Very clear view, imho, of ideology's effects on health care (#5).
david creighton
_______
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: [log in to unmask] )
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
1 Navarro V, ed. The political economy of social inequalities:
consequences for health and quality of life. Amityville: Baywood, 2003.
2 Townsend P, Gordon D. World poverty. Bristol: Policy Press, 2002.
3 United Nations Development Program. Human development report 2002. New
York: Oxford University Press, 2002.
4 Black RE, Morris SS, Bryce J. Where and why are 10 million children
dying every year? Lancet 2003; 361: 2226-34. [Text]
5 Yong Kim J, Miller J, Irwin A, Gershman J. Dying for growth: global
inequality and the health of the poor. Common Courage Press, 2000.
6 United Nations Development Program. Report on income inequalities in
the world today. New York: Oxford University Press, 2000.
7 World Health Organization. World Health Report 2000: health systems:
improving performance. Geneva, 2000.
8 Navarro V. Neoliberalism, "globalization," unemployment, inequalities,
and the welfare state. Int J Health Serv 1998; 28: 607-82. [PubMed]
9 Kiely R. Neoliberalism revised? A critical account of World Bank
conceptions of good governance and market friendly interventions. Int J
Health Serv 1998; 28: 683-702. [PubMed]
10 Banerji, D. A fundamental shift in the approach to international
health by WHO, UNICEF, and the World Bank. Int J Health Serv 1999; 29:
227-59. [PubMed]
11 Ku L. The number of Americans without health insurance rose in 2001
and continued to rise in 2002. Int J Health Serv 2003; 33: 359-67.
[PubMed]
12 Thompson T. The impact of the new WTO policies on the Canadian
national health system. PhD thesis, Johns Hopkins University, 2003.
13 World Health Organization. Report of the Commission on Macroeconomics
and Health: macroeconomics and health--investing in health for economic
development. Geneva:WHO, 2001.
14 Banerji D. Report of the WHO Commission on macroeconomics and health:
a critique. Int J Health Serv 2002; 32: 733-54. [PubMed]
15 Waitzkin H. Report of the WHO Commission on macroeconomics and
health: summary and critique. Lancet 2003; 361: 523-26. [Text]
16 Fee E, Brown TM. Pre-emptive biopreparedness: can we learn anything
from history? Am J Public Health 2001; 91: 721-26. [PubMed]
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