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Sickness and Wealth | Excerpt
From the Preface
In 2003, I met Dr. Steve Gloyd, one of the contributors to this fine book, at a meeting about implementing HIV treatment in resource poor settings. The meeting was held at our hospital in rural Haiti and was attended by AIDS experts from many developed countries. While many well meaning, European and North American medical academics, very new to the health landscape in the developing world, debated the merits of one HIV treatment regimen over another, Steve and I bemoaned the profound and entrenched poverty that underlies the fragile existence of the poor and the abysmal state of the public health sector that is charged with caring for them. At this well attended HIV treatment meeting, only the small group of us who regularly face the stark contrast between the developed and developing worlds continually returned from the important clinical discussion of HIV treatment to the more pressing problem of the international financial policies that foment poor health; the corporate interests and the neoliberal economic "reforms" which demand that governments decrease their public service budgets to promote the unfettered march toward the "free" market. No doubt, our clinical and scientific colleagues from places like United States, France, and England thought that such policy arguments should be vetted elsewhere, after all, we had come to Haiti to talk about scaling up access to HIV care. Certainly, they supposed, there must be groups better positioned to address the thorny issue of international finance.
But, in fact, for the first world doctors, nurses, activists and others who help to bring needed medical care to the world's most vulnerable groups, the paltry health budgets of less than five US dollars per person per year, that are allotted to the very countries where the health is poorest, serve as a grizzly barrier against substantive improvement in global health. In Haiti, the government health budget is just one dollar and seventy five cents per person per year; at this level of health funding even infant vaccination cannot be sustained. In Haitian Kreyol the word for poverty is mize, misery. Indeed, our work in poor countries demonstrates not the life of the "happy peasant" but the life of misery that is borne by the poor who have little or no access to food, shelter, education, or health care.
We are taught in medical school, that ninety percent of diagnoses are revealed by listening and taking a careful accounting of the symptoms present and the history of the illness. Worldwide problems such as AIDS, tuberculosis, maternal mortality, and infant death are only the symptoms of the larger global pathology. Of course we must tend to the symptoms of our sick body politic to the best of our ability—prevent diseases which are preventable and treat people who live with AIDS, tuberculosis, typhoid, malaria, and all the other diseases that have been relegated, increasingly, to the category "diseases of poverty." Just as it would be unthinkable not to offer strong narcotics to a dying patient wracked with the pain of cancer—so too, we must treat the pain of the illness. But to properly diagnose the sickness that affects the body politic we must ask, "What is the history of this problem? What is the cause of this sickness?" Our collective diagnosis, and the one outlined so well in this book, is that the cause of this global sickness is poverty, misery. Its history is rooted in the deliberately inequitable distribution of wealth. By dissecting the body and examining the pathology within it, this book, Sickness and Wealth: the Corporate Assault on Global Heath, attempts to give us an honest diagnosis with which to work.
The first and most important part of making the right diagnosis is to understand the history of this seemingly intractable poverty. The naked truth is that much of the current global inequality is a direct result of colonialism, subjugation, and the slave trade. Colonized countries from Brazil to Uganda, rich in natural resources, were not developed for the people of these lands. Rather, colonies were used solely to extract resources to support the empires of England, France, Spain, Portugal, Holland and others. Subjugates to this system had no right to the rich profits of their labor and were exploited by such brutality that can only be rooted in extreme racism and hatred. History is dense with examples from the Congolese slaves in their own land for the Belgian rubber trade, to the slaves brought by the English through the middle passage and sold to the French and Spanish to farm sugar cane in Hispaniola. Not a penny of reparations have been paid to affected countries by the colonial powers who the carried out this awful rape of peoples and lands and profited enormously from their exploits.
In fact, rather than reparations for the damage to the people, land, and psyche of these poor and deliberately undeveloped countries, once independence was hard fought and won—primarily in the 1950s and 1960s, the exploitation continued through legitimatized corporations. The same colonial interests were given a new capitalist face and underwritten by the new American superpower. The work force is nearly the same slavery barely hidden by the pretense of paying the laborers a meager wage. Some countries tried to reclaim their resources or nationalize them as did Zambia with the nationalization of copper mines. However, with little in the way of infrastructure to develop, poor countries became rapidly dependant on loans from the very countries that had historically exploited their land and people and wished to continue to do so. These loans come with harsh restrictions, or structural adjustment policies. The policies demand that governments "open markets," privatizing not only companies, but also public services such as health, education, and water; services upon which the poor are even more dependant than the wealthy.
This book outlines some of the consequences of these policies which were implemented without a shred of evidence in a massive global experiment to export the free market to the already exploited and starving poor world. Ironically, once forced into free market economies, the poorest countries are hardly allowed to trade freely on the global stage. Subsidies that protect farmers from financial ruin in wealthy countries are considered bad economics when they are given to the world's poorest farmers. Protective tariffs in rich countries ensure that agricultural goods such as sugar, cotton and beef will not be exported from the poor world to the rich. Moreover, the processing that adds value to a raw material or crop is protected by trade barriers and corporate interests. The coffee grown in East Africa, for example, cannot be roasted there. The difference between the price for the unprocessed coffee beans harvested by the poor and roasted beans sold in wealthy countries is ten fold, making an 8 billion dollar coffee harvest, and 80 billion dollar revenue generating venture for corporations.
The vicious cycle that breeds poverty is well outlined in these chapters: but bears repeating here as it is the pathology at the heart of global sickness and inequality. The exploitation of the resource rich South through colonialism and slavery served to bankrupt Southern nation states where, just as independence was gained, the colonial industries were privatized into the same hands that exploited the labor and land. These newly independent states, saddled with willfully under-developed infrastructures, were thus also stripped of income generating potential. The new states, therefore, became dependent on loans which restricted government power over commerce and tariffs in the name of free trade, but also limited government spending for health, education and welfare. Lastly, "free" trade is not free for subjugated countries—restrictions on trade and the development of industry leave these countries unable to export or to add value to the raw materials they produce.
What in the world does this financial cycle have to do with health—with infant vaccinations, water quality, or AIDS treatment? Unfortunately, this carefully crafted structural violence under which the poor suffer and die has everything to do with the colonial past and the neoliberal corporate present. There is no attention paid to the health and welfare of the poorest people in either the colonial or corporate models. While it is said that the rising economic tide expected by market reforms will "lift all boats," the poor have no boat and are most certainly drowning in this tsunami of corporate profit.
Human rights serve as a life boat, a safety net against the exploitation of the vulnerable. Yet not since 1978, when the Alma-Ata declaration called for "health care for all by the year 2000", have we heard a rights-based call for access to health care. The rights-based goals of Alma-Ata were modest; 90% of children should have weight for age that corresponds to reference values, every family should be within a 15-minute walk of potable water, and women should have access to medically trained attendants for childbirth. There was unanimous agreement that these goals could not be achieved and could not be sustained by the world's poorest governments without increased international aid. However, the proposed right to universal basic health care was attacked by international experts as naïve, too expensive and not "sustainable." In the next few decades and with foreign debt mounting, health sector reforms emphasized user fees, privatization, and other cost-recovery measures under the guise that health systems in heavily indebted countries could be internally sustainable by these measures. Most studies have documented that such reforms are certainly not enough to sustain the health budget of a poor country since so few people can pay for services. Moreover, by shifting the burden of payment to the poor rather than making it the responsibility of governments aided by the international community, the people who need care the most have least access. Many studies have documented that such policies have a deleterious effect on the health.
Revitalizing the public health infrastructure and improving the delivery of essentials such as vaccination, sanitation, and clean water is a critical aspect to addressing the social injustice that underlies disease. Governments, of course, must take responsibility for the health of their people by setting rational, stable, and rights-based policies that guarantee health care for even the most poor and vulnerable citizens. But, while this responsibility rests with the governments of the world's poorest countries, it is only with large scale and ongoing international assistance that poor governments will be able to address the right to health in a sustained way. Advocacy to redress the violations of this basic right to health must recognize that more money is needed for health now, and for decades to come and that calls for restrictions on government health spending, privatization, and market reforms serve to worsen inequality in health care and perpetual social injustice. Recent calls for debt relief are rooted in the notion that if governments spent less money paying back debt, there would be more money to invest in health and education. Additionally, novel strategies to put more money into health have been initiated in the last few years including the Global Fund to Fight AIDS, Tuberculosis, and Malaria, the largest multilateral public health fund. The Fund and the movement for debt relief are among the first steps towards a worldwide responsibility to fulfill the right to health care.
The deep roots of health inequality assure us that, until systemic change takes place, the misery will continue. Without money to train human resources, build real health infrastructure, procure medicines and diagnostics-successful health projects will remain pilots and large scale initiatives to improve health will seem naïve. But the past and present can help us diagnosis the sickness we find globally and it is only if we understand the pathology that we can imagine a healthier future. Sickness and Wealth: the Corporate Assault on Global Heath gives us the diagnosis, and suggests that the team to cure the sickness is the collective of those who care about the lives of the poor and are willing to address the real causes of inequality to truly improve global health.
Dr. Joia Mukherjee trained in Infectious Disease, Internal Medicine, and Pediatrics at the Harvard Medical School's Massachusetts General Hospital and has an MPH from the Harvard School of Public Health. Joia has been involved in health care access and human rights issues since 1989 in the United States, Africa, Latin America, the Caribbean, and the countries of the former Soviet Union. Since 1999, Joia has served as the Medical Director of Partners In Health, an international medical charity with clinical programs in Haiti, Peru, Mexico, Russia, and inner-city Boston. Dr. Mukherjee consults for the World Health Organization on the treatment of HIV and MDR-TB in developing countries and is a member of the Executive Board of Health AIDS Action, a campaign conducted with Physicians for Human Rights to engage the US health professional community in the international advocacy and education effort to stop the global AIDS pandemic.
In rural Haiti, Dr. Mukherjee along with colleagues Drs. Paul Farmer and Fernet Leandre has established a program to treat patients with HIV infection using highly active antiretroviral therapy. This program, the HIV Equity Initiative was the first of its kind in a developing country and served as a model for the Millennium Development Goals, the WHO's 3 by 5 initiative, and the Global Fund to Fight AIDS, TB and Malaria. Dr. Mukherjee is on the faculty at Harvard Medical School where she teaches Social Medicine and Infectious Disease to medical students, residents and fellows. Her scholarly work focuses on the human rights aspects of HIV treatment and on the implementation of complex health interventions in resource poor settings.
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