When I was still in high school, my father lost his job. He was a third-generation garment worker — a cutter in a coat factory in Jersey City — and the company he worked for closed its U.S. facility and shipped all the work down to Mexico. In the wake of that turn, the bank foreclosed on our house and I ended up striking out on my own, when I was probably still too young for that. For a long stretch, everything — buying groceries, paying rent, owning a car, getting through college — was a struggle. Sometimes that struggle felt grand and epic. Mostly it felt small and petty and humiliating.
Obviously things turned out fine in the end. But I spent at least part of my adolescence trying to grasp at the larger forces that were shaping the events that were shaping my life. I remember feeling like I and the people I loved most had been set adrift on a violent sea, and wanting desperately to know what the winds tossing us about were made of. Who was responsible for the factory’s closure? How did an industry that had sustained my father’s people for generations suddenly die? What would these jobs — jobs that had been ours for so long — mean to the men in Mexico?
I listened to Jello Biafra’s spoken word albums (I was like 17), and read some things by Chomsky. Both talked about this intricate web of what sounded to my teenage mind like conspiracy: NAFTA, GATT, the World Bank and this thing called the IMF were somehow in league against the working class and the global poor. But I wasn’t quite clever enough to fully understand what I was reading, and the internet didn’t exist yet, so it was hard to find additional information.
For their part, my parents blamed themselves. They’d spent their whole lives steeped in the notion that hard work and relatively decent living were enough to make a good life. And so they had to assume that the corollary was also true: if they had failed to make a good life, they must not have worked hard enough or lived decently enough. To me though, the idea itself seemed a fallacy. Because my father had worked hard. His whole life. And now he had very little to show for it.
My sense of adrift-ness, of being moved by things that I could not see or understand or rail meaningfully against, persisted until I was well out of college and consciously forsaking a career in science for one in journalism.
On fellowship, I took Paul Farmer’s excellent introductory global health course, where we talked (and read and wrote and thought) a lot about the vehicles of global poverty and the mechanics by which those vehicles operate. Those dialogues were fascinating to me; they gave the sensation of finally coming into a real understanding of things. Of pulling back the curtain, to mix metaphors. Or of watching that curtain grow threadbare.
One of the course’s co-professors gave this awesome lecture once about how the real problem with the WHO, World Bank, IMF, etc. is not that their policies don’t work. Their policies actually work just fine, once you come to understand the difference between their true aims and their stated aims. Their stated aims have to do with human health and economic growth and alleviating global poverty. Their true aims, however, are all about geopolitics and vested interests.
It’s difficult to say that without sounding like some radical conspiracy theory leftist. You have to really detail what you mean by the term geopolitics and then find as many specific examples as you can. And that probably means following a lot of money and paper trails and seeing where they lead. The prof who said it was a true expert, though; he made a strong case and when I followed up over coffee, gave some great leads and story ideas. At some point I’ll dig those notes up and post them here.
In the meantime, I’m posting a few excerpts from the course reader because I think they make for a good overview of an important story — the story of how neoliberalism obliterated primary health care and basic public health across the developing world. (I’ve got a piece coming out next week on a related issue, which is how I came to revisit all of this).
And because I wanted to think some more about those earlier grasps for understanding.
Alma Ata and primary health care for all.
In 1978, thousands of delegates from all corners of the planet rallied behind the goal of universal primary health care. “Health for all by the year 2000” was the audacious slogan of the day. But 2000 came and went, and the world is only marginally closer to universal health care than it was in 1978: billions of people across the globe still lack access to basic medical services. The global health discourse today is dominated by concepts like “cost-effectiveness” and “absorptive capacity.” “Hea;th for all” will sound utopian to some. WHat happened to the idealism of 1978?
The primary health care movement was a child of the hopeful but tumultuous 1970s. Divergent economic and political ideologies, driven by the interests of Cold War superpowers, animated the discourse of international health: most Soviet health ministers favored state-led health programs, while U.S. policymakers tended to promote market-based programs. This was also the era of decolonization: liberation struggles in the “Third World” fueled grand visions of self-determination and grassroots community mobilization. This heady atmosphere was tempered by growing global awareness of the lack of access to modern health services across the developing world.
It helped that disease eradication programs (the ‘vertical approach,’ as it was called, because it focused on solving discrete or narrow problems individually) was proving to have very limited effect, (Small Pox eradication was the only real success) and a consensus was emerging that since most diseases had no quick fixes, we needed a more “horizontal” approach.
The Alma-Ata International Conference on Primary Health Care, September 6 – 12, 1978, remains a landmark event in the history of global health. Some 3,000 representatives from 134 countries and 67 international organizations endorsed a commitment to achieving universal primary health care by 2000… Perhaps most notable was the Declaration’s all-encompassing definition of primary health care, which includes:
“education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs.”
It was a great idea. It never happened, though. Because…
Reagan, Thatcher and Free-Market Fundamentalism.
A few years after Alma Ata, a debt crisis emerged and conservative forces came to power in both the U.S. and England.
The champions of the primary health care movement at Alma-Ata soon discovered that even if they could forge consensus in the international health arena, their proposal was sailing against the winds of global politics. The “health for all” vision – which drew support from hundreds of policymakers in 1978 – became almost unthinkable during the rise of neoliberalism in the early 1980s… [when] economic advisers of the Reagan and Thatcher administrations argued that social safety-nets, including public sector health care and education, were preventing markets from achieving efficient social equilibria… Accordingly, by late 1981 the Thatcher and Reagan administrations had filled the World Bank and IMF with neoliberal policymakers. Over the next decades these two institutions, guided by market-based approaches to development and health reform. had far-reaching impact on the landscape of health care in the developing world.
In 1981, the World Bank published a controversial report, arguing that “excessive government intervention had driven sub-Saharan Africa’s economic stagnation.” Their prescription for change? Turn everything over to the free market. Make borrowers seriously cut their public sector spending, and then make them invest the loan money in the private sector. If they do that, their economies will grow, and the benefits of that growth will trickle down into healthcare, education, and everything else.
By 1982, these prescriptions had become mainstream in discussions of economic policy in developing countries. The IMF, created in 1944 to foster macroeconomic stability and avert a second Great Depression, was expanding its lending program to the governments of developing countries. Like the World Bank, the IMF issued loans with conditions: recipient countries had to agree to sweeping reforms of government intervention in the market, including shrinking public deficits, opening economies to free trade, and establishing rigid benchmarks for macroeconomic policy. “Stabilize, liberalize, privatize,” – the “Washington Consensus” – became the mantra of World Bank and IMF policy.
For developing countries across the globe meeting the conditions of these “structural adjustment” loans – as termed by the IMF – generally entailed slashing government expenditures, including outlays for social services. Scores of countries cut funding to their health sectors to meet conditions for deficit reduction demanded by the new loan requirements. The scale of lending was enormous: during the 1980s, the IMF or the World Bank issued six structural adjustment loans to the average country in Sub-Saharan Africa, five to those in Latin America, and four to those in Asia. In addition to the impact of these loans, the IMF and World Bank – governed by representatives of powerful Western nations – also exerted “soft power” over other development aid transactions, as donor agencies and official creditors coordinated with the IMF and World Bank in conditional lending practices.
What that soft power amounted to, often times, was the opening of a decimated country’s borders to privatization. So, basically, your economy is decimated. And now you owe us all this money that you can’t possibly hope to repay. So what we’re going to have you do instead is turn all of those basic government services that we made you stop providing when we forced you to curb spending over to us via these lovely multinationals….
One of the most famous examples of this is the privatization of water across Latin America, particularly in Bolivia.
Private corporations win. Everyone else loses.
Corporations like Bechtel, Veoila, Pepsi-Co and Nestle have done famously well for themselves in the developing world: cheap labor, non-existent regulations, and so on.
The countries themselves have not done nearly as well.
In a study conduct on the impact of the IMF on tuberculosis health sector of post-communist countries , David Stuckler, et. al. found that participating in an IMF structural adjustment program was associated with an eight percent drop in government spending as a percentage of GDP, a seven percent drop in the number of physicians per capita, and a 42 percent drop in population coverage for directly observed therapy for tb control.
When the initial loans and the reforms they required failed to produce economic growth, countries were forced to borrow additional funds from the only available lenders, the IMF and World Bank, which added to their debt burden and further weakened their economies….
It is now widely acknowledged that structural adjustment, as implemented, often did little to achieve growth, reduce poverty, or improve health…
In sum, more often than not, structural adjustment failed to fix the systemic problems – inefficient and inequitable allocation of resources, ballooning government deficits, graft and cronyism – it was designed to address; the 1980s and 1990s were characterized by sluggish economic performance and health system deterioration…