Debabar Banerji

A fundamental shift in the approach to international health by WHO UNICEF and the World Bank: instances of the practice of "intellectual fascism" and totalitarianism in some Asian countries.

Navarro has used the term “intellectual fascism” to depict the intellectual situation in the McCarthy era. Intellectual fascism is now more malignant in the poor countries of the world. The Indian Subcontinent, China, and some other Asian countries provide the context. The struggles of the working class culminated in the Alma-Ata Declaration of self-reliance in health by the peoples of the world. To protect their commercial and political interests, retribution from the rich countries was sharp and swift. they “invented” Selective Primary Health Care and used WHO, UNICEF, the World Bank, and other agencies to let loose on poor countries a barrage of “international initiatives” as global programs on immunization, AIDS, and tuberculosis. These programs were astonishingly defective in concept, design, and implementation. The agencies refused to take note of such criticisms when they were published by others. They have been fascistic, ahistorical, grossly unscientific, and Goebbelsian propagandists. The conscience keepers of public health have mostly kept quiet.

Crash of the immunization program: consequences of a totalitarian approach.

Indias Universal Immunization Program, which was to cover a population of more than 90 million pregnant mothers and 83 million infants living in more than 575,000 villages during 1986–90, has failed dismally. The coverage has been less than one-fifth of the requirement in more than half of the population. The situation in most third world countries, which have even weaker political clout and weaker health service infrastructures, is even more catastrophic. From a purely public health standpoint, the disaster was inevitable. No efforts were made even to define the problem of the six immunizable diseases; there was no question of understanding their natural history; the efficacy of the vaccines used was not well-known; the cold chain, which is meant to retain the potency of the vaccines at the time of inoculation, frequently broke down; there was confusion about the dosage; and even where the program is most successful, ecological conditions will erode much of the benefits from immunization. That such a technocentric program was imposed on the peoples of the third world by their governments was bad enough; even more frightening is that these countries were persuaded to follow the line developed in affluent countries by influential agencies such as UNICEF, WHO, the World Bank, the Rockefeller Foundation, and Rotary International. This is an awe-inspiring manifestation of the power of the affluent countries to impose their will on the weak and helpless peoples of the world. It is a bitter irony that UNICEF and WHO, which sponsored the famous global conference at Alma-Ata, should have lent their weight to a program that is the very antithesis of the Declaration. To embark on such a venture, the exponents had to ignore weighty scientific evidence that raised serious doubts about the program. They had to stoop to suppression of information, disinformation, and distortion of information. What is even worse, efforts will be made to erase this experience from memory, and similar efforts will again be made to launch such ill-conceived programs in the name of the welfare of the oppressed peoples of the world. Scholars who have concern for the oppressed must remain vigilant.

Report of the WHO Commission on Macroeconomics and Health: a critique.

The World Health Organization has been able to interest some of the worlds top economists in joining the Commission on Macroeconomics and Health, to study macroeconomics of health services for the poor peoples of the world. The commission has been ahistorical, apolitical, and atheoretical. It has adopted a selective approach to conform to a preconceived ideology. It has ignored earlier work done in this field. And it has pointedly ignored such major developments in the health services as the Alma-Ata Declaration. These failings have brought the quality of the scholastic work to an almost rock-bottom level. The commissions tunnel vision in its recommendations on so important a subject is not surprising. Its emphatic recommendations for perpetuating vertical programs against major communicable diseases (tuberculosis, AIDS, and malaria) on the grounds that such programs have proved convenient to “donors” reveals the real motivations for an almost openly ideology-driven agenda. This is a serious danger signal for scholars who wish to take a scientific attitude toward program formulations for the poor that provide maximum returns from limited resources. The concept of DALYs (disability adjusted life years) is bristling with gross infirmities. The WHO-generated data used for DALY calculations, converted into dollar terms, are patently invalid, unreliable, and not comparable between and even within countries.

Hidden Menace in the Universal Child Immunization Program

Short-term, technocentric approaches to health care–“selective primary health care”–in Third World countries, as advocated by UNICEF and other international agencies, threaten to reverse the historic gains made at the Alma-Ata Conference in 1978. The primary health care strategy presented in the Alma-Ata Declaration was the culmination of the struggle for democratization of health services in the Third World. In this article, the author discusses the effects of the selective primary health care approach, as exemplified by the Universal Child Immunization Program, on general health services and its fundamental contradictions with the primary health care approach, and presents the manifesto drawn up at the Meeting on Selective Primary Health Care held in Antwerp in 1985.

The People and Health Service Development in India: A Brief Overview

Health is politics, and politics is health as if people matter—this has been a refrain of such scholars as Rudolf Virchow, Halfdan Mahler, and B. C. Roy. Many seeds of hope for health were generated during Indias struggle against colonial rule. After Independence, with the changes in power relations, these seeds could not find the appropriate soil to nurture them. Power relations influence health service development, which is a sociocultural, economic, political, organizational, and managerial process with epidemiological and sociological dimensions. Even within the power structure, however, a carryover of the democratic process of the pre-Independence era has created a pro-people ambience. Despite considerable difficulties and shortcomings, India has developed an endogenous, alternative body of knowledge more suited to the prevailing social, cultural, economic, and epidemiological conditions. This has formed the content of alternative approaches to education, practice, and research in public health—strikingly similar to the Alma-Ata Declaration. The response to this declaration of self-reliance by the worlds poor, together with the earlier specter of population explosion, brought together the political leadership of all hues, the bureaucrats, and foreign agencies to impose prefabricated programs on the people. The result was a decimation and decay of the health service system, causing considerable suffering to the poor. The remedy is a return to the heritage of the alternative approaches that emerged during the early years of Independence.

Reflections on the Twenty-Fifth Anniversary of the Alma-Ata Declaration

The Alma-Ata Declaration on Primary Health Care of 1978—based on the World Health Assemblys resolution of 1977 on Health for All by the Year 2000—was a watershed in the concepts and practices of public health as a scientific discipline; it was endorsed by every country in the world, rich and poor. According to the Declaration, health is a fundamental right, to be guaranteed by the state; people should be the prime movers in shaping their health services, using and enlarging upon the capacities developed in their societies; health services should operate as an integral whole, with promotive, preventive, curative, and rehabilitative components; and any western medical technology used in non-western societies must conform to the cultural, social, economic, and epidemiological conditions of the individual countries. Since Alma-Ata, a syndicate of the rich countries and the ruling elites of the poor countries, aided by the WHO, World Bank, World Trade Organization, and other international institutions, has done much to overturn the Declarations primary health care initiatives. The WHOs recent attempt to regain some credibility, its Commission on Macroeconomics and Health, ignored the primary health care principles of the Alma-Ata Declaration. A struggle for these principles will have to be part of the larger struggle, by like-minded individuals working in individual countries, for a just world order.

Place of the indigenous and the western systems of medicine in the health services of India.

The interrelationships of the indigenous (traditional and western (modem) systems of medicine are a function of the interplay of social, economic, and political forces in the community. In India, western medicine was used as a political weapon by the colonialists to strengthen the oppressing classes and to weaken the oppressed. Not only were the masses denied access to the western system of medicine, but this system contributed to the decay and degeneration of the preexisting indigenous systems. This western and privileged-class orientation of the health services has been actively perpetuated and promoted by the postcolonial leadership of India. The issue in formulating an alternative health care system for India is essentially that of rectifying the distortions which have been brought about by various forces. The basic premise for such an alternative will be to start with the people. Action in this field will lead to a more harmonious mix between the indigenous and western systems of medicine.

A Simplistic Approach to Health Policy Analysis: The World Bank Team on the Indian Health Sector

A World Bank report on the health sector in India has set out to offer an alternative policy framework to cushion the impact of structural adjustment programs on health services. By choosing health financing as a tool for policy analysis, it has arrived at highly questionable conclusions.

Reinventing Mass Communication: A World Health Organization Tool for Behavioral Change to Control Disease

Most of the WHOs vertical programs, because they were ill-conceived, ill-designed, and defectively implemented, have fallen far short of expectations. These limitations have been doggedly ignored by the WHO, although the authorities in India have now realized that such vertical programs are expensive and not sustainable. Launching of Communication for Behavioral Impact (COMBI) appears to mark a desperate effort to revive their performance. It represents yet another deviation from the mandate given to the WHO. In 1983, the then director general warned against motivational manipulation of people to sell health ideas, but the WHO has now brazenly come forward to look for help from the private sector. COMBI uses the jargon and language of the market place to “market” health programs; it calls this “cause-related marketing.” The WHO has been most ahistorical in conceptualizing COMBI, as it has not learned from the failure of UNICEFs earlier venture to market child survival by employing experts in social marketing to bring about “community mobilization.” The WHO should have reviewed the large body of literature on work in the health social sciences, health education, and the many programs based on the concept of “information, education, and communication.” The pointed neglect of such key issues raises serious moral, ethical, and human rights questions. The COMBI approach amounts to be a breach of trust—a threat to human dignity.

Serious Crisis in the Practice of International Health by the World Health Organization: The Commission on Social Determinants of Health

The Commission on Social Determinants of Health (CSDH) is the latest effort by the World Health Organization to improve health and narrow health inequalities through action on social determinants. The CSDH does not note that much work has already been done in this direction, does not make a sufficient attempt to analyze why earlier efforts failed to yield the desired results, and does not seem to have devised approaches to ensure that it will be more successful this time. The CSDH intends to complement the work of the earlier WHO Commission on Macroeconomics and Health, which has not had the desired impact, and it is unclear how the CSDH can complement work that suffers from such serious infirmities. Inadequacies of both commissions reflect a crisis in the practice of international health at the WHO, stemming from a combination of unsatisfactory administrative practices and lack of technical competence to provide insights into the problems afflicting the most needy countries. Often the WHO has ended up distorting the rudimentary health systems of the poor countries, by pressuring them into accepting health policies, plans, and programs that lack sound scientific bases. The WHO no longer seems to take into account historical and political factors when it sets out to improve the health situation in low-income countries—which is supposed to be the focus of the CSDH. An alternative approach is suggested.