CH188: Second session – social theory, history, and neoliberalism

Yesterday, we had the second session for CH188: The Right to Health – Problems, Perspectives, and Progress.  We covered a broad overview of the recent history of the the global health project and discussed a toolkit of social theories that we’ll use throughout the course to analyze and try to understand progress and challenges in the social movement for the right to health.


Dr. Salmaan Keshavjee discusses the history of neoliberalism’s infiltration of global health logic.

We were also very fortunate to have Dr. Salmaan Keshavjee, professor of global health and social medicine at Harvard Medical School deliver a guest lecture on the history of neoliberalism as a set of economic, political, and moral ideas that have shaped global governance systems writ large and have had very specific (and devastating) effects on health care systems for poor people around the world.

See his slides here. 

Dr. Keshavjee made a compelling and sweeping argument about historically rooted  political and moral battle of ideas about the role of the state and the relationship between citizen, market, state, and rights. In order to understand neoliberalism, we first need to understand the roots of the cannon of Western liberal thought: Locke, Mill, Smith. In particular, he focused on Adam Smith who, while believing in the importance of free markets, also believed that states must intervene in the face of market failures, in education, health care, social services, and other types of publicly-valuable capital investments that private actors would not be willing to make. If Adam Smith saw a vibrant democratic state–countered in power by organized guilds, corporations, and democratically engaged citizens–that created the space for a vibrant free and productive economy, then neoliberal thinkers saw it in exactly opposite terms: a completely unfettered economy is the source of free and open democratic society. In other words, the elimination of government intervention equates to greater liberty.
“The central values of civilization are in danger…. The position of the individual and the voluntary group are progressively undermined by extensions of arbitrary power…The group holds that these developments have been fostered …. by a decline of belief in private property and the competitive market; for without the diffused power and initiative associated with these institutions it is difficult to imagine a society in which freedom may be effectively preserved.”
—Statement of Aims, The Mont Pèlerin Society, April 8, 1947

Dr. Keshavjee then went through a detailed historical account of how a group of neoliberal intellectuals (Hayek, Friedman, Mises) developed a very sophisticated strategy in the war of ideas in the wake of World War II. Playing off of fear of the rise of totalitarianism, the rise of the Soviet Union and the expansion of Communism, and the expansive New Deal politics in the United States, they situated economists in major universities, created new think tanks and policy research divisions, published papers and books, and found ways to ensure that their ideas diffused through nodes of symbolic power producers. This was a very Bourdeusian strategy of amassing symbolic capital via “anointing institutions” in order to alter the shape of the field of practice of the global economy. They weren’t just playing a game of politics; they were creating an entirely new set of rules for the game of the political economy.

This ontological revolution — that democracy and liberty come from unfettered economic systems and economic growth, rather than vice versa — was important in shaping of the transnational bureaucracies in the second half of the 20th century, especially the World Bank, the International Monetary Fund, and the World Health Organization.

Dr. Keshavjee ended his talk with a specific case contained in his book, “Blind Spot: How Neoliberalism Infiltrated Global Health“, an ethnography of the revolving drug fund in Badakhshan, Tajikistan. He described this region, between Afghanistan and China that became deeply impoverished after fall of the Soviet Union. It was also the site of an ideological contest between the East and the West due to its geopolitically strategic location. He witnessed how a great organization, the Aga Kahn Foundation (AKF), came to implement a program focused on the development of a “revolving drug fund” — essentially implementing user fees and charging patients to purchase drugs. The originally proposed title for the book was something like, “Charging starving people for medicine” (because that was literally what was happening), but the editors thought it sounded too harsh. What is interesting in his account is how powerfully the history of neoliberalism came to bear on the lives and the bodies of the people in this far-flung region of the world.

After Dr. Keshajvee’s lecture, we had a great conversation about a toolkit of social theories that we will continue to revisit as we encounter more global health challenges and opportunities in the right to health movement. Specifically, we discussed:
  • Peter Berger and Thomas Luckman: The Social Construction of Reality
  • Robert Merton: Unanticipated consequences of purposive social action
  • Max Weber: Power and authority, bureaucracies
  • Michel Foucault: Biopower and surveillance
  • Arthur Kleinman and Paul Farmer: Social suffering and structural violence
As we go forth over the coming weeks in our work to try to understand some of the biggest challenges facing the realization of the comprehensive right to health, we will constantly revisit this history and these social theories.

Dr. Salmaan Keshavjee Guest Lecture:

Liberalism (17th – 18th century):
  • John Locke:
  • Stewart Mill
  • Adam Smith
  • Importance of liberty and about equality
John Maynard Keynes
  • An assault on free market capitalism; need some intervention and investment from the state
  • There can be market failures; market responds to fear and short term gain
  • Society needs to have a broader and longer vision
  • Also needs to be a provider of social services; also involved in the fiscal cycle
  • Welfare state economics
  • A response to Keynsianism
  • Hayek and Freedman: University of Chicago
  • The iron cage, bureaucracy, the result of the more state: the artibrary dictates of government bureaucrats over rational ideas of the individual. A response to Weber — a solution to Weber’s iron cage of rationality
  • Rise of fascism in Austra; Stalin; rise of the New Deal; the fear of liberalism and progressivism and this is a response to that.
  • Fear of the rise of totalitarianism.

Free political system would yield a free economic system; neoliberalism flipped it: free economics drives free political system.

Reading Notes:

Reimagining Global Health – Chapter 1: A biosocial approach to global health
  • Biosocial analysis: global health is not yet a discipline, but a collection of problems. It requires an interdisciplinary approach. But, there is an opportunity to transform global health into a coherent discipline.
  • Roots of limited health care in poor and marginalized community but be historically deep and geographically broad: a biosocial approach is necessary.
  • Health disparities and the burden of disease:
    • Relationship between GDP and health — domestic and national aggregate and mask local inequities.
  • Collection of disciplines that make up global health create systematic blind spots that prevent us from seeing roots of certain health disparities and problems. That’s why we need a fully biosocial approach to properly build the field of global health.
  • Global health vs international health — an important, and historically rooted distinction. Pathogens do not recognize borders, and international health has a very specific and important set of historical roots, located in the history of colonialism.
Reimagining Global Health – Chapter 2: Unpacking global health – theory and critique
  • “toolkit” of social theories relevant to global health work.
  • Global health often characterized by action — getting stuff done. Most practitioners have little patience for social theory or critical reflection on the work.
  • Historical roots of schism between theory and practice: Marx, racist anthropologists.
  • Social scientists and theorists seek to “interpret the meaning of social action.”
  • Biosocial analysis and the sociology of knowledge:
    • Peter Berger and Thomas Luckman: The Social Construction of Reality:
      • institutionalization: “reciprocal typifications of habitualized action by types of actors” leads to the objectification of that habitualized action as an institution.
      • Assumptions and accidents become historicized into truths, and knowledge is created.
      • One must understand the social organization that permits the definers to do the defining. Must move from he abstract “what?” to the socially concrete, “says who?”
      • All knowledge in society, in order to be legitimated, is socially constructed through a historical / social process.
      • Diagnostic and Statistical Manual of Mental Illness: DSM, a good example of social construction of knowledge in medicine. DSM in 1970s claimed homosexuality was a mental disease. Medicalization of grieving into clinical depression requiring pharmaceutical intervention is an example of medicalization of illness experience.
      • Important to differentiate between: illness, disease, and sickness. Illness is subjective experience, disease is reinterpretation by medical experts, sickness is a pathology at a population level.
    • Robert Merton: Unanticipated consequences of purposive social action:
      • Purposive action involves motives, and therefor, choices amongst alternatives and must also have a goal and a process.
        • Knowledge assymmetry
        • rigidity of habit
        • imperious immediacy of interest
    • Weber: Power and authority
      • Traditional authority
      • Charismatic authority
      • Rational-legal authority —> derived from bureaucracy
      • Weber predicted that institutions / bureaucracies would become the most important structures governing our society.
      • Sometimes though, create ‘iron cage of rationality’ —> difficult to reform or destroy.
    • Foucault: Biopower
      • explains how biological and medical data are used by institutions of the modern world to define, count, and divide, “discipline” populations
    • Social suffering and structural violence:
      • forms of structural violence that constitute inequity
      • what political, economic, and institutional power do to people.
Reimagining Global Health – Chapter 3: Colonial medicine and its legacies
  • Sometimes it seems like the groundswell of global health is “new” — but global pandemics are not new nor are socialized attempts to control them.
  • The modern field of global health has its roots in colonial medicine and “international health”
  • Global health and global empire:
    • Notions of global health certainly informed the desire to build the aqueducts of Rome.
    • No accident that the redefinition of public health and biomedicine as scientific profession coincided with the moment at which European power started to build empires.
    • History of colonial medicine shows that the sites of imperial occupation often served as laboratories for medical strategies later taken up by colonizers
    • History is ripe with examples of colonial projects that harmed the health of colonized people
    • Colonizers interpreted differences in infectious disease mortality as providential signs that “savage” bodies were inferior and weaker compared to Europeans
    • Colonial medicine was not primarily geared towards beneficial action for the colonized, it was primarily a tool to keep white colonizers alive in service of extractive efforts —> links between “global health” and “global security”
      • Led to the widespread (and still used) term “tropical medicine”
      • Used to reify the idea that black bodies were “hardier” in tropical climates and used to rationalize slavery / exploitation / racism.
    • Concern over poor, sick distant lands and local wealthy ones continues to animate our discussions of biosecurity —> see Ebola / SARS.
    • History of tropical medicine, in part, explains why the term “global health” tends to mean health in other places than the US / Europe. Also a source of reification of difference and double standards.
    • The new paradigm of etiology — shifting locus of disease from the “native” to the organism — should have reformed global health, but it did not.
      • The “healthy carrier” became the locus of control — “Typhoid Mary”
      • Tropical Medicine far from removed radicalized language in global health — it enabled it
  • Missionary Medicine
    • linked to spreading Christianity —> for many in colonized nations, this was their sole source of contact with biomedicine.
    • Colonial medicine focused on populations, medical missions focused on individuals
      • reforming individual souls — personal illness, personal hygiene, personal sin.
  • Global health, global commerce, and the foundations of international health bureaucracies
    • Cholera shows how rise of transnational and continental commerce drives the need for new modes of public and global health intervention
      • OIHP: The Office International d’Hygiene Publique, one of the earliest permeant public health bureaucracies, attempted to contain and prevent the spread of cholera
      • John Snow: first to use epidemiological techniques to understand and demonstrate the etiology of cholera
      • Creation of the Panama Canal: caused the development of Pan-American Health Organization (PAHO), which remains an important player in the global health field today.
        • In many ways a demonstration of Max Weber’s prediction that bureaucracies would come to be the most important forms of organization in society.
  • Health, development, and the legacies of colonialism:
    • Political realities of inequality (post-colonialism) post-war (WW1 and WW2) became reorganized around the concept / language of “development” with practices send deeply rooted in colonial history
    • Limited resources drives “socialization for scarcity”
    • By 1948 the WHO was formed and the first World Health Assembly had been convened: cholera in Egypt demonstrated its power as a convening, coordinating, and technical assistance body
      • This set it up for a much more ambitious project: Malaria eradication
        • Focus on vector control rather than microbial control / treatment: socialization drives “either / or debate”
        • People had a strong belief in the power of technological innovation as a driver of human improvement: DDT as a way of killing mosquitos
        • Donor preferences for narrow, top-down strategies for stopping disease.
        • WHO abandoned the program in 1969 — it had failed
        • Ignored the biosocial fact that malaria biology is deeply embedded within the social fabric of farming and other practices.
      • Smallpox Eradication
        • WHO started the program in 1967 as the malaria program was starting to wind down.
        • Was successful because of better management, also because of an easier biology / life cycle in which to intervene
Reimagining Global Health – Chapter 4: Health for all? Competing theories and geopolitics
  • The notion that all people deserve access to health care was gained support in the 1978 international conference in Alma-Ata, Kazakhstan; but it was soon to be eclipsed by neoliberalism: a different kind of idealism that placed its hopes in the market to efficiently deliver services to the poor.
  • This history offers insight into the evolution and action of key global health bureaucracies:
    • WHO
    • United Nations Childrens Fund (UNICEF)
    • International Monetary Fund (IMF)
    • World Bank (WB)
  • Alma-Ata and the primary care movement —> ascendance of structural adjustment —> UNICEF’s selective primary care —> emergence of the WB as key player
  • 1978: Alma-Ata and “health for all by the year 2000″
    • Divergent economic and political ideologies of the Cold War shaped the public health discourse of the 1970s
    • Vertical programs a major focus: attempt at Malaria eradication and smallpox eradication campaigns by WHO: seeking out “magic bullets”
    • Chinese “barefoot doctor” model — example of “horizontal” primary care focus.
    • Halfdan Mahler: forceful leader in global health and one of the cheerleaders of the primary care movement
    • Alma-Ata Declaration:
      • Introduces the idea of “appropriate technology”
      • Critique of “medical elitism”: lambasts top-down delivery
      • Frames health as a mechanism for social and economic development
    • Bold goals failed for several reasons:
      • It did not specify who would pay for these scale-ups and service delivery.
      • Early 1980s brought the sovereign debt crisis that left many poor countries unable to pay and dried up foreign aid.
      • Emergence of an alternative health agenda: selective primary care.
  • Selective Primary Care: an interim agenda
    • Months after Alma-Ata, group of policy makers met in Bellagio, Italy to discuss future.
    • Selective Primary Care became the idea that emerged as an interim strategy
      • High return on each dollar spent
      • Focused on a narrow set of “cost-effective” interventions termed “GOBI”
        • Growth Monitoring
        • Oral rehydration therapy
        • Breastfeeding
        • Immunizations
      • UNICEF + Jim Grant (the director) became one of the biggest champions of SPHC
    • Shifting ideologies in Washington, the WB, began focusing increasingly on market-oriented solutions to health care provision.
  • Rise of neoliberalism:
    • Reagan + Thatcher: deep belief and faith in “free markets”: neoliberalism: Friedrich von Hayek and Milton Freedman
    • Appointed free market purists to head IMF / WB: became known as the “Washington Consensus”
      • “Stabilize, liberalize, privatize”
      • Structural adjustment policies tied to World Bank + IMF loans to low income countries
      • Forced cuts to public spending on social services (health care + education) in order to meet payment schedules and stipulations imposed by WB loans
  • Commodification of Health
    • Diminished role for the public sector in provision of health services led to increase in private sector and “market” oriented solutions.
    • This was a major erosion in the notion of a “state protected right to health”
  • Bamako Initiative: 1987
    • African Ministers of Health embraced WB’s policies for financing and instituted “user fees” to meet funding gaps
    • Poor people had no money to spend on health care services so no reduction in “overconsumption”
    • Did not raise the 15 – 20% of budget revenue they had anticipated.
    • Example of unintended consequences of purposive social action
    • Berger + Luckman: social construction of reality — technical knowledge of finance supplanted other forms of knowledge (social, political, medical, etc)
  • Rise of UNICEF
    • “Child Survival Revolution: Jim Grant as forceful advocate of GOBI-FFF
    • “national immunization days”
    • Critiqued as a narrow cheap interventions services that prevented the growth of stronger delivery systems
    • Arguments of cost effectiveness and efficiency were not challenges again by values of rights, equity, and justice until the rise of HIV and the HIV treatment movement led by ACT UP
  • 1993 WB World Development Report: Investing in Health
    • Codification of “cost effectiveness”
    • Invention and recommendation of the DALY as the means of measuring and deciding what to do in health
  • Redefining the possible: HIV and a social movement for treatment
L. London: What is a human-rights based approach to health and does it matter? (Health and Human Rights Journal)
  • Three aspects:
    • Indivisibility of civil + political rights and socioeconomic rights
    • active agency by those vulnerable to rights violations
    • powerful normative role of rights in establishing accountability and protections
  • Despite incredible technological progress, less than 40% of live births are attended by a skilled practitioner in poor countries.
  • In HIV care and treatment, rights-based approaches challenged public health to think about exclusion and enable integration of rights-based approaches to health.
  • Examples where we have fallen short of the rhetoric:
    • mandatory testing vs. scale up of treatment; continued discrimination of people living with HIV
    • MDR / XDR TB treatment and therapy: the artificial dichotomy of prevention and treatment
    • “This leads logically to the second consideration: without an active civil society, paper commitments to rights mean very little.”
  • Case of informal settlement outside of Cape Town, SA:
    • The case (known as the Grootboom case) made legal precedent in establishing the justiciability of socio-economic rights in the courts and was hailed beyond just the borders of South Africa as advancing popular claims to basic needs that are socio-economic entitlements in human rights law.
      • Despite the case, there has been no major shift in the housing or access to services guaranteed by law, largely because of a large social movement demanding the right to housing.
    • Contrary case: the treatment access movement:
      • The Treatment Access Campaign (TAC) is the most obvious illustration of success.
      • mutual reinforcement of the courts and grassroots political action in advancing and actualizing rights.
      • Amartya Sen:
        • “The implementation of human rights can go well beyond legislation, and a theory of human rights cannot besensibly confined within the juridical model within which it is frequently incarcerated. For example, public recognition and agitation can be part of the obligations … generated by the acknowledgement of human rights.”
  • Opportunity with rights: Defining who is a rights holder, who is a duty bearer, and what the nature of the obligation is, allows a much clearer opportunity to establish accountability (typically of government) for the realization of rights and creates a range of mechanisms to hold governments accountable.
  • Often, rather than acknowledging health as a right, policy-makers frame health policy decisions as service delivery issues, requiring technical inputs to reach the best “evidence-based” decisions, a public health phenomenon gaining increasing popularity worldwide.
    • In doing so, the state is relieved of its burden of progressive realization.
  • Making human rights a shared objective:
    • invoking a human rights framework does not, of itself, inevitably mean a conflictual relationship between civil society and the state.