Saturday, October 11, 2008

Will There Be Another Alma-Ata?

What of the declaration from 1978 promising “Health for All”?

Thirty years have gone by since the “Alma-Ata Declaration” – adopted on September 12, 1978 at the end of an international conference on primary healthcare at Alma-Ata in the then Soviet Union (now, Almaty in Kazakhstan) – set the goal of “Health for All” by the year 2000, to be realised through universal, comprehensive primary healthcare.

The declaration, non-binding on the member-states of the United Nations, came at a time when the first and the second worlds were contending among themselves for advancing their respective power and influence in the World Health Organisation
(WHO), and the third world was pushing for a “new international economic order”. The world has since changed so very dramatically that one wonders if one should at all look at Alma-Ata 30 years on. Hardly had the dust in the aftermath of the declaration
settled down when neo-liberalism as an ideology and as an agenda began its hegemonic ascent. So what of Alma-Ata?

Alma-Ata happened five years after the democratically-elected Popular Unity government in Chile was overthrown in the coup d’├ętat organised by Washington, in which president Salvador Allende was assassinated. Allende was a medical doctor who understood the social origins of disease and ill-health, just like Che Guevara, also a medical practitioner, did. Both of them saw “politics as medicine on a grand scale”.

Allende knew from his practice since the 1930s that a solution to the ill-health of the Chilean people lay not merely in the provision of healthcare but in bringing
about better conditions of work, housing, sanitation, nutrition, and so on. On its part, Cuba, a third world country that practised universal, comprehensive primary healthcare has attained health indicators corresponding to those of the developed world. Closer home, in our part of the world, Alma-Ata came at a time when the Maoist model of development in China – which had incorporated universal, comprehensive primary healthcare, among other things, as an integral part of a long-term programme – was being sought to be discarded following the third plenum of the 11th central committee of the Chinese Communist Party that announced the decision to launch “market reforms”.

The prospects of fulfilling Alma-Ata dimmed even further when conservative, right-wing governments in the United States and the United Kingdom headed by Ronald Reagan and Margaret Thatcher, respectively, took office. After all, Alma-Ata was informed by a
Weltanschauung that was wholly at odds with that of neoliberalism.

In the declaration, health “is a fundamental human right” whose attainment requires a multi pronged attack on the social determinants of ill-health and disease. Existing “gross inequality in the health status of the people is politically, socially, and economically unacceptable”. While the state is held responsible for the health of
the people, the latter “have a right and duty to participate...in the planning and implementation of their healthcare”. And, the conception and practice of primary healthcare should be informed by the understanding that social and economic relations and conditions profoundly influence health, disease and medicine (Paras VI
and VII of the declaration).

Sadly, on the ground, what was practised was selective primary healthcare, for instance, “targeting” children under age five with immunisation and oral rehydration salts (ORS), technical fixes that are useful but cannot go a long way in dealing with health problems whose roots are to be found in exploitation and oppression.

With World Bank-imposed structural adjustment programmes (SAPs) in the 1980s and the slashing of public health expenditure, poor families in the third world landed up at times spending a third of their daily earnings to buy the ORS packets that were being
promoted via “social marketing”. The SAPs adversely affected not only health expenditures, but also those related to education, food subsidy, public transport, etc, pruning a whole gamut of social welfare activity undertaken by states. User-fees, basically cost recovery measures, and the privatisation of health service functions
became the order of the day under the World Bank-mandated SAPs, even as the United Nations Children’s Fund (UNICEF) pleaded for undertaking them “with a human face”.


Whatever happened to healthcare as a “fundamental human right”?


The World Bank’s World Development Report 1993: Investing in Health, as David Werner wrote in an article in this journal 13 years ago (January 21, 1995), “put the last nail in the coffin of the Alma-Ata Declaration”. The World Bank has since pushed the
WHO into second place as the global agency influencing health policy, with a three-fold impact on the ground.

First, the responsibility for the coverage of health costs is a huge burden the poor have to bear more than ever before. Second, primary healthcare has become even more narrow and selective than it was in the 1980s. And, third, the private sector, including the insurance industry, has boomed in the “business” of healthcare. Yes, the business of healthcare – patients are now “clients” and clinical services are “product lines”.

The rights of the pharmaceutical corporations to their intellectual property precede the “fundamental right to healthcare”, which is anyway “non-binding”.

What then of Alma-Ata?

What goes around comes around. If disease is socially derived, then ill-health and disease are an indictment of the social, economic and political order. There will be many a “Sicko” (the title of the film on healthcare in the US by Michael Moore), and, sooner rather than later, the counter-movement against the market mechanism will generate its own Alma-Ata. The struggle for healthcare as a fundamental human right goes on.

Playing God: The Global Population Control Movement

Playing God: The Global Population Control Movement

Book Review, The Economic & Political Weekly, October 4, 2008

Fatal Misconception: The Struggle to Control World Population by Matthew Connelly; Harvard University Press, Cambridge, Massachusetts, 2008

by

Mohan Rao

This is a truly extraordinary book that I cannot recommend too
highly, not just to the small community of historians working in the area of health and population, but for public health workers, demographers, scholars in gender studies, feminist and health
activists and, indeed, even the occasional policymaker who reads.

The book has been reviewed favourably in extremely unlikely places, including the New York Times and the Economist. Both point out
that the author is born in a Catholic family, with many children, implying this would explain the critique of the global population control movement that this book is. Both reviews did not point out
that some of the harshest criticism in the book is reserved for the Catholic church’s stand on contraception and abortion.

Reviewers in both places seem to think ideas underlying population control is a thing of the past, like political incorrectness.
And here, they have some misguided support from the author himself, but more on this later.

Here is a scholar who had infamously written in the Atlantic Monthly, with that Cold Warrior Paul Kennedy, that population
growth in the third world, along with growing economic inequalities and migration, portended nothing less than a clash of civilisations, in a familiar replay of neo-Malthusian tropes. Here he is several years later, with extensive research under his belt, prepared not
only to critique his own earlier position, but examine what factors lead to that position itself. This self-questioning, selfdoubt,
is truly catholic – with a small c –and indeed a conversion.

Hopefully, reading this book will take others through the same journey of discovery. Being politically correct, influential
people in policymaking circles in the first world no longer talk of the yellow peril, or use phrases such as population explosion,
or metaphors like the population bomb. Nevertheless, neo-Malthusian thinking –that population growth is the cause of a host of problems, of hunger and poverty, or indeed famines, and today, genocide
and global warming – frames other policy discourses, that on immigration and the environment being prominent ones. “Most
Americans Want Immigration Drastically Reduced” reads a full-page advertisement in Harper’s, put forth by Negative Population
Growth. It goes on to argue about the “catastrophic effect of overpopulation on our environment, resources and standard
of living” (Harper’s 2004:19).1 Neo-Malthusian underpinnings are evident in some of the security discourses on refugees.

The ghastly Rwandan tragedy was seen as an inevitable consequence of
p opulation growth, not the politics of g enocide (Mamdani 2001).2 Hum do hamare do, who paanch, unke pachees (“The two of us have two, the five of them have 25”), was a slogan that won an infamous election in Gujarat after the genocide of Muslims in 2002 (Rao 2007).3 We only need to remember that as soon as the last elections
were announced in the UK, immigration became an issue, not just for the Conservatives but for the New Labour of Tony Blair as well. Both Italy and France have recently elected right wing presidents on an explicit anti-immigration platform.

Fundamentalism

At the same time, a sub-discipline of “strategic demography” has emerged, that seeks to locate the growth of slamic “fundamentalism”4 in the “youth bulge theory”. This fanciful theory argues that population growth in Islamic countries, characterised by a high proportion of youth, leads to the growth of Islamic funda mentalism, spelling political d anger, not just to democracy in these co untries but to the so-called free world (Hendrixson 2004).5 This search for biological metaphors to political and economic problems does not, for instance, explain the rise to political dominance of Protestant fundamentalism in the United States, which has of course no youth bulge, nor indeed significant po pulation growth. But such matters of truth or rigour rarely troubled demographic discourses in the past, and obviously do not, today. In other words, the population growth argument remains compelling, and truly protean, explaining just about everything, and thus of course
explaining nothing.

Here is a remarkable book, of solid scholarship (although rather overburdened with more than a 100 pages of notes and references. Another quick paperback edition is called for without this, cheaper, and thus accessible to more people). Along with a host of secondary
materials, the author has extensively tracked government and UN reports, and, most extraordinarily, been granted permission
to go through the records of organisations such as the Rockefeller
Foundation, the Population Council and so on – the prime players, or villains, in the population drama. Does this mean they have come to terms with their pasts? Or does it mean they do not really care?
Whatever it is, we must salute these organisations for the unusual courage they have displayed.

Fatal Misconception abjures rhetoric and conspiracy theories, indicating the concatenation of ideas, institutions and the
contingencies of global politics to, to use current jargon, deconstruct neo- Malthusian assumptions that lie at the heart of
population policies. It shows with meticulous attention to details of ideas, personalities and funding, how the global population
control movement was created, tracing the extraordinary unfolding of
population policies under the guidance of this movement, in India and China in particular. However, for a book that claims
to be “the first global history of population control” (p 10), the book does not give enough attention to events in Africa, Peru
(forced sterilisation of indigenous people), or indeed the US itself, with its history of eugenic sterilisations.

The book documents admirably this movement’s command over resources,
financial, and intellectual, and the strategies adopted to win friends and influence people – that is so overwhelming even
today.6 And how, in the process, was established a pattern of domination, and a network of institutions, that continues to be
effective in areas as diverse as HIV/AIDS policy and indeed reproductive health policy. Yet, it is not a simple, or simplistic,
first world – imperialism story, which it fundamentally is, but a nuanced, multilayered one. The book is above all rich in
tracing the ideas that influenced such a motley, and huge, group of people. Yes, imperialism is central to the population control movement, but there is also the element of individual freedom and rights it promises, especially to women. Yes, it was hugely racist – and sexist – and this was of course at the heart of the science of
eugenics, which saw its apogee in the Holocaust, but this was not unique to G ermany.7 Indeed the Scandinavian countries and Canada had eugenic sterilisation laws long after the Nuremburg trials discredited them. Yes, cold war politics – communism will spread because of population growth – dictated many of the urges of the movement in the hopeful post- second world war years. Yes, too, that the things done were terrible, but above all that there was consent, approval and indeed active participation from a host of
third world elites. This was a joint global elite project, using different threads of arguments at various times. The movement
felt it could decide who could be allowed to be born and where, and who could be allowed to die.

At times the arguments were eugenic: that the worst were breeding whilst the best were not. This argument seemed to find particular resonance in India with all the leading population control people,
predominantly upper caste Hindus (and indeed a few upper caste Muslims), being particularly suspicious, and fearful of
lower caste and Muslim reproduction. This argument was what led to the sterilisation laws in a host of states in the US, and indeed the US’ immigration policies early in the 20th century. Eugenics is of course currently being reinvented as n eo-eugenics in the wake of advances in biotechnology: parents can now “freely” decide, if they can afford it, what genetic characteristics they do not want in
their child.

Women’s Rights

At other places, the arguments were about women’s rights, as is the case today. It is indeed a case for women’s and men’s rights – but the problem was that this was used instrumentally. Margaret
Sanger, who made this argument forcefully, was also a eugenist, causing profound embarrassment to her erstwhile socialist colleagues. Matthew Connelly is inexplicably rather sweet on Sanger. I would suggest he quickly read Sarah Hodges (2006)8 and Sanjam Ahluwalia (2008)9 before the quick new edition of this book. A question Connelly does not raise is why Sanger, during her tour of
India influencing people to the population control cause,10 did not make overtures to Periyar or Ambedkar, both fierce proponents of birth control. The reason is of course very simple: for Sanger contraception was for eugenic purposes; for Periyar and Ambedkar, it was a quest for gender justice and a blow against
patriarchy and caste.

Above all, the arguments were about economics and development. Population growth in third world countries was seen as the primary reason for their horrible poverty. Colonialism, or indeed the continuing drain of resources from these countries, did not figure. Economic growth could only take place if population was
controlled, it was argued, if necessary with force. I was astonished to discover in this book that Kingsley Davis, the guru of
demographers, who gave testimony in the US senate as to why population control is necessary to combat communism, gave
approval to Sanjay Gandhi’s fearful policies of coercive sterilisations during the Emergency in India (p 320).

The many-headed, hydra-like beast that was created, acting globally, accountable to no one but themselves – which is unfortunately characteristic of most non-governmental organisations (NGOs) – comprised a network of organisations including the Population Council, the Rockefeller Foundation, the For Foundation, the
International Planned Parenthood Federation (with its clutch of poodle national family planning associations) and so on.
They obtained funding from organisations such as the World Bank, the USAID and the UNFPA, and in turn funded a whole range of activist NGOs. As the book documents, during the 20th century more money has
been poured into this movement by first world governments, and others, than any other cause. Linked through funds and people were the leading academic departments at Harvard, Princeton and so on,
and think tanks that increasingly influenced foreign policy. Significantly, all the major demographic journals were funded
by the same institutions and were thus largely responsible for the scientific sheen demography carried. The interconnection between these that Connelly demonstrates is both mind-boggling and
frighteningly impressive.

Revealing Facts

Connelly also shows us how these ideas were used to push the population control agenda globally. Utterly revealing was the
fact that leading donors knew what the Emergency was doing to family planning in India and welcomed it (pp 322-23). Similarly,
I was shocked to discover that donors knew that ultrasounds were
d istorting child sex ratios in China – but that, in their anxiety to control population, encouraged China to import ultrasounds
with aid funds (p 347), and indeed, that the World Bank used structural adjustment loans to push population control policies (p 349).

Connelly does not note the irony that it is precisely these groups and organisations that are involved with reproductive
health and rights today. He seems to believe, inexplicably, that population control is a thing of the past. Thus we have
some paeans to the idea of reproductive health and rights that came to centrestage at the International Conference on Population
and Development at Cairo in 1994. There is such a wealth of literature on the troubled relationship between this evocation of women and reproductive rights – and the wrongs that accompanied it. He misses the significant point that what was being pushed through as the Cairo consensus was the agenda of US feminists. It has been described as white, western and quintessentially bourgeoise.

From Angela Davis onwards, a whole lot of people have written about this. I have described this as an outcome of the marriage
of multinational feminisms with international debt. Surely it is significant that the Cairo consensus not only had the imprimatur of the World Bank, but was silent on what the Bank’s policies had
unleashed on women and their rights and entitlements globally through structural adjustment programmes. Indeed, the Cairo consensus came in for scathing criticism by the leading women’s groups in India on precisely this ground. There is also a movement for reproductive justice, which rejects this concept of
reproductive rights.

Birth rates are declining across the globe, although it is not clear if this is linked in any significant manner with population control programmes. Yet, as we have seen, ideas associated with this
movement have a way of resurfacing in inexplicable ways. Today, warns Connelly, we may already be witnessing something no
less pernicious: the privatisation of population control. It is governmentality without government, in which people police themselves, unconsciously reproducing and reinforcing
inequality with every generation.…

Parents increasingly experience genetic counselling and solicitous concern for foetal health as social pressure to have perfect children, even if standards for perfection are constantly changing. In everyday conversation, people ascribe a whole range of
behaviours to good or bad genes, faithfully reciting a eugenic catechism without the faintest idea of where it comes from or where
it can lead (p 382).

Email: mohanrao2008@gmail.com

Notes
1 Harper’s (2004), Vol 309, No 1853, October.
2 Mahmood Mamdani (2001), When Victims Become
Killers: Colonialism, Nativism and the Genocide in
Rwanda, Princeton University Press, Princeton.
3 Mohan Rao (2007), ‘Saffron Demography: So
Dangerous, Yet So Appealing’, Different Takes,
No 48, Spring 2007, Amherst, Mass, Reprinted in
Babies, Burdens and Threats: Current Faces of
P opulation Control, Hampshire College, Mass.
4 The untroubled use of this word, as of the phrase
“Hindu nationalism”, to describe Hindu fascist
groups indicates the reach and dominance of
crude western thinking, repeated unquestioningly
in India and elsewhere. The word fundamentalism
of course derives very specifically from
the history of Protestant groups in the US, wishing
to reach into the fundamentals of their version
of Christianity to guide their politics and
everyday lives. There are enormous problems
with this characterisation of the Sangh parivar as
Hindu fundamentalist or Hindu nationalist. In
the first place, they do not represent Hindus, and
indeed seem to be deeply ashamed of Hinduism,
wishing to transform it into a more semitic, “masculine”
religion, like Christianity or Islam. There
are of course no fundamentals in Hinduism. Their
claim to be nationalistic is equally moot since
they played an extremely marginal role in India’s
freedom struggle. Indeed, the assassin of
Mahatma Gandhi, a good and proper Hindu, was
a member of the Sangh parivar as it then existed.
5 Anne Hendrixson (2004), Angry Young Men,
Veiled Young Women: Constructing a New Population
Threat, Cornerhouse Briefing No 34, December,
Dorset.
6 As I write the review I see a news item in the
Times of India (‘In Kerala, Having a 3rd Kid May
Invite Penalty’, July 30, 2008) that Kerala seeks
to introduce a two-child norm, with a number of
penalising disincentives. The Kerala Law
C ommission that has mooted this, under the
leadership of the progressive justice Krishna Iyer,
does not seem to know that Kerala has long completed
her demographic transition. In other
words, that even for purely instrumental reasons,
the move is entirely unnecessary, and equally
entirely foolish.
7 Indeed, many doctors and scientists involved in
eugenic sterilisation, and worse, in Nazi G ermany,
got away at the Nuremberg trials where it was
pointed out that the German laws were modelled
on ones current in the US and in many other countries.
Indeed, the US Supreme Court had found
these laws constitutionally valid and thus acceptable.
See Harry Brunius (2006), Better for All the
World: The Secret History of Forced Sterilisations
and America’s Quest for Racial Purity, Alfred
A Knopf, NY.
8 Sarah Hodges (2006), Reproductive Health in
India: History, Politics, Controversies, Orient
Longman, New Delhi.
9 Sanjam Ahluwalia (2008), Reproductive
Restraints: Birth Control in India, 1877-1947,
P ermanent Black, Ranikhet.
10 This, incidentally has been famously rebuffed by
Gandhi. Gandhi rejected contraception sometimes
arguing that contraception would lead to sin and
the weakening of individuals and nations; he sometimes
also rejected contraception on the grounds
that neo-Malthusianism was fundamentally flawed;
at all times arguing that celibacy was the solution
where women, and indeed men, were concerned.

Health care costs: A market-based view

If health care costs continue to rise at current rates, they could amount to 20 percent or more of the GDP of many developed countries. To understand how to manage—or influence—this expenditure, decision makers should look at the factors that influence the supply and demand of health care services.

* Throughout the world, leaders of government health agencies, heads of health care companies, and even patients—collectively, the shapers of the modern health care system—behold the growth of health care spending with alarm. For almost 50 years, spending has grown by 2 percentage points in excess of GDP growth across all Organisation for Economic Co-operation and Development (OECD) countries. As a result, health care has become a much bigger part of most of these economies.
* If current trends persist to 2050, most OECD countries will spend more than a fifth of GDP on health care. By 2080 Switzerland and the United States will devote more than half of GDP to it—and by 2100 most other OECD countries will reach this level of spending.
* Health care leaders fervently hope that the projections are off the mark. What will have to change to prevent health care from devouring half of a national economy?

This article contains the following exhibits:

* Exhibit 1: In the health-care market, the line between supply and demand is sometimes blurred.
* Exhibit 2: Per capita spending on health care strongly correlates with national GDP.
* Exhibit 3: The median increase in health-care spending in member countries of the Organisation for Economic Co-operation and Development (OECD) has been two percentage points above GDP for nearly 50 years.
* Exhibit 4: At the historic growth rate, health care will consume an ever-growing proportion of developed nations' wealth.
* Exhibit 5: In many countries, the tax-financed part of health care represents a massive transfer from young taxpayers to older health care users.

The McKinsey Quarterly

The Corner House on Health

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