. Levin, ‘When Are Prescriptive Statements in Educational Research Justified?’, Educational Psychology Review 23, no. 2 (2011): 197–206, doi:10.1007/s10648-011-9154-y.221Ibid.



suggest proper counselling to the mothers about the importance of breast feeding. My methods of data collection were semi-structured questionnaire and interviews. I visit the houses on a Saturday since it is a holiday and hence informant would be at home. Based on the recommendations of the study an intensive promotional program was developed and mothers were given health literacy awareness, awareness programs in local radio and posters and pictures in schools to increase awareness among the children who in turn would diffuse the message in the family. Now another researcher comes to the same study site and studies the same issues on breast feeding among the same sample population. The researcher goes to the site and does an ethnographic study and comes up with the conclusion that women giving birth only get 40 days of leave with salary from the factories. After forty days the mother’s have to work 9 hours shift and if they start taking leave after the allotted 40 days of leave their daily wage or salary will be subtracted. Moreover if she does not join the work after a maximum of two months their job contract will be terminated and she will be replaced. The researcher finds that mothers know the importance of breast feeding for the first six months but she is faced with a choice, the choice of losing a job in a region with high unemployment. The researcher sees the solution in having a collaborative effort at solving the problem by bringing in the factory management, local and national government, the mothers and health workers.



Figure 3 Methodological framework

In figure three the methodological process has been shown. The epistemic well informs the researcher as a result of which the research methods, findings and recommendations display certain assumptions on which the research is built. These assumptions of different nature that exist at different levels when taken together can be identified as the philosophical foundations of the researcher. The philosophical foundations of a researcher when shaped by components of the epistemic well can produce research that is detached from the reality it studies. For instance, how useful is a research if a researcher conducts a research on effects of teaching hand washing practices among school going children, how valid will the research objectives, research questions and the findings be if the researcher were to discover that the school has no regular and constant water supply.



4 – Findings

The findings of the study are written in paragraphs. Each individual research has been subject to the steps mentioned in the methodology. The objectives, research questions, hypotheses, aims, goals, methodology, methods recommendations and conclusions are identified for each research which is mentioned in the first part. The second part (in italics) deals with the philosophical foundations that can be discerned from the first part of the research. The sections in italics are the comments on the research. The comments have been informed by literatures available through journals and publications available and the ontological understanding possessed by the author. Being a native the author tries to look at the researches done not by detaching one’s self but by incorporating the real lived experiences that the author experiences.

1. Mothers knowledge, attitude, behaviour regarding diet physical activity of pre-school children

Cross-sectional study, interviewed all mothers having children aged 2 to 7 years, knowledge, attitude and behaviour responses. Poor correlation of mothers’ knowledge and attitude with children’s behaviour regarding diet and physical activity. Barriers, facilitators that affect mothers’ practices towards their children be explored and addressed.

The ontological assumption that ignorance of mother's knowledge attitude is barrier regarding children's eating behaviour. The epistemological assumption that barriers can be studied epidemiologically and facilitating factors can be explored at the individual level. Methodological assumption that the process of study and data collection at the individual level will provide a true picture of the studied subject. Atomistic nature dealing at the individual behavioural level. Cross-sectional studies do not resolve problems relating to health care systems or the results of quantitative research methods are often not implemented in clinical practice, particularly using cross sectional studies in examining attitudes, beliefs, and values and quasi- experimental designs222. Historically from the 1916 onwards the understanding that ignorance of the mother was the primary cause for poor health conditions of the children was accepted as a truism 223. This understanding has continued strongly and under a neoliberal system when commodification is the norm the women are often assumed to have no specific health needs outside of their mothering roles, an assumption borne out by most of the existing health programmes that target women only during their reproductive years 224 (McFadden

222 M Tavakol and Zeinaloo Aa, 'Medical Research Paradigms : Positivistic Inquiry Paradigm versus Naturalistic Inquiry Paradigm', Journal of Medical Education 5 no. 2 (2004) 75-80223 Porter, Health, Civilization and the State A History of Public Health from Ancient to Modern Times.224 Damaris Parsitau, ‘The Impact of Structural Adjustment Programmes (SAPs) on Women’s Health in Kenya’, Governing Health Systems in Africa, no. June (2008): 191–200.



(1992). The vicious cycle of ill health, ignorance, and poverty starts in the womb225..The mother's apparent lack of interest can be appreciated when one realizes that parents in highly impoverished families have varied and tremendous burdens to bear 226.

2. Prevalence of depression, identify factors associated with depression among inmates

Cross-sectional study, depression assessed using centre for epidemiologic studies depression scale CESD). High rate of depression, need medical/psychiatric care.

Assumptions that questionnaires will give correct answers. Prisoners will give correct answers irrespective of their present mood condition. “Subjectifying nature” of the questionnaire has been criticized on many counts. Interest in depression in the field of international health was intertwined with the emergence of a new generation of antidepressant drugs, the serotonin reuptake inhibitors (SSRIs) 227. The pharmaceuticalisation 228229230231232 233234235 236, medicalization and

225 Duncan Green, From Poverty : How Active Citizens and Effective States Can Change the World, 2nd ed. (Practical Action Publishing and Oxford: Oxfam International, 2012).226 Kamala S Jayarno and in J . Patel Asb, UNDER THE LENS HEALTH AND MEDICINE (New Delhi: MEDICO FRIEND CIRCLE by VOLUNTARY HEALTH ASSOCIATTON OF INOlA, 1986).227 Stefan Ecks, ‘Pharmaceutical Citizenship: Antidepressant Marketing and the Promise of Demarginalization in India’, Anthropology & Medicine 12, no. 3 (2005): 239–54, doi:10.1080/13648470500291360.228 Simon J Williams, Jonathan Gabe, and Peter Davis, ‘THE SOCIOLOGY OF PHARMACEUTICALS: PROGRESS AND PROSPECTS’, University of Warwick Institutional Repository: Http://go.warwick.ac.uk/wrap, 2008.229 Wemrell et al., ‘Contemporary Epidemiology : A Review of Critical Discussions Within the Discipline and A Call for Further Dialogue with Social Theory’.230 Nick J Fox, ‘Lifestyle Drugs and the Domestication of Pharmaceutical Risk’, in Hellenic Sociological Society Conference (Athens, 2015), 20.231 Patrick Brown and Michael Calnan, ‘Braving a Faceless New World? Conceptualizing Trust in the Pharmaceutical Industry and Its Products’, Health 20 (2010), doi:10.1177/1363459309360783.232 Sjaak van der Geest, Susan Reynolds Whyte, and Anita Hardon, ‘THE ANTHROPOLOGY OF PHARMACEUTICALS: A Biographical Approach’, Annual Review of Anthropology 25, no. 1 (1996): 153–78, doi:10.1146/annurev.anthro.25.1.153.233 Jill A. Fisher, ‘Coming Soon to a Physician Near You: Medical Neoliberalism and Pharmaceutical Clinical Trials’, Harvard Health Policy Rev 8, no. 1 (2007): 1–9.234 Michael J. Oldani, ‘Thick Prescriptions: Toward an Interpretation of Pharmaceutical Sales Practices’, Medical Anthropology Quarterly 18, no. 3 (2004): 325–56, doi:10.1525/maq.2004.18.3.325.235 David Healy, ‘The Shipwreck of the Singular’, Social Studies of Science 44, no. 4 (2014): 7, doi:10.1177/0306312714536270.236 Maren Klawiter, ‘The Biopolitics of Risk and the Configuration of Users: Clinical Trials, Pharmaceutical Technologies, and the New Consumption-Junction’, in The New Political Sociology of Science: Institutions, Networks, and Power ((Madison: University of Wisoconsin Press), 2006).



biomedicalization, 237238239240241242243244245246247248249 of everyday life conditions including mental health have been addressed. The epistemological and ontological problems in defining the concept mental disorder and in delineating clinical entities are conspicuous, and many clinicians and psychotherapists find the categories and diagnostic criteria of both the DSM and the WHO’s ICD-10 in many ways inconvenient or trivial when applied to individual cases in clinical practice 250. The general way in which the questions are asked raises the suspicion that even people who would not fall into the category of ‘depression’ if diagnosed by a professional psychiatrist might be pushed to believe that they are depressed and in need of medicines 251. The murky relationship between the universalistic biomedical perspective of psychiatric problems and a locally informed one has been discussed by Harper. Much psychiatric research in Nepal is a direct outgrowth of the former, wherein statistics that suggest how prevalent conditions like “depression,” etc. are generated. Such research not only contributes to the Westernization of psychiatric problems, but in Nepal also perpetuates structural inequality by the very categories used in statistical studies252. The pharmaceutical industry is increasingly employing strategies of direct- to-consumer marketing, aiming to create a popular recognition of depressive symptoms, to ‘grow the market’, and to foster a demand for specific medications253. The increasing trend of the use of pharmaceutical products for various mental conditions has termed this era as ‘the antidepressant era’254.

237 Peter Conrad and Valerie Leiter, ‘Medicalization , Markets and Consumers’, Journal of Health and Social Behavior 45, no. 2004 (2011): 158–76.238 Clark, ‘Medicalization of Global Health 1: Has the Global Health Agenda Become Too Medicalized?’239 Rick Mayes and Allan V. Horwitz, ‘DSM-III and the Revolution in the Classification of Mental Illness’, Journal of the History of the Behavioral Sciences 41, no. 3 (2005): 249–67, doi:10.1002/jhbs.20103.240 Bruno J Strasser, ‘Biomedicine: Meanings, Assumptions, and Possible Futures’, 2014.241 Bjørn Hofmann, ‘The Technological Invention of Disease - On Disease , Technology and Values’ (University of Oslo, 2002).242 Author Nancy Scheper-hughes and Margaret M Lock, ‘The Mindful Body  : A Prolegomenon to Future Work in Medical Anthropology’, Medical Anthropology Quarterly 1, no. 1 (2010): 6–41.243 Oonagh Corrigan, ‘Genetics and Social Theory’, in The New Blackwell Companion to Social Theory, ed. bryan s. Turner (Blackwell Publishing Ltd Blackwell, 2009), 281–99, doi:10.1002/9781444304992.ch14.244 J. Visser and Z. Jehan, ‘ADHD: A Scientific Fact or a Factual Opinion? A Critique of the Veracity of Attention Deficit Hyperactivity Disorder’, Emotional and Behavioural Difficulties 14, no. 2 (2009): 127–40, doi:10.1080/13632750902921930.245 S I Saarni and H A Gylling, ‘Evidence Based Medicine Guidelines: A Solution to Rationing or Politics Disguised as Science?’, Journal of Medical Ethics 30, no. 2 (2004): 171–75, doi:10.1136/jme.2003.003145.246 Consumers International (CI), ‘Drugs , Doctors and Dinners How Drug Companies Influence Health in the Developing World’ (London, 2007).247 Health Committee, ‘The Influence of the Pharmaceutical -Volume 2’ (London, 2005).248 Steven Robins, ‘Mobilising and Mediating Global Medicine and Health Citizenship : The Politics of AIDS Knowledge Production in Rural South Africa’ (University of Sussex, 2009).249 Williams, Gabe, and Calnan, Health , Medicine and Society.250 Ilpo Helén, ‘The Depression Paradigm and beyond The Practical Ontology of Mood Disorders’, Science Studies 24, no. 1 (2011): 81–112.251 Ecks, ‘Pharmaceutical Citizenship: Antidepressant Marketing and the Promise of Demarginalization in India’.252 Steve Folmar, ‘Review of’Development and Public Health in the Himalaya: Reflections on Healing in Contemporary Nepal’by Ian Harper’, Himalaya, the Journal of the Association for Nepal and Himalayan Studies 35, no. 1 (2015).253 Ecks, ‘Pharmaceutical Citizenship: Antidepressant Marketing and the Promise of Demarginalization in India’.254 David Healy, The Antidepressant Era, vol. 95, 1999.



3. Determinants of health related quality of life in COPD chronic obstructive pulmonary disease

Hospital based survey. Older age, financial difficulties, smoking status, increasing dyspnea score, number of exacerbations, self perceived declining health status, and perceived impact on working capacity.

Assumes checklists and HRQL (health related quality of life) instruments are enough to gather information. Controversy around validity of these measures; investigators concerned with the question of whether these systems are measuring what they intend to measure. Given an absence of a benchmark of health, determining criterion validity—comparing the results achieved to an accepted gold standard—is impossible255. HRQL measures, placed a greater emphasis on issues such as measure responsiveness, sensitivity and reliability, paying less attention to generating overall models of disease distribution, severity, and mortality256. The concepts of perceived health status, quality of life and health-related quality of life can be complex to analyse as they might be mediated by several interrelated variables, including self-related constructs (e.g. self-efficacy, self-esteem, perceived control over life) and subjective evaluations could be influenced, in theory, by cognitive mechanisms (e.g. expectations of life, level of optimism or pessimism, social and cultural values, aspirations, standards for social comparisons of one’s circumstances in life)257. Without taking into consideration political unrest, environmental disaster, declining economic performance, the introduction of structural adjustment programmes, un-responsive governance, and weak public-health infrastructure changing population dynamics, the advent of HIV/AIDS, and the onset of globalisation, the HRQL is limited. A universal questionnaire to elicit the relevant information for a number of conditions would need to be of enormous length258.

4. Perceptions and beliefs of people living with type 2 diabetes

In-depth interview, individual interview with policy level people. Unhealthy life style is the main cause of diabetes, awareness program should be initiated, should be kept in the school level curriculum also.

Assumption at an ontological level of the reality and the epistemological assumptions about the knowledge generated. Atomistic, individualistic and reductionist in nature. The life-style one acquires must be based on rational choices and if one gets diabetes it is because of the

255 Marthe R Gold, David Stevenson, and Dennis G Fryback, ‘HALYS and QALYS and DALYS, Oh My: Similarities and Differences in Summary Measures of Population Health.’, Annual Review of Public Health 23 (2002): 115–34, doi:10.1146/annurev.publhealth.23.100901.140513.256 Ibid.257 Ann Bowling, RESEARCH METHODS IN HEALTH Investigating Health and Health Services, Health San Francisco (Buckingham: Open University Press, 2002).258 Ibid.



individual who makes wrong decisions. Public health influenced by the biomedical model has a tendency of victim blaming, 259260261262263264265 266267 which locates the cause and cure of disease as exclusively within the individual. The awareness program that it talks about is with an ontological understanding of the reality guided by the individualist, reductionist and de-politicized philosophy. Without taking into account the structure of neoliberalism and by naturalising the commodification and marketisation the school level curriculum based awareness program will focus on individual habits, morals and life-style.

5. Factors associated with physical activities, experiences of elderly regarding functional activities

Cross sectional survey, individual interviews using structured pretested interview guideline, hermeneutical phenomenological approach, Gibson’s qualitative analysis method. Functional limitation in basic and intermediate activities. National policy needs to consider the factors for enhancing functional activities, also promote role of the family members for elderly care.

Assumptions that government has full control and power along with willingness to care and can make and implement policies that promote elderly care. The policies it implements such as removal of subsidies, cutbacks in social expenditures and austerity measures indicate a contradictory approach to welfarism. Ontological assumptions regarding functional activities. For example, A has to share a common toilet where as B has a private bathroom and hence their functional needs are different. Epistemological assumptions seen when physical activities and functional activities are considered as knowledge that is desirable and needed.

6. Find the health literacy and knowledge of disease among the patients with chronic disease.

Cross sectional study was conducted, interviewed face to face, translated, pretested, validated European health literacy survey (HLS-EU-ASIA-Q)2 questionnaire. Respondents with sufficient

259 Deborah Lupton, ‘Digitized Health Promotion : Personal Responsibility for Health in the Web 2 . 0 Era.’ (Sydney, 2013).260 Deborah Lupton, ‘The Pedagogy of Disgust: The Ethical, Moral and Political Implications of Using Disgust in Public Health Campaigns Deborah’, Critical Public Health 25, no. 1 (2014): 14, doi:10.1080/09581596.2014.885115.261 Monaghan, ‘Extending the Obesity Debate, Repudiating Misrecognition: Politicising Fatness and Health (Practice)’.262 Stacey M Carter, Alan Cribb, and John P Allegrante, ‘How to Think about Health Promotion Ethics’, Public Health Reviews 34, no. 1 (2012): 1–24.263 Brhlikova et al., ‘Trust and the Regulation of Pharmaceuticals: South Asia in a Globalised World’.264 Klim Mcpherson, ‘Wider “ Causal Thinking in the Health Sciences ”’, Health, J Epidemiol Community, no. 1 (1998): 612–18.265 Rose. Galvin, ‘Disturbing Notions of Chronic Illness and Individual Responsibility: Towards a Genealogy of Morals’, Health: 6, no. 2 (2002): 107–37, doi:10.1177/136345930200600201.266 Nancy Krieger, ‘Theories for Social Epidemiology in the 21st Century: An Ecosocial Perspective.’, International Journal of Epidemiology 30, no. 4 (2001): 668–77, doi:10.1093/ije/30.4.668.267 Doncho Donev, Gordana Pavlekovic, and Lijana Zaletel Kragelj, Health Promotion and Disease Prevention A HANDBOOK FOR TEACHERS, RESEARCHES, HEALTH PROFESSIONALS AND DECISION MAKERS , Public Health Nursing (Boston, Mass.), German Aca (Hans Jacobs Publishing Company, 2010), doi:10.1111/j.1525-1446.2010.00878.x.



health literacy knew significantly more about the disease than those with inadequate health literacy. Health literacy is independently associated with disease knowledge.

Health literacy or mass education strategies is an individualistic approach which views the responsibility for reducing exposure to risk factors in individuals, and is emblematic of a medicalized framing of health problems 268. Assumptions that increased knowledge and health literacy will translate to better practise. The ‘upstream’ social determinants of health such as marketing of unhealthy foods to children and later drift ‘downstream’ by relying on strategies to directly change the behaviour of individuals has been described as a ‘lifestyle drift’ promoted by the policy makers as reductionist in nature 269. The neoliberal philosophy where the invisible hands of the market will suffice to create a developed nation seems rather tempting but these activities have a lasting effect especially as NCD’s are often interconnected and require long term solutions270.

7. Reliability and factor structure of perceived stress scale-14 (PSS-14) among Nepalese adolescents.

Cross-sectional and school-based survey was conducted in Myagdi district in Nepal in 2015. Reliable tool with caution to measure stress.

Assumptions that PSS-scale and questionnaires can be used for stress amongst adolescents. Questionnaires are supposed to eliminate observer biases, to provide a routine method of investigation and analysis which presents the same stimuli to all respondents. Rather, at every stage, a host of assumptions and interpretations are made by everyone employed on a project, which are commonly unacknowledged and uninvestigated in the presentation of results 271

8. Prevalence of depression among survivors of female trafficking in shelter homes of Kathmandu valley

Clinical diagnosis according to ICD-10 classification of mental and behavioural disorders-diagnostic criteria. Hamilton rating scale for depression (HAM-D) was used to assess the severity of depression (mild, moderate and severe). Evidence on trafficked people’s experiences of violence and of depression and other mental health problems is extremely limited. Requires a coordinated response by health care providers and other support services.

268 Jocalyn Clark, ‘Medicalization of Global Health 3: The Medicalization of the Non-Communicable Diseases Agenda’, Global Health Action 1 (2014): 1–8.269 Ibid.270 Ibid.271 E. Murphy et al., ‘Qualitative Research Methods in Health Technology Assessment: A Review of the Literature’, Health Technology Assessment, vol. 2, 1998, doi:10.3310/hta2160.



The current depression paradigm is the tendency to think of depression as well as other mood disorders as objects instead of as an experience with a specific context. Movement toward thing-like status makes mania and depression seems possible to identify, manipulate, and optimize through the technology of psychotropic drugs and through taxonomic apparatuses272. The thousand-fold increase in the prevalence of depression and it becoming a public health problem happened largely due to the development of psychiatric epidemiology since 1950’s273 274 . The sale of psychotropic drugs is big business275.

9. The prevalence of depression and their correlates and association of physical activity with physical activity among higher secondary students

Descriptive cross-sectional study was designed global physical activity questionnaire (GPAQ) for physical activity and beck depression inventory IBDI-IA) for depression along with some socio-demographic variables. Global physical activity questionnaire (GPAQ) for physical activity and beck depression inventory IBDI-IA) for depression along with some socio-demographic variables.

Questionnaires in effect filter the social processes under study through a pre-defined ‘grid’ of categories assumed to represent the range of possible alternative responses appropriate to the area of research. Fixed choice (yes/no) questions represent the extreme in this respect, but scaling techniques may be no less inappropriate. It is meaningless to produce measurements or qualifications of phenomena whose dynamics are not yet understood276. Most studies of area effects on health are cross sectional; that is; measures of the place and of the residents’ health are collected at roughly the same time. When one starts to think about socially and biologically plausible causal pathways by which place might influence health these cross-sectional designs often appear inappropriate277. In the attempts to make psychiatry more scientific the triumph of the styles of reasoning familiar from epidemiology and social medicine–statistical induction, probability calculus and risk estimation– has been much more crucial than the rise of psychopharmacology and neuropsychiatry. It is nowadays almost impossible to present claims about mental health facts without supporting them by statistical analysis of data from epidemiological questionnaires or randomised clinical trials278.

272 Helén, ‘The Depression Paradigm and beyond The Practical Ontology of Mood Disorders’.273 Healy, The Antidepressant Era.274 Helén, ‘The Depression Paradigm and beyond The Practical Ontology of Mood Disorders’.275 Stephen E Wong, ‘BEHAVIOR ANALYSIS OF PSYCHOTIC DISORDERS: SCIENTIFIC DEAD END OR CASUALTY OF THE MENTAL HEALTH POLITICAL ECONOMY?’, Behavior and Social Issues 177, no. 15 (2006): 152–77.276 Murphy et al., ‘Qualitative Research Methods in Health Technology Assessment: A Review of the Literature’.277 Sally Macintyre, Anne Ellaway, and Steven Cummins, ‘Place Effects on Health: How Can We Conseptualise. Operationalise and Measure Them?’, Social Science and Medicine 55 (2002): 125–39.278 Helén, ‘The Depression Paradigm and beyond The Practical Ontology of Mood Disorders’.



10. To assess the utilization of health care services among the elderly

Quantitative descriptive-cross sectional study, using an interviewer administered semi-structured questionnaire

Monthly family income, chronic disease, elderly on medication and self rated health are strongly associated with utilization of health care services by elderly people and suggests further interventions to improve the health care service utilization by elderly people.

This suggestion is based upon the idea that individuals should have the opportunity to live to the same age as others—that there is a prima facie right to a minimum number of life-years. The limitations of conventional health care systems are obvious. The narrowly technological approach to health care serves to block the integrated utilization of health economic and other resources. In fact highly professionalized and technological health services cannot be equitably distributed as it is neither possible nor desirable to have a hospital in every village. The task rather, is to attempt to change the composition of health services-away from hospitals and towards primary care-through their more equitable Distribution and to make them part of overall economic and social development279280.Since access to such public provision is often heavily unequal across locations, and within communities, this gap constitutes a significant weakness, especially in the context of cross-sectional or inter-temporal comparative analysis. In many situations, even households that have the financial capacity might find it impossible to obtain adequate education and health services simply because those services are not available locally. The poverty-line approach implicitly assumes that money can buy health, education and other services at any time and in any place, or that these are provided by the State281.

11. To explore the quitting attempts among adolescent smokers in Dharan municipality of eastern Nepal

Cross sectional study was conducted using pre-tested self administered questionnaire adapted from global youth tobacco survey to assess current smokers and quitting attempts

Relapse often occurs. Tobacco focused interventions to support abstinence are of potential value.

Self-report surveys share certain limitations that are characteristic of the self-report method. The primary weaknesses of self-report surveys are a function of the adequacy of the sample and the accuracy of measurement. The issues bearing on the adequacy of a survey’s sample are ensuring representative participation and receiving cooperation throughout the survey 279 Oscar Gish, ‘THE POLITICAL ECONOMY OF PRIMARY CARE AND “ HEALTH BY THE PEOPLE ”: AN HISTORICAL EXPLORATION’, Soc Sci Med 130 (1979): 9.280 Lois L. Janet L. DolginShepherd, Bioethics and the Law (Aspen Publishers, 2009).281 United Nations, ‘Rethinking Poverty Report’, United Nations Publication, vol. 14, 2016, doi:10.1007/s13398-014-0173-7.2.



questionnaire. Measurement accuracy is an outcome of asking questions correctly and respondent candor and memory. Although it appears that respondents are generally truthful in reporting their experiences underreporting is a threat to validity for self-report studies282.

12. To find out the prevalence of hypertension along with other associated cardiovascular risk factors in a rural community of eastern Nepal

Cross sectional study, who step questionnaire.

Prevalence of hypertension in the rural setting was found to be as high as 38.6%, effective intervention regarding prevention along with early diagnosis and treatment is necessary for control of increasing burden of hypertension.

The focus on practitioner cultural competence is based on assumptions that: (i) mental health services and interventions can reduce health disparities; (ii) that these interventions are more accessible, acceptable and effective when they are culturally adapted; and (iii) that practitioners can acquire specific knowledge, attitudes and skills that will improve their delivery of effective culturally appropriate and responsive mental health services. There is modest evidence for each of these propositions. Questionnaires rest on the assumption of a deficit model wherein laypeople are assumed to be lacking in scientific knowledge or literacy283. The issues of sampling, method of data collection (e.g. questionnaire, observation, and document analysis), and design of questions are all subsidiary to the matter of `What evidence do I need to collect?'

13. Factors affecting the medication taking behaviour of psychiatric patients: a preliminary study from central Nepal

Cross-sectional study semi-structured questionnaire

Medication missing behaviour is high in psychiatric disorders patients, significantly more in those with anxiety disorder and those who had never attended school, suggesting necessary intervention in these groups. To evaluate medication taking behaviour in future studies through more specific methods such as pill counting and biochemical analysis.

Advantages claimed for questionnaires would rarely stand up to scrutiny. They are supposed to eliminate observer biases, to provide a routine method of investigation and analysis which presents the same stimuli to all respondents. Rather, at every stage, a host of assumptions and

282 Bryant and Peck, 21st Century Sociology: A Reference Handbook.283 Mike Michael, ‘Between Citizen and Consumer: Multiplying the Meanings of The “public Understanding of Science”’, Public Understanding of Science 7, no. 4 (1998): 313–27, doi:10.1088/0963-6625/7/4/004.



interpretations are made by everyone employed on a project, which are commonly unacknowledged and uninvestigated in the presentation of results.284

14. Effectiveness of an information booklet on knowledge regarding life style management among coronary heart disease patients in a cardiac centre, Kathmandu valley

Pre-experimental research design education intervention programme had significant role in increasing knowledge of life style management among CHD patients. It was effective and useful for their day to day life style management.

Underlying all of these models is the assumption that individuals are goal-driven, strategists who weight choices according to their own ends (i.e. they are cost-benefit decision-makers)285. Assumption that information leads to change in behaviour. Public health intervention that adopts the biomedical model fails to address issues of wider social injustices that are responsible for health and the related vulnerability and risks286?

15. A case- control study on behavioural risk factors of client with ischemic heart disease of selected cardiac hospitals of Kathmandu district

Hospital based pair match case-control design. Reduce the burden of complex IHD treatment minimizing exposure to the identified risk factors is essential.

Ontological assumption of strong ‘pre-existing reality’ in experiments, require high extend of control over the environment by which investigator directly, precisely and systematically manipulates the reality (yin, 2003). This can only occur in laboratory conditions and a pure experimental design cannot manipulate behaviour in real life context287.

16. Adherence to recommended management among hypertensive people in eastern Nepal

Cross-sectional study. Adherence was measured with Morisky medication adherence scale (MMAS–8)and patients’ health beliefs were measured with the constructs of the health belief model. Adherence to antihypertensive medication seems to be inadequate. Therefore, only prescribing medication is not enough in managing hypertension.

For Roland Kuhn, vital depression was a specific disease for which imipramine was a cure, whereas Nathan Kline, the other pioneer of antidepressant medication, thought that all kinds of 284 Murphy et al., ‘Qualitative Research Methods in Health Technology Assessment: A Review of the Literature’.285 Joseph Henrich, ‘Decision-Making , Cultural Transmission and Adaptation’, Theory in Economic Anthropology, 1998.286 Jacquineau Azétsop and Stuart Rennie, ‘Publisher Main Menu Principlism , Medical Individualism , and Health Promotion in Resource Poor Countries : Can Autonomy Based Bioethics Promote Social Justice and Population Health ?’, Philosophy, Ethics, and Humanities in Medicine, 2010, 1–16, doi:10.1186/1747.287 N Thurairajah, R Haigh, and R.D.G. Amaratunga, ‘Leadership in Construction Partnering Projects : Research Methodological Perspective’, in 6th International Postgraduate Research Conference in the Built and Human Environment (Research institute for Built and Human Environment, University of Salford, 2006), 35–48.



depressive states had a biological origin and that medication was therefore suitable for depression in general. The current standard of depression treatment contains a preventive rationale implicitly promoting medication even in less severe depressions288. Antidepressants have been also termed as ‘psychic energisers’ and these block buster drugs 289 290 291 have given rise to a new era, the antidepressant era292 . When it comes to medical markets, under neoliberalism it exhibits a theoretical anomaly 293 since medicines have been traditionally and historically different than other consumer goods.

17. To assess the relationship between illness perception and depression among patients with diabetes

Analytical cross-sectional study, illness perception. Questionnaire-revised (IPQ-R) and beck depression inventory-ii (BDI-II). High prevalence of depressive symptoms among diabetic patients in Kathmandu Nepal need comprehensive diabetes education program for changing poor illness perception, which ultimately helps to prevent development of depressive.

Questionnaire responses have a problematic relationship to actual behaviour; they are better treated as evidence of attitudes or what people think they ought to say rather than as evidence of what they do294. Questionnaires reflect the application of the biomedical model to public health, with questions that deal primarily with genetic predispositions and behavioural practices: family history of CVD, hypertension, and diabetes; patterns of smoking and alcohol consumption; physical activity levels (including work and leisure); dietary patterns and history of weight gain; and the presence of symptoms of CVD questionnaire must be designed to collect data that meet the statistical assumptions of the quantitative techniques to be used295.

Questionnaires rest on the assumption of a deficit model wherein laypeople are assumed to be lacking in scientific knowledge or literacy296. The issues of sampling, method of data collection (e.g. questionnaire, observation, and document analysis), and design of questions are all subsidiary to the matter of `What evidence do I need to collect?'

288 Helén, ‘The Depression Paradigm and beyond The Practical Ontology of Mood Disorders’.289 Susan Mary Baxter, ‘MEDICINE , METAPHORS AND METAPHYSICS : An Interdisciplinary Analysis of the Ethical , Medical and Sociocultural Questions Raised by Therapeutic Equivalence’, Social Sciences (Simon Fraser University, 2006).290 Amy C Brodkey, ‘The Role of the Pharmaceutical Industry in Teaching Psychopharmacology: A Growing Problem Amy’, Academic Psychiatry 29, no. June (2005).291 International (CI) Consumers, ‘Drugs , Doctors and Dinners How Drug Companies Influence Health in the Developing World’, 2007.292 Healy, The Antidepressant Era.293 Conrad and Leiter, ‘Medicalization , Markets and Consumers’.294 Murphy et al., ‘Qualitative Research Methods in Health Technology Assessment: A Review of the Literature’.295 Sara M Glasgow, ‘What Goes Up : The Genesis and Context of Health Reform in Sweden’, GLOBAL HEALTH GOVERNANCE 3 (2009): 18.296 Michael, ‘Between Citizen and Consumer: Multiplying the Meanings of The “public Understanding of Science”’.



18. To determine the prevalence of CAD risk factors among a target female population in Nepal

Semi-structured interview schedule was followed for the data collection. Diabetes, drinking alcohol, LDL-C and generalized obesity were found as the significant predictors of cad need of appropriate control strategies and measures among women.

Focus is on the upper, superficial, echelons of the process and is rarely of the process itself. It stands in contrast to the view dubbed "holistic" or "physiological" that stresses individuals and their adaptation - physical, psychological, social - to their environment297. Yach and Beaglehole say that globalization has contributed to the rise in chronic diseases and blame major transnational corporations and the global communications media for the marketing of tobacco, alcohol, sugary and fatty foods in nearly all parts of the world298.

19. To assess the stages, self- efficacy, motivation and decision making of smoking cessation among adolescents in selected schools of Pokhara

Cross-sectional descriptive design using quantitative approach, self–administered semi-structured questionnaire. Smokers were not prepared to quit because they were less motivated, not wanting to change was found associated with lower self- efficacy.

Public health workers are determined to focus on problems that interest them as researchers and not on the problems of concern to individuals299. Much of public health continues to treat behaviours such as diet, smoking, violence, drug use, and sex work as if they were voluntary decisions, without regard to social constraints, inducements, or pressures300.

20. To identify the prevalence and the risk factors associated with elder mistreatment in urban Nepal.

Descriptive cross-sectional study, information was collected using an interviewer administered Semi-structured questionnaire. Older adults in urban Nepal self-reported a higher rate of mistreatment. Awareness, intervention and prevention strategies targeting elder population and their family is required to address such mistreatment.

297 Susan Mary Baxter, ‘MEDICINE , METAPHORS AND METAPHYSICS : An Interdisciplinary Analysis of the Ethical , Medical and Sociocultural Questions Raised by Therapeutic Equivalence’, Social Sciences 2006.298 Richard Harris and Melinda Seid, ‘The Globalization of Health: Risks, Responses, and Alternatives’, Perspectives on Global Development and Technology 3, no. 1 (2004): 245–69, doi:10.1163/1569150042036657.299 S Leonard Syme and Miranda L Ritterman, ‘The Importance of Community Development For Health and Well-Being’, Community Development INVESTMENT REVIEW, 2009.300 Thomas A. Glass and Matthew J. McAtee, ‘Behavioral Science at the Crossroads in Public Health: Extending Horizons, Envisioning the Future’, Social Science and Medicine 62, no. 7 (2006): 1650–71, doi:10.1016/j.socscimed.2005.08.044.



Elders generally felt that improved health should “start at home”; partnerships at the community and systems levels were often referred to as more likely solutions than individual and interpersonal ones301.

301 Janice Hermann et al., ‘Utilizing the Socioecological Model as a Framework for Understanding Elder Native Americans’ Views of Type 2 Diabetes for the Development of an Indigenous Prevention Plan’, Education, 2010.



5 – Discussion and conclusion

The researches and their findings could provide a true picture of a particular reality in quantitative terms, for instance the practise of breast feeding could be low, school attendance low, low family control practices, unhygienic surroundings, high road traffic accidents and so on, in any particular region of Nepal. Knowing the incidence, prevalence or occurrence of any particular phenomenon is important and this can be known through surveys, questionnaires and interviews. The problem arises when interpreting the reasons for existence of a phenomenon and based on these reasons the recommendations made. Ignorance and illiteracy are the chief culprits for an individual who does not wash hands before eating, who does not visit a health post in terms of illness, who has some health conditions related to life style, who is engaged in high risk taking behaviour (commercial sex without condom) or not wearing a helmet on a motorcycle. The solutions recommendations that stem out from this belief are predominantly individualist and suggest behavioural interventions by health literacy campaigns and awareness programs. The needs for more awareness programs seem a very realist and pragmatic approach, since rationally it has been understood that one acts in a harmful way out of ignorance. If one were to read Rakku’s story 302 or Acephie’s story the limits to our understanding when researcher and the research processes are detached, dehistoricized, decontextualized, depoliticized or deproblematized is displayed. The negation of the social, political, economical, historical facets of the researched can create research reminiscent to what Frankfurt conceptualised and analysed as bullshit.

Frankfurt’s conceptual analysis of the notion of bullshit can add to our understanding of how universities have deprofessionalized the faculty while producing its own official bullshit about education and research303. A core feature for Frankfurt’s definition of bullshit is a lack of concern with truth and an indifference towards reality304. Bullshitting creates bad research. Bad research often uses accurate data, but manipulates and misrepresents the information to support a particular conclusion. Questions can be defined, statistics selected and analysis structured to reach a desired outcome. Alternative perspectives and data can be ignored or distorted. Critics of an idea sometimes exaggerate issues of uncertainty. They imply because we don’t know everything about an issue, we know nothing about it305. This approach ignores the presence and intersections of structural phenomena. Public health, however, is usually premised on the notion of community health and well-being306.

302 Sheila Zubrigg, Rakku’s Story Structures of Ill-Health and the Source of Change (George Joseph, on behalf of Centre for social Action, 1981).303Chris Lorenz, ‘If You ’ Re So Smart , Why Are You under Surveillance? Universities , Neoliberalism , and New Public Management’, Critical Inquiry 38 (2012): 599–629.304Thomas Teo, ‘Empirical Race Psychology and the Hermeneutics of Epistemological Violence’, Human Studies A Journal for Philosophy and the Social Sciences 34, no. 3 (2011): 237–55, doi:10.1007/s10746-011-9179-8.305By Todd Litman, ‘Evaluating Research Quality’, Victoria Transport Policy Institute, 2012.



Epistemic well is a combination of various traits of researches that have been identified under neoliberalism. What makes epistemic well different is the gaze it offers when a researcher or a team of researchers look at issues from its depth. For example if a well in a village is polluted and if one were to only examine the well and conclude that the pollution is a result of the villagers who have failed to maintain the well. But what if the researcher has not taken into consideration an industrial factory that was built a few years ago? When it comes to studying behavioural practices and adherences of others, the onus lies with the concerned individual.

Now for instance let’s imagine a situation where different individuals do certain acts such as parking the car under a no-parking sign, not wearing a helmet when riding a motorcycle or not giving way to an ambulance on a busy road. Now if asked to identify or characterise the basic behavioural attributes, such as education and profession of these individuals, what would be the answer? Usually whenever I pose these questions the answers that I receive characterise such individuals as illiterate, less-educated, unethical, immoral etc. If the answers had been true I would not have worried much. But since the individuals behaving in these types of actions go beyond the stereotypical images and include highly educated academicians, administrators, scientists, professors, doctors etc is the issue of concern.

These people are ethical in their professional life, a good husband/wife, a good father/ mother, practices yoga; in fact these people are all law obeying citizens. They would match the perfect rational human being acting on maximizing their behaviour in the pursuit of self interest and yet they do not wear helmets when riding motorcycles doing local travels which ranges from a few hundred meters to a couple of kilometres 307.

The principal reason for driving within a two km circle is because the traffic police do not enter the campus. Other unethical or uncivil behaviours like parking under the no-parking sign and not making any effort to give way to the ambulance also happen because of lack of monitoring. An incident that I once witnessed was seeing a colleague jumping the queue in a visa issuing office. On our return I asked the colleague of mine about the incident and very indifferently my colleague answered back, “ I took the opportunity as provided by the moment when there was that little commotion and what difference does it make it ? When asked as a researcher would he/she do such insignificant acts as provided by the moment when doing a research? He/she vehemently denied of any such doing and stressed on professionalism and also suggested not to make comparison of personal actions and professional actions.

306Fran Baum, ‘Overcoming Barriers to Improved Research on the Social Determinants of Health’, MEDICC Review 12, no. 3 (2010): 36–38.307 This narration is based on witnessing these behaviors in an institute in Nepal. I do not claim to be self-righteous.



Can a researcher who does not follow the traffic signal when not being monitored, collect data in the field or do a research with honesty and integrity even when not being monitored? Can these acts be a detached action from other social actions which one is supposed to follow when not being observed? Regarding other activities do they maintain the ethical/civil standards even when not being observed? Is this act not a picture of the larger social, political, economical and cultural manifestations that exist in our context? The individual who has not behaved ethically in one’s daily life since no one is observing will follow ethical guidelines when taking decisions at one’s professional or work level even when not being observed? As a native, when seeing certain individual actions taking place when not being observed by concerned regulatory authorities compel me to question the validity and strength of the practice of self-regulation. From individuals to groups, boards and other social, political and economic conglomerates, are all of them also following the practice of following ethical and legal guidelines only when being observed? So does that mean all our activities should be observed just as the ‘big brother’ does in Animal Farm?

The neo-liberal research, researcher, universities, organisations are all in sync with one another and this creates a culture of doing research projects one after another. The neo-liberal researcher is bound by practices set by councils, universities, committees and so on. Since the promotion criteria of a faculty depends largely on the number of research publications in peer review journals, the number of research projects completed, number of conferences attended and so on, the pressure of doing research and publishing them is omnipresent. Hence for example ‘A’ an assistant professor joins a university after finishing MD or PhD and in three years time ‘‘A’’ can become an associate professor with an increase in pay and other facilities such as conference grants. But they are some basic conditions that ‘A’ will have to fulfil in order to get promoted such as ‘A’ needs three research publications in peer reviewed indexed journals, received one project grant and completion of one project or study. If ‘A’ has fulfilled this in paper ‘A’ gets promoted. This process continues till ‘A’ becomes a professor. The other indispensible function that ‘‘A’’ does is teaches students a course in the university. And if ‘A’ since as a physician ‘A’ also caters to the patients. Now what is perplexing is the role of a teacher and a surgeon are not given any significant weight. ‘A’ may be an excellent teacher and surgeon but without the minimum number of research publications ‘A’ cannot be promoted. So despite the busy schedule ‘A’ has, starts doing a questionnaire survey among visiting OPD patients and generates the hypotheses that, ‘patients coming to the hospital in red colour cars are more prone to diabetes than patients coming in black colour cars’. So ‘A’ selects the sample population, collects the data, generates the data and publishes the data in a peer review journal. Now ‘A’ has to do several researches in this case let us keep it to three for every stage of promotion and with three years intervals. To be a professor, one begins as assistant professor then associate, additional and finally a professor.



The mantra of faculty promotion is influenced by the practise of, ‘publish or perish’ where for every level of promotion one needs to fulfil the required number of publications. The pressure to climb up the hierarchy is desirable among all of us including academicians, researchers or any other profession. So the combination of this desire to climb up and along with the criteria set by universities the onus falls on the individual to publish. Under this system the evaluation is not affected by the views of those who are at the receiving end such as the community. To clarify my point here I again bring in ‘A’ who qualifies for promotion in three years time but without the minimum number of publications i.e. three ‘A’ will not be promoted. To publish is a time consuming process and after teaching activities and clinical duties ‘A’ has very less time. Also let me mention that ‘A’ values the role of a teacher and spends time on preparing classes which the students appreciate since they learn a lot. The patients that visit ‘A’ are also very satisfied. But soon ‘A’ realises that it is research publications that counts and not the everyday dealings with students and patients. So ‘A’ starts valuing research publications more and within a few years, the new students and the new patients that are affected by ‘A’ have an opinion different than before. The students are not happy with the classes and neither is the patient that ‘A’ deal’s with. For ‘A’ satisfying criteria’s set by the university are more important, like number of articles published and number of projects completed. As these are decisive factors for promotion and since no or a minimal value is given to opinions of patients and students, these processes begin to be devalued. Citing bias as a factor if patients and students evaluations are given credence, the notion that if there are given any weight it could become a bargaining tool. Publications are tangible products which can be seen and quantified where as feelings are not.



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