[stop-imf] Navarro: Globalization, Health, WHO and IMF/WB

[robert.weissman@essentialinformation.org]

Viewpoint

The world situation and WHO

Volume 363, Number 9417     17 April 2004

Vicente Navarro



Lancet 2004; 363: 1321-23


Public and Health Policy Program, The Johns Hopkins University-Pompeu
Fabra University, Baltimore MD, USA, and Barcelona, Spain (V Navarro MD)

Correspondence to: Dr Vicente Navarro, The Johns Hopkins University, 624
North Broadway, Baltimore MD 21205, USA (e-mail: vnavarro@jhsph.edu )


A few developed countries control, or have a dominant influence over, the
world's economic, political, and cultural resources.1,2 This reality,
however, should not lead to the conclusion that the primary conflict today
is between developed and developing countries. Such an interpretation is
seen, for example, in the UN Development Programme (UNDP) Human
Development Reports. In describing the world social situation, these
reports contrast such things as the amount of money spent by people on
feeding their pets in developed countries with the amount of money spent
on feeding children in poorer countries.3

This type of presentation and analysis, besides making people from
economically advanced countries feel guilty, seems to carry the message
that the problem of famine in children in poorer countries--one of the
largest public health problems4--could be solved by transferring funds
from the people living in wealthy countries (funds saved by not feeding
pets) to feed children in developing countries. This analysis is wrong and
naively apolitical; it erroneously assumes that famine and poverty in
developing countries are caused by a lack of funds (and other resources).
But the well documented reality is that these countries have enough
resources to feed populations many times their size.5 Even Bangladesh and
Haiti, to mention just two countries where famine is endemic, have enough
productive land to feed their populations five times over. To be fair to
the UNDP, however, this position is now being questioned within the
organisation, but the view is still prevalent in that agency, as well as
in many human development and foreign aid agencies of the UN.

This division of the world ignores the fact that the distribution of
economic, political, and cultural resources is highly concentrated in
specific areas in both high and low income countries.1 Frequently
forgotten is that 20% of the richest people in the world live in
developing
countries.6 The extremely luxurious standard of living of Arab sheiks who
reside in a sea of poverty in some Arab countries is an example of a
situation common in developing countries. It is precisely this
concentration of economic, political, and cultural power among and within
all countries that is at the root of the world's most important social
(including health) problems. What is usually referred to as the world
order (though better described as world disorder) is based on an alliance
of the dominant classes (and other social groups) of the developed world
with the dominant classes (and other social groups) of developing regions
who are against a
redistribution of resources that would adversely affect their interests.
The evidence for this situation is overwhelming.1 Moreover, we cannot
understand the behaviour of today's international agencies, including the
International Monetary Fund (IMF), World Bank, and World Trade
Organisation (WTO), without understanding their articulation in this set
of alliances.
How WHO fits into this situation




Within the context described above, what are the patterns of influence
over WHO? This is certainly an understudied area of policy research. But
there are some strong pointers that can help us with an initial diagnosis.
The economic, political, and health institutions in developed countries,
and especially the USA (including its federal agencies, foundations, and
leading academic institutions), have an enormous effect on the culture,
discourse, practices, and policies of WHO (and of the Pan American Health
Organisation [PAHO]). The dominant ideologies in such institutions
(especially in the USA) are seen in WHO documents shortly after surfacing
in mainstream medical and economics journals. One example is the WHO
report evaluating countries' health systems.7 This report reproduced the
ideology predominant in the political and health establishments of the USA
(and to a lesser extent the UK) since the 1980s. Since President Reagan's
administration, the
commodification of medicine, with its emphasis on market values (as
guarantors of choice) and on private management systems (as purveyors of
economic efficiency), has become part of the dominant discourse and
practice of the US establishment, despite abundant scientific evidence
that challenges the underlying assumptions of this ideological position
known as neoliberalism.8 The administrations of US presidents Reagan, Bush
senior, Clinton, and Bush junior, and of British prime ministers Thatcher,
Major, and Blair have actively promoted neoliberal policies in all the
international agencies over which they have a dominant influence,
including WHO.

The discourse and practice of these establishments--such as the use of the
term clients rather than patients, or promotion of health markets
(erroneously identified with choice) rather than health planning
(dismissed as encouraging inefficiency and bureaucracy)--now dominate in
the IMF, World Bank, WTO, and also WHO. In this ideological scenario,
managed competition is in and national health services are out. Thus, the
WHO report ranking health care systems puts Colombia (which has promoted
managed competition based on commercial health insurance at the cost of
further weakening of its national health services) at the top of the list
of Latin American countries, whereas Cuba's national health service was
ranked low. Evidence, however, shows otherwise: Cuban indicators of
accessibility to health services and of mortality and infant mortality are
among the best in Latin America.

Yet it would be erroneous to see the promotion of managed competition and
the commodification and privatisation of health care (all characteristics
of neoliberal discourse with respect to health) as policies imposed by the
USA and its allies on developing countries. Rather, it is the US political
and health establishments, their allies and the dominant classes and
groups of the developing world who are imposing neoliberal policies on the
dominated classes of both developed and developing countries. Most of the
US population opposes, and has a profound distrust of, managed competition
(and its operational programme, the much disliked health maintenance
organisations, run by private health insurance companies). Also, support
for market-based reforms in developing countries has come not from their
popular classes but from their establishments.9 So it is important to
clarify that policies that are pushed forward by the establishments of
developed countries and their allies in developing countries are neither
the best nor the most popular for most people of these countries. These
policies are being resisted both within and outside WHO. Also, WHO has
indeed opposed some of the most blatant pressure from the US government in
key areas of intervention, such as the recent sugar and food lobby
campaigns. Thus, WHO is able to stand up to powerful governments and
pressure groups. The point that needs to be made, however, is that it does
so rarely.


Structural adjustment




Another consequence of this pattern of influence and control is structural
adjustment programmes (characterised by a reduction of public social
expenditure and by privatisation of health services), for many years
presented by the US government and by the IMF and World Bank as the
solution to world poverty. Such programmes, however, have done a great
deal of damage to the health service infrastructures in developing
countries.10 In the USA, effects of structural adjustment policies
implemented by the current Bush administration are evident, showing them
to have been disadvantageous for the US population.11

Another example of neoliberal policies is the WTO's strategies for the
free trade of services, forcing countries with national health services or
even national health insurance, such as Canada, to dismantle these
services in order to allow the operation of commercial health insurance
companies or medical business corporations in their countries.12

In both instances, WHO, through its collaboration with the World Bank, has
been an active participant in the promotion of such policies. WHO has
submerged itself in a cultural and ideological environment in which
investment in health services must be justified on the basis of what it
contributes to economic development. An example is the recent report on
health development from a group chaired by Jeffrey Sachs13 (the same
economist who advised on Russian policies of privatisation and who was
chief economic adviser at Davos)--a report justifiably criticised by
Professor Banerji, India,14 and by Professor Waitzkin, USA.15 In the WHO
report, health investments seem to be evaluated in terms of their
contribution to economic development, instead of, as it should be, the
other way round.

WHO itself has privatised several of its services. For example, WHO-EURO
chose to establish its European Primary Health Care Study Centre in
Catalonia, Spain, because the conservative Catalan regional government
offered the most money, competing successfully against other regional
governments that have done a much better job in developing regional public
primary health care centre networks but have fewer funds. Needless to say,
the Catalan regional government presented Catalonia as the best site for
such a centre because of its so-called excellent primary health care
centre network, when actually this network is one of the worst in Spain.
Thus, WHO's decision was to sell to the highest bidder, rather than the
best provider.


Categorical versus comprehensive approach




Developed countries' health and medical establishments also emphasise
categorical interventions (a disease-by-disease approach) that weaken the
infrastructure of public health services, including national health
services. In view of this experience, the eradication of smallpox is a
mixed blessing, since its success has inspired many other technological
silver-bullet types of solutions that degrade rather than improve public
health services. Professor Banerji has extensively documented the damage
caused by such categorical interventions.10 The pressure from donor
agencies to resolve specific disease problems is so overwhelming that most
recipient governments concede and accept programmes that have a
devastating effect on their nations' health services. A similar situation
is now evident in the USA, where the smallpox vaccination campaign (part
of the present
administration's highly politicised anti-bioterrorism campaign) is
considerably weakening the country's public health services, which are
being forced to shift resources to the campaign.16


The solutions




WHO was the product of the political climate generated after the victory
over Nazism and fascism in World War II. Its Constitution is a splendid
document that should provide the principles on which WHO operates. It has
produced excellent guidelines, such as the Alma-Ata Declaration, which are
still valid and offer a framework for addressing the important health
problems in today's world (which, incidentally, are easily solvable from a
scientific perspective). Postwar changes around the world, with the USA
becoming the predominant force, have had a highly adverse effect on WHO,
which has all too frequently become almost a transmission belt for the US
establishment, whose dominance is assisted by its providing 20% of WHO's
budget. This dominance is seen even in the language used in official
documents, with the term hunger now replaced by underweight, and
inequalities now described as disparities. The aim is to avoid any
expression or tone that may seem value laden, ignoring the fact that the
new terminology and discourse are themselves profoundly ideological and
political, disregarding existing realities and their causes.

WHO should be faithful to its Constitution (which calls, for example, for
public responsibility for health care), making health care and access to
health care a human right, confronting powerful governments including the
US government, which is in clear violation of the WHO Charter's
instruction that member countries should ensure their citizens' access to
health care in time of need. The USA, despite being one of the richest
countries in the world, does not guarantee such a right to its citizens.
WHO should regain its credibility and moral standing, and could include
growing movements of protest (such as the anti-globalisation movement)
that are providing pointers to another possible world. Membership of WHO
should be conditional on governments' acceptance of a whole set of
principles and practices, including the promotion of health as a human
right and the obligations deriving from this right. Membership should also
require truthful and transparent disclosure about health and social
situations that might adversely affect health and treatment of disease,
and the denunciation of governments and agencies whose practices adversely
affect the health of their own and the world's populations.


References





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