The Global Assault on Health
In the wake of the freedom struggles against
colonialism and repressive regimes, for self-determination and
independence, many Third World societies in their attempts to create
self-reliant models of development carried out people - centred national
policies. In the area of health, many remarkable advances were made.
China’s contribution to public health was the ‘barefoot
doctor’ model which was based on community led health initiatives and
the integration of traditional Chinese health systems in healthcare: its
success in eradicating schistosomiasis through mass mobilisation
inspired health workers the world over. China’s success was the
outcome of its liberation movement. Elsewhere, the experiences of Cuba,
Vietnam and Tanzania in adopting people centred approaches and the
growing emphasis on the socioeconomic causes of diseases and health was
gaining attention.
Pioneering work in community based health initiatives
were also carried out by individual health workers and community workers
working on their own. In the 1960s and 70s, these grassroots programmes
centred on participatory and awareness raising approaches, grew in
India, South Africa, Bangladesh, the Philippines, Nicaragua, Mexico,
Costa Rica, Honduras and Guatemala (Werner & Sanders 1997:16). In
India, significant achievements were made in Primary Health Care which
became the basis of people driven manpower development, community
health, research, public health services and the inclusion of indigenous
health systems. India’s pioneering work in TB research had a major
impact on TB programmes all over the world including the North (Banerji
1999:235).
WHO under Attack
These developments help trigger major changes and a
paradigm shift also occurred in the WHO and its policies. In 1978 WHO
introduced an Action Programme on Essential Drugs and in 1981 the
World Health Assembly passed the International Code of Marketing of
Breastmilk Substitutes. This resulted in fierce opposition to WHO
from the food and drugs industry. Both the pharmaceutical and baby food
companies campaigned vigorously against these developments. When the Code
was passed, the US was the single country to oppose it on the grounds
that this would interfere with free trade. Shaken by this success, the
pharmaceutical industry (many of which were also baby foods
manufacturers) decided to kill any moves by WHO to frame an
international code on the marketing of pharmaceuticals: the US leapt
into action and withdrew its contribution to WHO in 1986 and 1987.
Despite this, the WHA in 1988 approved the ‘WHO Ethical Criteria for
Medicinal Drug Promotion’ but this was subverted by the International
Federation of Pharmaceutical Manufacturers’ Associations (IFPMA) which
produced its own self regulatory marketing code (Hardon 1992). The IFPMA
is the Secretariat for the International Conference on Harmonisation of
Technical Requirements for Registration of Pharmaceuticals for Human Use
(ICH). The ICH is the leading global regulatory regime on
pharmaceuticals led by corporate interests. The world’s twenty-five
largest firms have adopted nearly all of the first set of guidelines.
With the ICH, the pharmaceutical lobby together with the European
Commission have disempowered the role of WHO in the regulation of the
pharmaceutical trade (Braithwaite & Drahos 2000).
The tobacco companies have not been idle either:
their sustained undermining of WHO was recently uncovered. WHO has
issued a report detailing the covert activities of the tobacco industry
dating back to the 1980s, which included having ostensibly independent
surrogates attack the credibility of international health organisations
and spin the concern with smoking as a First World issue, not worthy of
the Third World’s attention. Based on tobacco company documents that
surfaced in recent lawsuits, WHO reveals that the tobacco companies
created bogus front groups, misrepresenting research, pitting other
international organisations against the WHO and lobbying to cut its
funding. The Report reveals that some consultants served both WHO and
the tobacco industry. No one knows for certain the extent to which this
industry campaign is still being waged. But the tobacco industry will
gear itself up to fight the WHO in October when negotiations to frame
the international tobacco control treaty starts: by diluting the treaty
language that would leave Third World consumers unprotected (IHT
Aug 4, 2000). There is too much at stake for the tobacco industry with
an annual turnover of US$400 billion. By the year 2030, tobacco will
kill 10 million worldwide; some 70 percent of tobacco related deaths
will occur in the Third World unless current trends are reversed. The
WHO Director General noted that: ‘By 2020 the burden of disease due to
tobacco is expected to outweigh that caused by any single disease’.
The Alma Ata Declaration
However, the real challenge to the global free market
in the area of health, was the WHO - UNICEF Alma-Ata Declaration (AAD)
in 1979. Alma-Ata was inspired by the changes and experiments in
healthcare, which in turn was a result of the struggles and attempts at
social transformation, by societies in the Third World. The AAD was the
culmination of this radical approach to health and health policies.
In this historic document, Primary Health Care (PHC)
was the cornerstone of community self-reliance. It affirmed health as a
fundamental human right; it called for: peoples’ participation in
health care; the responsibility of governments for the health of their
people; community self reliance and self-determination; intersectoral
approach to health; social control over health services; use of
traditional health systems; provision of essential drugs and social
justice and government commitment to health for all by 2000. In short,
Alma Ata addressed the underlying social, economic and political causes
of illness and disease.
The community based health initiatives which formed
the basis of Primary Health Care in the AAD, were part of a larger
struggle by the marginalised for their well being and rights. The
emphasis on addressing the root causes of the poor health and efforts to
put health in the hands of the people posed a threat to entrenched
interests, namely the elites, governments and the medical establishment,
who had the monopoly on knowledge and the power of healing (Werner &
Sanders 1997:19). In some countries community health workers were
harassed or arrested: in Latin America, anyone found in possession of
David Werner’s pathbreaking book, Where There Is No Doctor was
either arrested, brutally dealt with or even shot.
The Alma Ata document posed a direct challenge to the
economic and political thinking of the day. It was only a matter of time
before a full-scale attack against its principles was launched.
Undermining Primary Health Care
The sustained attack against the AAD has also come
from international public health ‘experts’ associated with the large
donors of the North. The first salvo was fired with the invention of the
concept of Selective Primary Health Care (SPHC). This was launched to
strip PHC of its comprehensive and revolutionary characteristics and
reduce it to a narrow technocentric approach (Ibid:20).
The justification for SPHC was that Primary Health
Care (PHC) was too ambitious a project, therefore one should be
selective in choosing areas that are cost effective. Led by the
Rockefeller Foundation, PHC was considered ‘costly and unrealistic:
high risks groups need to be targeted with ‘selective cost effective
interventions.’ SPHC was reduced to a few high priority technological
interventions determined by international health experts with no role
for the communities: the emphasis on socio economic development was
removed, together with the need to include other areas that related to
health in the focus of the programmes. The centrality of involving
communities in the planning, implementation and control of PHC was done
away with (Ibid:23).
Although, countries like Nicaragua and Mozambique did
carry out PHC in the Alma Ata mould in the 1980s, and showed impressive
health improvements; these successes were shortlived as they were
destabilised by the US and apartheid South Africa respectively.
UNICEF’s role in SPHC
In 1983, UNICEF adopted a new child survival strategy
of health interventions called GOBI (growth monitoring, oral rehydration
therapy and immunisation). This was expanded to include family planning,
food supplements and female education (FFF). GOBI was an instant hit
with donors and money poured in from the World Bank, USAID, the Vatican
and Rotary International. By the 1980s almost all Third World countries
were promoting GOBI (Ibid:25). Many countries however limited
their child survival campaigns to oral rehydration therapy and
immunisation, which UNICEF called the twin engines of the ‘Child
Survival Revolution’. In India, GOBI was reduced to the distribution
of oral rehydration solution packets and immunisation: in family
planning, the focus was ante natal care namely registering pregnancies
and nutrition (food supplements) meant the distribution of iodised salt,
iron and Vitamin A supplements (Jan Swasthya Sabha 2000:21).
UNICEF’s endorsement of SPHC through GOBI was a
major shift in health policy, and had profound implications. SPHC and
GOBI put paid to the ideals of Alma Ata and ‘was a way for governments
and health professionals to avoid dealing with the social and political
causes of poor health and thus preserve the inequities of the status
quo.’ … UNICEF’s policy ‘was tantamount to accepting inequity
and poverty as unalterable facts of life’ (Werner & Sanders
1997:24-25).
Thus these ‘vertical’ ‘top-down’ programmes
were claimed to be as good as the comprehensive local service model
promoted under the name of Primary Health Care. Instead of local
communities deciding their health priorities, these were instead set in
some far off capital or by the World Bank and thrust on the entire
population. It was not just selective health care: it was selection of
health priorities by a distant medical burreacracy not even by local
health officials, let alone the people. Thus if a particular area has a
major disease like hepatitis or snakebite, there is no mechanism by
which SPHC can respond to these problems let alone be aware of it
(Jan Swasthya Sabha 2000). By the 1980s the WHO, UNICEF and WB had
launched the global initiative for SPHC focusing on immunisation, AIDS
and TB. Many concerned public health experts have questioned the
scientific validity of the concept. The global initiative programmes
were criticised for its ‘inconsistencies, contradictions and was
deemed scientifically flawed’. These programmes do not take into
account the extreme variations among and within Third World countries
under the ‘prefabricated’ global initiative (Banerji 1999:239).
Thus the claim that these global programmes are cost
effective given the wide variations among and within countries was
contradictory whilst the selection of the health problems targeted for
action conformed to the special interests of the North. These
international initiatives were highly technocratic and the very
antithesis of community self-reliance promoted in the Alma-Ata.
The Indian Experience with SPHC
In the case of India, the Universal Programme of
Immunisation/Expanded Programme of Immunisation (UPI/EPI) was revealed
to be a failure. The EPI was launched by WHO in 1974 to immunise the
world’s children against six diseases namely measles, polio,
diptheria, pertussis, tetanus and tuberculosis (TB). By the-mid 80s,
Northern donors began to concentrate their resources for PHC in the EPI.
Under the global objective set by WHO and UNICEF, 80 percent of the
world’s infants will be immunised by 1990. The EPI/UPI programme of
India, which began in 1985, was the largest in the world. But it began
to unravel when a joint Government of India, WHO UNICEF evaluation in
1989 showed immunisation coverage was less than a fifth in the two
thirds of the population which accounts for the most poor and for most
of the infant mortality in the country (Ibid: 247). The study
revealed that reports of immunisation coverage had been exaggerated by
100 percent or more to please the national and international officers
responsible for administrating the programme. The surveillance system
was non-existent and no potency tests were carried out at the time of
inoculation. At least 56 deaths were recorded due to the vaccination
process (Ibid: 247).
The WHO Global Programme for AIDS (GPA) which was
shaped in the US did not take into account the variations in the
epidemiological behavior of the disease and its complex, social and
cultural dimensions worldwide, which required a flexible approach to
programme formulation. The first Union Budget (1992 - 1993) after India
submitted to IMF conditionalities saw a 20 percent cut in the health
allocation (including the TB programme). However, the WB and WHO
assisted India in setting up the National AIDS Control Programme (NACP)
which accounted for a quarter of the total allocation of the health
budget in the same financial year (Ibid: 248). Because the NACP
was designed on the US model, many of the basic assumptions have been
questioned (Ibid: 248).
WHO’s declaration of the tuberculosis problem as a
‘Global Emergency’ in the 1990s took the health community by
surprise: the database to justify such a sweeping declaration was
virtually non-existent (Ibid: 243). TB became a problem however
in the US and the North when the AIDS epidemic activated TB in many AIDS
victims and led to its spread. This TB outbreak was ‘extrapolated to
the entire world’ and the Global Programme for Tuberculosis (GPT) was
born. A campaign was launched in a massive effort to identify TB cases
in entire populations in which DOTs (Directly Observed Treatment with
Shortcourse Chemotherapy) was applied. DOTs entails regular monitoring
of patients by health personnel to ensure that patients take their
medication regularly. This was impractical and designed to fail. The
option of involving the community in case detection of TB and monitoring
compliance is not considered though the success of such an approach has
been demonstrated. Increasingly, concerns have been raised among public
health proponents that DOTs has been promoted as a single intervention
worldwide, without taking into account the socioeconomic inequalities
that underlie the resurgence of TB.
The prefabricated DOTs driven agenda of the GPT was
hardly impressive. In India the major epidemiological, sociological,
economic and administrative flaws in the GPT were highlighted by
tuberculosis workers. India has had a distinguished record in
tuberculosis research and control, which was acknowledged worldwide. But
the ‘overriding priority given to international initiatives all down
the line have led to the neglect of other services provided at the
grassroots level including TB work’ (Ibid: 230). Thus the
imposition of global initiatives under SPHC has led to in the words of
Prof. Banerji, ‘a frightening spectacle of distortion of the
principles and practice of international public health by WHO, UNICEF
and the World Bank… It has virtually decimated the somewhat promising
growth of people oriented health services in a country such as India’
(Ibid:250).
SPHC in Africa
In Africa, the story is no different. By the mid
1980s, donors were pouring large sums of money into the EPI. This
initiative was carried out when the continent was reeling under the
burden of SAPs. African governments were struggling with deficient
budgets and coping under tremendous pressure in a situation where
communication and transportation systems barely existed; communities
were highly impoverished and poorly educated; and government health
workers remain unpaid.
Donors concentrated their money on a single
intervention i.e. immunisation. This purely technical topdown and
fragmented approach used vertical systems, and highly selective
assistance. The EPI took precedence and other health needs and services
became neglected. While it did achieve short term and measurable
results, it was not sustainable. There was no community involvement. It
was increasingly clear that such global initiatives preclude national
and local participation. As it was donor driven, quick and visible
results were the desired objectives (Weeks: 2000).
The same problems surfaced with the ‘eradication of
polio by the year 2000’ initiative under WHO. Large numbers of
refrigerators, the backbone of the EPI programme, were sent to Africa
despite the absence of effective equipment inventory and maintenance
systems. These global initiatives are highly visible, measurable and
short-lived. Eradication strategy involves national mass immunisation
campaigns, which are concentrated during only a few days of the year.
According to a public health expert: ‘Donor funded campaigns provide a
carnival-like atmosphere. Banners with organisations’ logos fly;
T-shirts and caps are given away; celebrities make an appearance. Such
big media events provide visible, evidence of action by governments and
donors. Eliminating a disease from the planet appeals to the North’s
fast paced hi-tech culture…..diverts us from the more complex reality:
the declining quality of life for millions in poverty, environmental
degradation and the failures of our development projects.’ WHO was
involved with other donors in selling a product called ‘eradication’
(Ibid).
To date many countries in Africa have yet to achieve
the global immunisation target of 1990. In 1998 only one of 21 countries
in SSA managed to achieve the 80 percent global coverage target for more
than one vaccine. None were able to sustain coverage of 80 percent or
better for three consecutive years between 1995-1998. (Ibid) This
global immunisation agenda is being carried out at the expense of
malaria and HIV/AIDS, which are posing a more serious threat to Africa.
In short the global initiatives for SPHC has undermined existing public
health services, by creating conflicting priorities between the targets
of donors and local community needs. It has led to the dismantling of
primary health care approaches. Indeed, ‘when a child has received ten
or even more doses of oral polio vaccine, dies from measles, dehydration
or malaria; or must grow up malnourished without parents because of the
AIDS pandemic or in urban squalor, without hope’ what has been
achieved with polio eradication? (Ibid).
UNICEF and User Fees
In response to the crippling impact of SAPs, UNICEF
announced the Bamako Initiative which promoted user-financing in rural
health centres. Health cutbacks under SAPs had led to the closure of
many rural health posts because of the lack of medicines: to keep them
stocked and functioning, fees were charged for medicines. The Bamako
Initiative was very well received by donors especially the US, as it
shifts the cost of health care from governments to individuals. The drug
companies were happy because it actively promotes and increases the
sales of medicines to the poor. Thus cost recovery schemes through the
Bamako Initiative have aggravated inequities, ‘since the distinction
between willingness and ability to pay has not been addressed’. It has
resulted in the rapid expansion of the private sector and irrational and
expensive drug use (The Ukunda Declaration 1990).
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