jul 09

Published in Global Social Policy

The work of international agencies such as WHO (as well as other U.N. agencies) is very much determined by the distribution of power in the world. It is well-known that the governments of some countries have more power in today’s world than others. And, it is also well known that within each country some social classes, as well as some genders and races, have more power than others. The implications of this reality for WHO has been rarely studied even though these country, class, race and gender power differentials shape in large degree the reports and documents made public by this international agency. Examples of this situation are many. And one of the best known is the Alma Ata Report. When that document was approved by the WHO Assembly, back in 1978, there were several power blocks in the world (The First, the Second and the Third Worlds) competing among themselves for power and influence in WHO. It was also at that time that we witnessed great social agitation, not only in the developed, but also in developing countries, agitation that started in the middle 60’s and had continued during the 70’s. It was indeed a period of agitation, creativity and exploration. No one taboo was left untouched. Not even the dogmas that were reproduced in the House of Medicine. The hospital-centric biological model was indeed challenged all over the world. And a new alternative model was developed that materialized in the Alma Ata Report. The ideological column that sustained that report was Primary Health Care, based on not only medical, but also social interventions governed by the communities and by the citizenry. Needless to say, it was a moderate step, but at least it was a step in the right direction. Some of us were critical. I wrote a critique of Alma Ata, side-by-side with a critique of another important report at that time, the Willy Brandt Report. (“Navarro, V. “A Critique of the Ideological and Political Positions of the Willy Brandt Report” and “The WHO Alma Ata Declaration” in the International Journal of Health Services, 1984). As young people we were, we wanted more and felt frustrated that the train forward was going so slow. But, at least, I repeat, it moved in the right direction.

The world since then has changed dramatically. And it has become almost a monopolar world. The U.S. establishment has become the dominant power all over the world, not only because of military force, but more importantly, because of the dominance of its ideology –neoliberalism – ideology that is being reproduced, also in WHO. This ideology claims that, 1) the state (or what is wrongly referred to as government) is part of the problem rather than the solution and it needs to be reduced.  2) labor and financial markets need to be deregulated in order to liberate what is defined as “the enormous creativity of the markets”, and, 3) commerce and investments need to be stimulated by eliminating borders and barriers to allow for the full mobility of labor, capital, goods and services. The translation of this ideology in the health sector meant, 1) a decline of public expenditures in health care, 2) a privatization of the health care services, 3) the impoverishing, when not the dismantling of public health infrastructures, 4) full mobility of health professionals primarily from developing to developed countries, 5) full mobility of medical equipment and drugs from developed to developing countries, without protection of the populations and regulation of those products. Social dumping has become the name of the game, and 6) full recovery of the biological and behavioral      centric view of medicine, with the bio industry becoming the seventh financial wonder in the world. This ideology appears also in the new terminology used in health policy circles. Patients become clients, planning disappears and is substituted by terms such as markets and competition. And in more than one country, national health services have been dismantled and substituted with commercial health insurance. This is what has been happening in the world for over thirty years now..

The outcome of these policies on the health and quality of life has been extremely negative as we have documented in my recent collection Neoliberalism, Globalization and Inequalities. Consequences for Health and Quality of Life. Baywood, 2007). Continent by continent; (Latin America, Africa, Asia, Europe or North America)  the damages created by those neoliberal policies are large. And the evidence is there for all to see. And as we show, WHO bears an enormous responsibility for that situation (see my critique “Assessment of the World Health Organization Report 2000”,  The Lancet, Vol 56, Nov 4, 2000).

Meanwhile, an alternative movement – the anti globalization movement – has appeared. First in Seattle, U.S.A., second in Porto Allegre, Brazil, and then in many other parts of the world that claim that “other world is possible”. And while they are right, I question that the way they go about it will ever reach that world. Some of the assumptions that are made in this movement are questionable. One of them considers the new world order as dominated by multinational corporations that have substituted the states as the primary focus of power. This assumption, however, ignores that there are no multinational corporations, owed by several nations: rather, they are trans national corporations based in one country and distributed all over the world. The U.S. insurance companies (like Humana) or the U.S. drug industries are based in the U.S. and the German drug industry is based in Germany. And you cannot understand their production and distribution and international behavior without understanding the relationship between them and the states in which they are based. The states in the world continue to be the centers of action. Actually, if the states were irrelevant, as some theorists of the anti-globalization movement claim, then we will have difficulties in understanding why the so-called multinational are spending millions of dollars (or any other local currency) to influence state politicians. The states, however,  are not mere instruments of economic elites. They are subject to all type of influences from different actors besides these economic interests. The societies in which those states operates are divided into classes, races, gender, and other power groups. These actors have different degrees of influence on the state.
This reality is critical to understand the promotion and reproduction of neoliberalism. Indeed, the primary conflict in the world today is not as is frequently said, between the North (rich) countries and the South (poor countries). Both the North and the South have social classes. It was not the U.S. who imposed Pinochet to Chile. I was advisor to President Allende and can testify that the primary actors of the coup were Chileans (the dominant class, the major employers, the bankers, the land owners, the Church, the liberal professional associations, the private doctors, the private health care companies, and so on). And,  it was not the U.S., but rather the U.S. federal government, led by President Nixon (who was extremely unpopular in the U.S.A. having sent the Army to put down the coal miner strikes in Appalachia, the coal mining region of the U.S.), who supported that coup. The U.S. is not a country with 220 million imperialists! The working class of the U.S. is one of the first victims of the dominant class of that country. It is the only working class in the developed world without right-of-access to heath care in time of need. (See Sicko by Michael Moore). Neoliberalism could have not been expanded had it not been for the alliance of the dominant classes of the rich countries with the so-called “poor” countries. There are no poor countries in the world. But there are a lot of countries with a lot of very poor people. And 20% of the richest people in the world live in so-called poor countries. The dominant classes of the so-called poor countries benefit from the neoliberal policies. The promotion of neoliberalism in the health sector is supported not only by the dominant classes of the North, but also by the dominant classes of the South. The active promotion of the privatization of health care, the aggressive sold of the private conservative insurance, the support of the biomedical hospito-centric model of medicine, and many other neoliberal health policies are supported by the dominant classes of the North and of the South.

This is why to establish an alternative model, we have to recover our sense of history, showing that other alternatives (such as the Alma Ata), are possible based on an alliance of the dominated classes of both the developed and developing countries, that needs to link the local with the international struggles.

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