The World Bank's involvement in health care in LDCs is ambiguous
right now as far as I am concerned and I would appreciate clarification
from anyone who knows more about it than I do. The World Bank has
announced a major health-sector loan to India of US$350 million
which will go to health-care reform in the states of Karnataka,
Punjab, and West Bengal. In India, or at least in Punjab, where
the project has been pushed the furthest, it has been greeted with
controversy because labor unions fear that the reforms involve
what has been described as privatization in the health care system.
There are fears in India that some reforms will result in making
it harder for poor people to get access to care. The Bank denies
this. I have looked at World Bank materials describing the planned
reforms and I don't think that there is really much privatization as we
understand that term, though there is an intention to
to impose more user levies at referral levels of care. If anyone
on the list understands the Indian project and how we should feel
about it I would appreciate hearing from them. Likewise, if
anyone knows about World Bank health initiatives anywhere
else on the globe, I would like to hear about it. Incidentally,
I have tried corresponding with someone I know who is involved in health
care at the World Bank, asking what the underlying theory or overall
strategy is which guides the bank in their health policies. The
answer I received is that they are still working on it and that they
don't have a theory or a strategy!
Dale Tussing
On Fri, 4 Oct 1996, Jeffrey Fellows wrote:
>
> In response to Nancy Breen's note
>
> The plan to "invest" in health is quite significant, especially in light
> of its potential to create previously nonexistent markets in LDCs that
> may then provide new profit streams (Debt supported) to US, European
> and Japanese medical technology firms, particularly those in the US who
> have been adversely effected by cost-containment strategies imposed by
> public and private third party payers.
>
> The promotion of "western models" of health, illness, and health care in
> LDCs is likely to produce changes that would greatly benefit LDC
> as well as DC capitalists. The benefits could be three-fold (at least).
>
>
> 1. The promotion of health by the WB/IMF crowd means the promotion of western
> scientific notions of health, disease causation, and biophysical interventions.
> In the reductionist mechanical medical model that is the foundation of
> western scientific medicine, the causal roles of human cognition and
> emotion in the development and elimination of illness (health and
> illness themselves being socially defined) have been fundamentally
> excluded from the analysis. The medical hat is tipped somewhat in
> recognition of psychosomatic illness, but the curative role of the human
> will is largely left unrecognized (ironically, the rapid
> expansion of outcomes research has done much to establish the
> role of emotion in the transition from illness to health).
>
> For capitalists, excluding the affects of the human mind is an easy way of
> eliminating consideration of the social causes, cures and prevention of
> individual illnesses. A worker who becomes ill does so because an external
> disease agent has invaded the body and shocked the body out of a steady-state
> equilibrium condition of health. The cause is attributed to some observed
> pathophysiology (objective, natural laws of biological cause-effect). The cure
> (if one is available) involves some form of biological intervention that
> eliminates the disease mechanism and returns the body to its steady-state
> equilibrium condition. In such situations, work-related stress that creates
> hypertension and chronic heart disease is not cured (or prevented) by the
> practitioners' calls for social changes (i.e. to alter the social
> relations of production as a means of eliminating stress-related
> illnesses), but by physical interventions like drugs, surgery, etc. Once
> "cured" the poor bastard is thrust right back into the social situation
> that may have led to the problem in the first place. The effects of
> poverty and pollution are dealt with on individual terms as well, the
> causes are still attributed to the individual's personal situation, or
> genetic proclivity for certain diseases.
>
> Result: health and illness are individual conditions, not social problems
> needing social cures. Thus, the medical model can act as a protective
> device against a disgruntled working class population.
>
> Here I defer to the excellent work by Vincente Navarro (and a few others, such
> as Howard Berliner, Nancy Tannenbaum, and Henry Sigerist--for the last
> reference I must thank Navarro for an article pointing out the important
> contributions to the history of medicine, which a young scholar like
> myself had found utterly overlooked in the literature).
>
>
> 2. In capitalist societies, health is largely defined in terms of
> work. A healthy person is more productive than an unhealthy person, and a
> healthy person is expected to participate in the system of production to
> their fullest capacity. On the surface, neoclassicals and marxists would likely
> agree to the importance of work in the determination of one's social relevance.
> However, NCs would consider work, and productivity, in largely output price
> and technical terms, whereas in the marxian model work becomes not only an
> expression of one's individual creativity, but also the force that leads
> workers to expand their creative intellects. In the context of purely
> physical definitions of work, health and illness, practitioners can
> become agents of social control if employers demand medical
> legitimization of health-related lost work time, and if
> biological diseases that originate in the psychosocial realm are treated
> only in terms of the former, where upon their patients are returned to
> the unanalyzed social situation that caused the problem in the first place.
>
> Result: Capitalist employers gain an important degree of control
> over what constitutes valid ill-health among the working class. Those
> lacking biological diseases should be at work, producing value for their
> employers. Others must be faking it to get out of work, and thus are
> subject to reprimand. (sounds a lot like the English Poor Laws doesn't it?)
>
>
>
> 3. Lastly, and possibly of greatest importance to the WB/IMF and
> industrialized nations, the redefinition of "health" and "health care"
> along western lines will effectively create a capitalist market where none
> existed before. This is analogous to the transformation of traditional
> agricultural systems around the use of High Yield Variety seeds.
> Sterile seeds genetically engineered to be highly responsive to certain
> combinations of chemicals and water, and pest resistant, were
> introduced to replace locally-developed fertile seed varieties that were as
> productive (in terms of useful biomass) but utilized natural (largely
> nonmarket) fertilizers and water supplies. Seeds were self-generating
> and pests and diseases were controlled through naturally built-up genetic
> resistance and crop rotating methods. The use of sterile seeds, expensive
> (and ecologically destructive) chemical fertilizers, and large-scale
> water delivery systems, linkages to (dependence on) the market were
> established. The establishment of a market-driven system of agricultural
> production allowed capitalists to extract surpluses from a relam of
> productive activity heretofore beyond their effective reach.
>
> The establishment of western-based health care systems does essentially the
> same thing. Traditional medical systems that were not based on monetized
> exchange relations are broken down and replaced, usually called
> "enhanced," and some form of market-based health care system are put in
> their place. This may not happen all at once, but by introducing
> scientific medicine you create a need for its associated technology and
> practitioners. Medical technology, such as drugs and medical equipment
> and devices, become the chemical fertilizers in the new health care
> system, patients are the responsive but sterile seeds, and the newly
> trained physician farmers are there to read the instructions and make
> sure all are combined at the proper time. The practitioners' scientific
> knowledge is the water that, having been diverted from its traditional
> patterns, is kept from flooding (reverting to traditional ways) by
> the restrictions imposed by the science, and likely the new state-supported
> practice laws. Of course the big winners here are the medical technology
> and pharmaceutical companies, and if health insurance is needed, well
> then I'm sure Aetna et al., will not object to the opportunity to make some
> money.
>
>
> I do apologize for the length. Comments, further references, and a dialog
> on the issue of LDC health systems are most welcome.
>
>
> Vty,
>
> Jeffrey L. Fellows
> Adjunct Instructor of Economics
> Lewis & Clark College
> Portland, Ore.
> [EMAIL PROTECTED]
>
>
> > the business section of yesterday's Wash Post discusses this change. It
> > includes more debt forgiveness, more money for ed & health. The article
> > points out that this is a change in rhetoric and policy, but it won't affect
> > a large number of countries and they are only the very poorest, most in debt
> > countries.
> >
> > Nancy Breen>
> >
>
