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’(Campbell, Shrestha and Stone, 2010). More recently others have also expressed the fact that the overwhelming majority of articles reported on quantitative(Karmacharya, 2011) and calls for making health a public health agenda have also been made(Subedi Sharma Madhusudan, 2016). 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 frameworks(Sharma, Khatri and Harper, 2016). The public health education has also been characterised as having its stress on managerial, administrative and project specific and lacking academically the public health graduates are trained to work as public health practitioners in districts(Mahat et al., 2013). 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 forestry(Ahlborg and Nightingale, 2012) (Schulz and Siriwardane, 2015) (Ojha et al., 2016) (Campbell, Shrestha and Stone, 2010). 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 arose due to three primary reasons.
The first reason is due to the historical processes that has conditioned contemporary Nepal. The second reason is due to the influence of neoliberal values and the third reason is due to the empirical experiences of the author. A very brief history of Nepal is discussed since; a historicized understanding of the present condition has been deemed an important approach(Rosenberg, 2003). 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 percent(Kernot, 2006).
More than one hundred years ago in 1887 when various inventions, discoveries were taking place around the world, Richard Temple had declared Nepal to be ‘closed to the eyes of science’(Chene, 2007). The 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)(Pherali and John, 2011) (World Health Organization, 2006) (Rai et al., 2001). 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 development(Campbell and Jovchelovitch, 2000) (Sharma, 2010) (Kernot, 2006) (Van Teijlingen et al., 2015).
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 principles(Sugden, 2009). As a process, neoliberalization is variegated, unfinished, and contingent(Annetts et al., 2017). It is a slippery concept to theorize(Nik-Khah and Van Horn, 2016), let alone study empirically(Nik-Khah and Van Horn, 2016). 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 society”(Porter, 2005a). Key to this process is “an attempt to instil a series of values and social practices in subjects(Petersen and Davies, 2010) and by virtue of being embedded in practices of governance at the local level often leads to a sense of neoliberalism being everywhere”(Castree, 2011).
Depending upon the social, economic and political conditions of a nation, the adoption of free-market and neoliberalism can have varied affects and consequences. Neoliberal values and principles like, 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. Reification of research has led to research being done for fulfilling objectives leading to personal gain. 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.
In figure one the research process shows, the researcher at one end of the process and the results, recommendations and the knowledge generation that the research provides 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, ontology(metaphysics), axiology, epistemology in totality our philosophy or paradigm. Though ontology and epistemology have been shown separately, claims have been made that these cannot be considered separable as axiology, epistemology and ontology co-evolve(Allen and Varga, 2007). 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 results are generated, findings are made and recommendations done.
Since the neoliberal environment condition our ideas, it is imperative that neoliberalism and its ideology, its assumptions and its processes be discussed and understood. Since its coinage the term has been in constant use and its popularity can be fathomed by the fact that a Google scholar search of the term neoliberal in its title since 2019 yielded more than 1500 results. With so much use of the term, neoliberalism risks being tagged as just another buzzword(Noonan, 2018) or fuzz word, or is it already one? Use of the term neoliberal has also led to some describing as being lazy, too vague, too ready to denounce, frequently undefined, unevenly employed, too overblown and the need for it to be ‘severely circumscribed’ has been called for(Clack and Paule, 2019). Despite the allegations, neoliberalism still holds an important place as evident by the large number of publications which mention the term.
The term neoliberalism resulted from the participants during the Walter Lippmann Colloquium held in Paris in 1938 to discuss the French publication of, An Inquiry into the Principles of the Good Society by Lippmann(Cahill et al., 2018). The central presuppositions of neoliberalism include the rational self-interested individual, free market economics, a commitment to laissez-faire and a commitment to free trade(Olssen and Peters, 2005). Neoliberalism has shaped our cognition and it espouses neoliberal ideologies that emphasize individual-level decision making about economics and healthcare(Sanders and McKay, 2013). Neoliberal view and practise has directly implicated in shaping the way health is promoted(Ayo, 2012) and thoughts are shaped(Rose, 2001).The neoliberal ontological project supposes homo economicus as principal model for individual behaviour which occurs from subject’s economic rationality functioning in a world of perfect information and inert notions of equilibrium(Madra and Adaman, 2014). Neoliberalism touches all aspects of life including research.
Neoliberalism and its ‘regime of truth’ values characteristic features like individualisation(Clack and Paule, 2019), marketisation(Dutta, 2016), financialisation(Rossi, 2013), commoditisation(Fisher, 2009), commodification(Esposito and Perez, 2014), commercialisation(Pinto, 2017), privatisation, accumulation(Subramaniam, 2014), dispossession(Subramaniam, 2014), adaptation(Phillips, McMichael and O’Keefe, 2018), freedom(Odysseos, 2010), competition(Baronov, 2012), monetisation(Fox, 2017), disimagination, melioration(Birn, 2014) and de-democratization(Brown, 2006). Humans being rational, independent, entrepreneurial, profit seeking and opportunity maximising humans will thrive competitively in a free market where the “invisible hands of the market” will take care of it all. It has been seen as a “hard-wired reality”, a doctrine, an ideology which sees institutions adapting to variegated strands of capitalism(Fine and Saad-Filho, 2017).
Under neo-liberal influence research is predominantly positivist(Esposito and Perez, 2014) by nature and the recommendations, findings; interventions are predominantly individualist in nature(Rentmeester and Dasgupta, 2012). 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 beings”(Stahl, 2007). A positivist ontological approach, “presumes the existence of a ‘‘real,’’ apprehendable reality driven by immutable natural laws and mechanisms and that researchers are capable of studying objects without influencing them or being influenced by them”(Carpiano and Daley, 2006). “Positivism relies on a reductionist view in its search for universal mechanistic rules that are not contextually bounded and seeks to verify hypotheses”(Carpiano and Daley, 2006). Positivists view the individual as an essentially biophysiological and neurophysiological system, a reductionist view(Yadavendu, 2013). An offshoot of the positivist school of thought is methodological individualism (MI) which, “emphasises; homo economicus, based on assumptions of individuality, rationality, self-interest; and the doctrine of spontaneous order”(Roberts and Peters, 2019). Methodological individualism has been the “central monistic-ideological stand of existing economic theory, from which individual economic policies fastidiously acquire neoliberal basis”(Draskovic, 2016).
Methodological individualism as a position and process consists of several assumptions. Some of the assumptions inherent within the approach which have been identified are ontological assumptions(Prozorov and Rentea, 2016), epistemological assumptions(Cosgrove and Karter, 2018), fundamentalist assumptions(Sparke, 2020), atomistic assumptions(Mcdowell, 1994), methodological assumptions(Rillo, 2018), observability assumptions(Backhouse, 2007) and axiological assumptions(de Camargo, Ortega and Coeli, 2013). A “positivist ontological approach combined with methodological individualism can create a disposition to treat humans as objects”(Stahl, 2007). “Treating humans as things means that one can treat them as means rather than ends, thus violating Kant’s well-known account of the categorical Imperative”(Amstutz, 2013), “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”(Nissen, 1985).
This combination of methodological individualism and positivism has been incorporated in epidemiology, the discipline most actively involved in the study of health problems(Breilh, Campana and Hidalgo, 2005). Claims against mainstream/traditional epidemiology being “too dull to analyse 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”(Pearce, 1996). “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 focus”(Pearce, 1996). Citing the Leeds declaration in 1994, “the Lancet editors concluded that common epidemiological research has always been based on simplistic notions of causality”(van Der Maesen and Nijhuis, 2000). “The Research Unit in Health and Behavioural Chance at Edinburgh University construed that mainstream epidemiology has little to offer in modernising public health, that its positivistic orientation highlights a key flaw in its recognition of the social dynamics of health and disease, therefore weakening its potential to achieve transformation in public health”(van Der Maesen and Nijhuis, 2000).
The dominant risk factor epidemiology prevailing has several limitations(Pearce, 1996)(Goldberg, 2013) and operates under ‘atomistic metaphysics’(de Camargo, Ortega and Coeli, 2013) and individualistic suppositions(Wemrell et al., 2016). “The principal approach of epidemiological explanation takes place entirely within the confines of a scientific way that has been termed Cartesian reductionism, an analytical advance categorized by a focus on factors measured in seclusion from their context”(McPherson, 1998). “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 choices”(Doll, 1999).
The practise of victim blaming does not question, structural, social and other external forces that puts an individual at risk. Individualistic approaches do not deal with the root causes, “which not only include industrial activity but also elements of the global political economy that give rise to the crisis in the first place”. Occasionally called the ‘causes of the causes of the causes’, “several commentators argue that these broader societal factors can be tackled only by passing policies that deal with structural drivers, particularly those that generate poor nutrition: liberalisation of food trade; the acceleration of foreign investment by transnational food companies; the rapid spread of cheap, ultra-processed food that affect the availability, affordability and acceptability of what people eat; and deregulation of commodities markets that cause food price instability and dietary dependency” .
The hallmark trait of contemporary public health has been dominated by behavioralism(Staddon, 2004) and the individualization of risk(Peet, Robbins and Watts, 2010). 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 strategies”(Gray and Mcdonald, 2006). The emergence of evidence-based practice must be appreciated within the context of neo-liberalism(Gray and Mcdonald, 2006). The EBPH like EBM tries, “to position health policies and interventions on ‘sound facts’ and this uncritical acceptance of evidence-based medicine by the public health field has been seen to substantiate blaming individual patients for health problems ensuing from social conditions or that the EBPH approach may rationalize cuts in public health spending”(Nadav and Dani, 2006). Both EBM and EBHP presuppose universal biological response 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 population(Victora, Habicht and Bryce, 2004).
“The critics of EBP warn that the concept of ‘what works’ evidence is parochial and myopic, because it defines ‘evidence’ scientifically and mechanically that is too limited from public health perspective”(Ahmed, 2014). The evidence-based approach has been claimed to have led to the commodification of health care and public health(Nadav and Dani, 2006). 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”(McGuire, 2005). “Commonly ignored, yet seriously health-damaging, contextual factors include: being a second-class citizen or being made to feel like a second-class citizen”(Monaghan, 2013). 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 people”(Rich, Monaghan and Aphramor, 2010).
Most theoretical debates about the pros and cons of public health approaches are confined to the methodological scientific level. “Philosophical foundations such as fundamental ontological notions are seldom part of public health debates, but these are always inherent and lie behind the opinions and interpretation of diverse standpoints or traditions”(Nijhuis and van der Maesen, 1994). “In empiricist science, dominant in contemporary epidemiology, exposure and risk assessment, the principal accepted philosophical approach is that of the positivist paradigm —unbiased examination; the separation of ‘facts’ from ‘‘values’’; and the stress on verification to build up universal laws”(Briggs, Sabel and Lee, 2009).
The combined empirical experiences of the authors gained in day to day academic activities such as classroom interactions, seminars and research activities have also considerably prompted us to explore research philosophy in the field of health. Experiences such as when teaching public health and community medicine at the post-graduate level in the first semester 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 are situated at the micro level. The lack of historically informed analysis is absent and this lacuna manifests itself when doing health research.