Targeting the vulnerable: A critical analysis of helicopter transport for obstetric emergencies in Nepal
DOI:
https://doi.org/10.55016/ojs/jcph.vi.79666Keywords:
birth, emergency medicine, transport, maternal mortality, NepalAbstract
In tandem with national efforts to develop a system of pre-hospital care via ground ambulance services, leading private hospitals in Nepal are competing to institute air ambulances, or helicopter emergency medical services (HEMS). In a nation with limited infrastructure and extreme geography, helicopters offer a high-tech solution to overcoming transportation delays in emergency medicine. Private HEMS, due to the exorbitant costs, invites intersectional analysis along the lines of how wealth, caste or ethnicity, gender, and remoteness shape who is able to utilize it. In contrast, the launch of a governmental program devoted to transporting rural obstetric emergency patients to hospitals, using army helicopters, stands out as an unexpected transformation of a status quo in which only wealthy, elite individuals could access such medical care. Through a review of the trends in maternal mortality and ethnographic field research with doctors in Kathmandu and Kavrepalanchok who are leading the development of emergency medical transport, this paper explores competing interpretations of the driving forces and implications of HEMS, analyzing the benefits and drawbacks to targeting the vulnerable in health interventions.
Downloads
References
Acharya, S. P. (2013) Critical care medicine in Nepal: Where are we? International Health, 5(2), 92-95. https://doi.org/10.1093/inthealth/iht010 DOI: https://doi.org/10.1093/inthealth/iht010
Anon (2024, March 13th) Air rescue of 659 pregnant women and children. Khabarhub. https://khabarhub.com/2024/13/605908/
Aryal, B. P. (2016, Dec 31st) Critical health care centralized in capital. My República. Critical health care centralized in capital - myRepublica - The New York Times Partner, Latest news of Nepal in English, Latest News Articles | Republica
Berry, N. (2010) Unsafe motherhood: Mayan maternal mortality and subjectivity in post-war Guatemala. Berghan. https://doi.org/https://doi.org/10.3167/9781845457525 DOI: https://doi.org/10.3167/9781845457525
Bhandari, D., & Yadav, N. K. (2020) Developing an integrated emergency medical services in a low-income country like Nepal: A concept paper. International Journal of Emergency Medicine, 13(1), 7. https://doi.org/10.1186/s12245-020-0268-1 DOI: https://doi.org/10.1186/s12245-020-0268-1
Bourgois, P., Holmes, S. M., Sue, K., & Quesada, J. (2017) Structural vulnerability: Operationalizing the concept to address health disparities in clinical care. Academic Medicine, 92(3), 299-307. https://doi.org/10.1097/acm.0000000000001294 DOI: https://doi.org/10.1097/ACM.0000000000001294
Bridges, K. (2011) Reproducing race: An ethnography of pregnancy as a site of racialization. University of California Press. DOI: https://doi.org/10.1525/california/9780520268944.001.0001
Brunson, J. (2016) Planning families in Nepal: Global and local projects of reproduction. Rutgers University Press.
Brunson, J. (2017) Maternal, newborn, and child health after the 2015 Nepal earthquakes: An investigation of the long-term gendered impacts of disasters. Maternal & Child Health Journal, 21, 2267–2273. https://doi.org/10.1007/s10995-017-2350-8 DOI: https://doi.org/10.1007/s10995-017-2350-8
Brunson, J. (2018) Maternal health in Nepal and other low-income countries: Causes, contexts, and future directions. In N. Riley & J. Brunson (Eds.), International handbook on gender and demographic processes (pp. 141-152). Springer. https://doi.org/10.1007/978-94-024-1290-1_10 DOI: https://doi.org/10.1007/978-94-024-1290-1_10
Brunson, J. (2020a) Concealed pregnancies and protected postpartum periods: Defining critical periods of maternal health in Nepal. In V. Petit, K. Qureshi, Y. Charbit, & P. Kreager (Eds.), The anthropological demography of health (pp. 472-492). Oxford University Press. DOI: https://doi.org/10.1093/oso/9780198862437.003.0018
Brunson, J. (2020b) Tool of economic development, metric of global health: Promoting planned families and economized life in Nepal. Social Science & Medicine, 254, 112298. https://doi.org/https://doi.org/10.1016/j.socscimed.2019.05.003 DOI: https://doi.org/10.1016/j.socscimed.2019.05.003
Brunson, J. (2021) Reproduction through revolution: Maoist women’s struggle for equity in post-development Nepal. In S. Han & C. Tomori (Eds.), The Routledge handbook of anthropology and reproduction (pp. 137-149). Routledge. DOI: https://doi.org/10.4324/9781003216452-11
Brunson, J. (2024) The golden hour. HIMALAYA, 43(2), 35-37. https://doi.org/10.2218/himalaya.2024.9106 DOI: https://doi.org/10.2218/himalaya.2024.9106
Brunson, J., & Suh, S. (2020) Behind the measures of maternal and reproductive health: Ethnographic accounts of inventory and intervention. Social Science & Medicine, 254, 112730. https://doi.org/https://doi.org/10.1016/j.socscimed.2019.112730 DOI: https://doi.org/10.1016/j.socscimed.2019.112730
Chatterjee, N., & Riley, N. E. (2001) Planning an Indian modernity: The gendered politics of fertility control. Signs, 26(3), 811-845. https://doi.org/10.1086/495629 DOI: https://doi.org/10.1086/495629
Collins, P., & Bilge, S. (2020) Intersectionality (2nd ed.). Polity.
Farmer, P. (1999) Infections and inequalities: The modern plagues. University of California Press.
Farmer, P., Kleinman, A., Kim, J., & Basilico, M. (2013) Reimagining global health. University of California Press.
Hussein, J., Bell, J., Dar Iang, M., Mesko, N., Amery, J., & Graham, W. (2011) An appraisal of the maternal mortality decline in Nepal. PLOS ONE, 6(5), e19898. https://doi.org/10.1371/journal.pone.0019898 DOI: https://doi.org/10.1371/journal.pone.0019898
Jacobson, C., Basnet, S., Bhatt, A. (2021) Emergency medical dispatcher training as a strategy to improve pre-hospital care in low- and middle-income countries: The case study of Nepal. International Journal of Emergency Medicine, 14(28) https://doi.org/10.1186/s12245-021-00355-8 DOI: https://doi.org/10.1186/s12245-021-00355-8
Jones, A., Donald, M. J., & Jansen, J. O. (2018) Evaluation of the provision of helicopter emergency medical services in Europe. Emergency Medicine Journal, 35(12), 720-725. https://doi.org/10.1136/emermed-2018-207553 DOI: https://doi.org/10.1136/emermed-2018-207553
Karkee, R., Tumbahanghe, K. M., Morgan, A., Maharjan, N., Budhathoki, B., & Manandhar, D. S. (2022) Policies and actions to reduce maternal mortality in Nepal: Perspectives of key informants. Sexual and Reproductive Health Matters, 29(2), 1907026. https://doi.org/10.1080/26410397.2021.1907026 DOI: https://doi.org/10.1080/26410397.2021.1907026
Karki, S., Singh, S., Malla, D. K., Basnet, Y., Chaudhary, V., Neupane, E., Bhandari, R., & Adhikary, A. (2022) System of helicopter emergency medical services in Nepal: A study at Nepal Mediciti Hospital. Air Medical Journal, 41(1), 37-41. https://doi.org/10.1016/j.amj.2021.09.009 DOI: https://doi.org/10.1016/j.amj.2021.09.009
Karki, S., & Sprinkle, D.J. (2021) Helicopter emergency medical services during Coronavirus disease 2019 in Nepal. Air Medical Journal, 40(4), 287-288. https://doi:10.1016/j.amj.2021.04.005 DOI: https://doi.org/10.1016/j.amj.2021.04.005
Maeder, M. M., Basnyat, B., & Harris, N. S. (2014) From Matterhorn to Mt Everest: Empowering rescuers and improving medical care in Nepal. Wilderness Environmental Medicine, 25(2), 177-81. https://doi:10.1016/j.wem.2013.12.029 DOI: https://doi.org/10.1016/j.wem.2013.12.029
Ministry of Health and Population & National Statistics Office (2022) National Population and Housing Census 2021: Nepal Maternal Mortality Study 2021. Ministry of Health and Population & National Statistics Office.
Murray, S. F., & Pearson, S. C. (2006) Maternity referral systems in developing countries: Current knowledge and future research needs. Social Science & Medicine, 62(9), 2205-2215. https://doi.org/https://doi.org/10.1016/j.socscimed.2005.10.025 DOI: https://doi.org/10.1016/j.socscimed.2005.10.025
Neupane, H.C., Gauli, B., Adhikari, S., & Shrestha, N. (2020) Contextualizing critical care medicine in the face of Covid-19 pandemic. Journal of Nepal Medical Association, 58(226), 447-452. https://doi:10.31729/jnma.5153 DOI: https://doi.org/10.31729/jnma.5153
Pandhi, N. (2024) The ‘caste’ of decolonization: Structural casteism, public health praxis, and radical accountability in contemporary India. In T. Masvawure and E. Foley (Eds.), The Routledge handbook of anthropology and global health (Vol. 1, pp. 19–34). Routledge. https://doi.org/10.4324/9781003284345-3 DOI: https://doi.org/10.4324/9781003284345-3
Pigg, S. L. (1992) Inventing social categories through place: Social representations and development in Nepal. Comparative Studies in Society and History, 34(3), 491-513. DOI: https://doi.org/10.1017/S0010417500017928
Quesada, J., Hart, L. K., & Bourgois, P. (2011) Structural vulnerability and health: Latino migrant laborers in the United States. Medical Anthropology, 30(4), 339-362. https://doi.org/10.1080/01459740.2011.576725 DOI: https://doi.org/10.1080/01459740.2011.576725
Riese, S., & Dhakal, R. (2023) Understanding the three delays among postpartum women in Nepal. DHS Further Analysis Report No. 144. ICF.
Scheper-Hughes, N. (1993) Death without weeping: The violence of everyday life in Brazil. University of California Press. DOI: https://doi.org/10.1525/9780520911567
Senderowicz, L. (2019) ‘I was obligated to accept’: A qualitative exploration of contraceptive coercion. Social Science & Medicine, 239, 112531. https://doi.org/https://doi.org/10.1016/j.socscimed.2019.112531 DOI: https://doi.org/10.1016/j.socscimed.2019.112531
Serajuddin, U., & Hamadeh, N. (2020) New World Bank country classifications by income level: 2020-2021. https://blogs.worldbank.org/en/opendata/new-world-bank-country-classifications-income-level-2020-2021.
Singh, H. D. (2020) Numbering others: Religious demography, identity, and fertility management experiences in contemporary India. Social Science & Medicine, 254, 112534. https://doi.org/10.1016/j.socscimed.2019.112534 DOI: https://doi.org/10.1016/j.socscimed.2019.112534
Sharma, B. B., Pennell, C., Sharma, B., & Smith, R. (2024) Reducing maternal mortality in low- and middle-income countries: The Nepalese approach of helicopter retrieval. American Journal of Obstetrics and Gynecology, 230(5), 473-475. https://doi.org/https://doi.org/10.1016/j.ajog.2024.01.026 DOI: https://doi.org/10.1016/j.ajog.2024.01.026
Shrestha, S., Bell, J. S., & Marais, D. (2014) An analysis of factors linked to the decline in maternal mortality in Nepal. PLOS ONE, 9(4), e93029. https://doi.org/10.1371/journal.pone.0093029 DOI: https://doi.org/10.1371/journal.pone.0093029
Shrestha, S. K., Koirala, K., & Amatya, B. (2018) Patient’s mode of transportation presented in the emergency department of a tertiary care centre, Kavre, Nepal. Kathmandu University Medical Journal. 61(1):39-42.
Smith-Oka, V. (2013) Shaping the motherhood of Indigenous Mexico. Vanderbilt University Press.
Storeng, K. T., & Béhague, D. P. (2016) Lives in the balance: The politics of integration in the Partnership for Maternal, Newborn and Child Health. Health Policy and Planning, 31(8), 992-1000. https://doi.org/10.1093/heapol/czw023 DOI: https://doi.org/10.1093/heapol/czw023
Storeng, K. T., & Béhague, D. P. (2017) ‘Guilty until proven innocent’: The contested use of maternal mortality indicators in global health. Critical Public Health, 27(2), 163-176. https://doi.org/10.1080/09581596.2016.1259459 DOI: https://doi.org/10.1080/09581596.2016.1259459
Thaddeus, S., & Maine, D. (1994) Too far to walk: Maternal mortality in context. Social Science & Medicine, 38(8), 1091-1110. https://doi.org/10.1016/0277-9536(94)90226-7 DOI: https://doi.org/10.1016/0277-9536(94)90226-7
Varley, E., & Duplessis, E. (2023) The Global Safe Motherhood Initiative’s ‘unintended consequences.’ In C. Van Hollen & N. Appleton (Eds.), A companion to the anthropology of reproductive medicine and technology (pp. 119–137). John Wiley & Sons. https://doi.org/10.1002/9781119845379.ch6 DOI: https://doi.org/10.1002/9781119845379.ch6
Wendland, C. (2016) Estimating death: A close reading of maternal mortality metrics in Malawi. In V. Adams (Ed.), Metrics: What counts in global health (pp. 57-81). Duke University Press. DOI: https://doi.org/10.2307/j.ctv1168c3w.5
Wong, K., & Brunson, J. (2025) Marshallese mothers navigating discrimination in Hawai‘i: Bwebwenato as method. Medical Anthropology Quarterly, 39(3), e70008. https://doi.org/10.1111/maq.70008 DOI: https://doi.org/10.1111/maq.70008
Published
Issue
Section
License
Copyright (c) 2025 Jan Brunson, Suman Raj Tamrakar
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
All articles in the Journal of Critical Public Health are published under a CC-BY-NC-ND license, or a CC-BY license if authors or their funders require this. The default CC-BY-NC-ND license means that authors and users may copy and distribute the material in any medium or format in un-adapted form only, for non-commercial purposes only, and only so long as proper credit is given (as is customary in academic work). Authors retain copyright of their work published in Journal of Critical Public Health and full publishing rights without restrictions
