CHAPTER 11

HISTORICAL BACKGROUND

In his “The Condition of the Working Class in England” (1), published in 1845, Engels described the dangerous working and housing conditions that resulted in illness and disease, and related the incidence of tuberculosis, typhoid and typhus to malnutrition, inadequate housing, contaminated water supplies and overcrowding. Rudolf Virchow, a German physician, was greatly influenced by Engel’s work and when, in 1847, he was requested by the Prussian government to investigate a typhus epidemic, he realised that the origins of ill-health lay in social problems and the priority, therefore, was to change the conditions that permitted them to occur. Virchow, in his recommendations to the Prussian government, did not call for more clinics or hospitals; instead, he recommended economic, political and social changes, such as increased employment, better wages, local autonomy in government, agricultural co-operatives, and a more progressive taxation structure (2). In the following year, Virchow took part in a major working class revolt in Berlin; as direct combat declined, he took to political activism. Virchow wrote that the most important causative factors of disease are the material conditions of people’s everyday lives; for health care systems to be effective, improvements in health care must coincide with fundamental economic, political and social changes. As these changes would threaten the wealth and power of the dominant groups in society, the responsibilities of health workers should include direct political action (3).

Although the development of the germ theory of disease improved medical practice during the late nineteenth century, improvements in the control of disease occurred before the advances in bacteriology could be utilised and were, in fact, the result of the introduction of better sanitation, improved nutrition and better living and working conditions.

The Flexner Report, which was commissioned by the ruling class in the U.S. in the early years of this century, was intended to aid the “streamlining” of medical education in the U.S. The Report alleged, without any evidence, that other medical traditions, e.g. homeopathy, traditional folk healing and chiropractic resulted in the mistreatment of the public. The Report was broadly accepted and scientific laboratory-based medicine became the norm in the field of medicine. Medical schools that did not possess the resources to teach laboratory-based medicine were closed, including six of the eight black medical schools functioning at the time. The two black medical schools that were permitted to continue were the medical school attached to Howard University in Washington, D.C., and Meharry Medical College (part of the Central Tennesse College). This had a devastating effect on the production of black physicians for several decades.

The multifactorial and politically oriented medical model, such ashad been expounded by Virchow, remained in abeyance in Western Europe and the United States until the period of raised political consciousness in the 1960s. However, these principles were utilised by Lenin in the construction of the Soviet health system (4); Salvador Allende in his treatise on the political economy of health care; the Canadian surgeon, Norman Bethune, in his attack on tuberculosis and other diseases during the Chinese Revolution (5); and Che Guevara, in the shaping of the Cuban medical system (6).

CLASS STRUCTURE IN CAPITALIST STATES

Societies in the metropolitan centre (U.S., Western Europe and Japan) and in the dependent Third World periphery are characterized by the presence of highly stratified class structures, the basis of which is the relations of economic production. In the social relations of economic production, one group of people, the capitalist class or bourgeoisie own and/or control the means of production: the machines, factories, land and raw materials which are necessary for the manufacture of a product for the market. The working class (proletariat) sell their labour for a wage. The value of the product that the workers produce is always greater than their wage. ‘Surplus value’ is the difference between the wage paid to workers and the value of the product they create, and is the basis of the capitalist’s profit. It is also the source of ‘exploitation’ and it motivates the capitalist to keep wages low, to change the work process (in ways that keep costs down) and to resist workers’ attempts at organisation.

In the U.S., the corporate class which includes the large owners and controllers of wealth comprises 1% of the population and owns 80% of all corporate stocks and government bonds. In 1975, their median annual income was between $114,000 and $142,000. The working class is composed of manual, service and farm workers; they make up 49% of the population and earn about $8,500 or less a year. Between these two classes are other groups. Professionals, like doctors and lawyers, constitute the upper middle class. They comprise 14% of the population and earn about $25,000 a year. This class includes middle level business executives who earn about $22,700 a year and constitutes 6% of the population. Shopkeepers, the self-employed, craftsmen and artisans (7% of the population) earn about $12,100 a year and constitute the lower middle class. This class includes clerical and sales workers who earn about $9,200 and constitute 23% of the population (7).

The health system mirrors the class structure of the broader society. Members of the corporate and upper classes exert great control in the policy-making bodies of American health institutions(8), viz., the governing bodies of private foundations, private and state medical teaching institutions, and local voluntary hospitals. On the boards of the latter two, there may be slighter greater representation from the lower middle and working classes. In Britain, the control over health institutions reflects the same patterns of class dominance that exist in other areas of economic and political life (9).

HIERARCHIES IN MEDICINE

In the U.S., physicians who constitute 7% of the labour force in the health sector, are members of the upper middle class. Their median net income of $53,900 (in 1975) places them in the upper 5% of the income distribution. The professional administrators share a position, in the highest stratum among health workers, with the physicians. Below these two groups are the nurses, physical and occupational, therapists, and technicians. Mostly women, they make up 29% of the health labour force, are members of the lower middle class and earn about $8,500. At the bottom are the nursing aides, orderlies, clerical staff, catering staff and janitorial personnel. Members of the working class, they constitute 54% of the health labour force, are 84% female and 30% black, and have an income of about $5,700 per year. Racism, sexism, elitism and professionalization operate to maintain and perpetuate institutional hierarchies and also to prevent members of the health labour force from realising common interests.

The factor of racism operates to a greater degree within the hospital labour force in the United Kingdom. At the end of the seventies, about 30% of all National Health Service (NHS) doctors had come from overseas, the great majority from the Indian subcontinent (10). The racial segregation of doctors amongst and within departments and according to pay and tenure of employment has already been dealt with. Similarly, about 12% of all student nurses and pupil midwives were, in the late seventies, from overseas. Of these 66% were from the New Commonwealth (i.e. non-white) (11). Ancillary workers constitute some 30% of the hospital labour force in Britain; some 14% of male and 21% of female ancillary workers were born overseas (12). In one London hospital studied, 78% of all ancillary workers in the hospital came from abroad; a further breakdown revealed that 84% of domestic workers and 82% of catering workers were born overseas (13). There were, therefore, marked regional variations.

Whilst the situation of overseas workers in the NHS is one of subordination, the female worker from overseas is found most consistently in the lowest levels of work in the health labour force. In 1979, as a result of the deepening recession and consequent increasing unemployment, the provision of work permits for ancillary workers from overseas was stopped, and these women have, in the eighties, been replaced by the black British.

THE ROLE OF BLACK WORKERS IN THE RATIONALIZATION OF THE LABOUR PROCESS IN THE BRITISH NATIONAL HEALTH SERVICE

Blacks are widely used in the NHS as a source of cheap labour and to do the unpopular jobs. Use has been made of them in the rationalization of the labour process in the delivery of health care by de-skilling, e.g., the channelling of black nurses into low status, lower paid S.E.N. (State Enrolled Nurse) training instead of the standard S.R.N. (State Registered Nurse) training. The nursing profession has changed dramatically in recent years and the nursing workforce itself has become differentiated, specialised and stratified. Black nurses have played an important part in this rationalization of the labour process by facilitating a division, along racial lines, of the nursing force into white career nurses, on the one hand, and black de-skilied, practical nurses and nursing auxiliaries, on the other hand. These divisions are exacerbated by the staffing of the unpopular specialities of geriatrics, psychiatry and mental subnormality with black nurses.

In the mid-sixties, a Committee was set up by the Ministry of Health in Britain to look into ways of attracting more (white) English women into nursing (14). The result, the Salmon Report, recommended the creation of a professional career structure leading to elite clinical and management positions through the further differentiation of the non-medical aspects of patient care. Non-skilled tasks were to be handed over to the less qualified state enrolled nurses and nursing auxiliaries. These changes intensified the continuing process of deskilling in nursing; furthermore, black nurses were overrepresented in both the state enrolled nurse and nursing auxiliary categories.

Vulnerable because of their material situation, black nurses are relatively compliant. If they have come from abroad, their status in Britain is contingent upon their performance, as assessed by their superiors, being graded as satisfactory. With an increasing number of the aged in the population, there has been a sharp rise in the number of patients suffering from chronic mental and physical disabilities and who need labour intensive care. These are also the least popular fields of nursing.

In the ancillary grades, amongst the lowest paid in Britain, black workers have taken up posts that have remained vacant for want of applicants. In doing so, they have made these jobs even less popular.

As one study put it: “Many potential non-coloured workers are dissuaded from taking up such work since, in their minds, it is associated with a high concentration of coloured staff” (15).

The National Health Service, continues to recruit overseas black doctors, mainly into the unpopular branches of medicine such as geriatrics and psychiatry. As with black nurses, they occupy those posts which British doctors would be unwillingly to accept. In this manner they, unwittingly, help perpetuate the existing divisions within the medical labour force, and maintain the hierarchical and pyramidal career structure. The large number of overseas doctors on the lowest rungs of the medical ladder help to maintain a career structure which narrows greatly at the top and allows only a few, mainly white, doctors to attain permanent elite consultant positions.

When overseas doctors who have worked in Britain return to practise in their own countries, they take with them not only the values of Western medicine which ensure the continuing cultural domination of Western medical science in that country, but also the accompanying demand for the technical infrastructure, thus providing an important market for British drug companies and British medical technical equipment manufacturers. David Ennals, a Labour Secretary of State for the Social Services, noted in 1976: “We have exporting potential which I am doing the best I can to help mobilise. One way of encouraging exports is to train people here, where they will become accustomed to using some of the best products we are making and which can be used abroad” (16), The contradictions in the functions of the NHS - the need to reproduce labour power effectively whilst keeping down the costs, to capital, of that reproduction - explains the continuing need for cheap black and migrant labour in the NHS both historically and at the present time. With the continuing run-down of the NHS, however, and with hospital closures and job losses, workers from overseas suffer more heavily than indigenous workers. The demand for skilled workers, however, is unlikely to be greatly diminished. In Britain, it cost, at the beginning of this decade, over £40,000 to train one doctor. It would be beneficial to this country, therefore, if these costs could be borne by foreign nations.

OCCUPATIONAL MOBILITY

Examinations of the class backgrounds of physicians in both the U.S. and Britain will reveal persistently low representations from the lower middle and working classes amongst medical students and doctors. Since the implementation of the Flexner Report in the U.S., in the second decade of this century, the proportion of medical students, in that country, from working class homes, has remained at a constant 12%. There has been some improvement in this regard, however, in the case of some of the other disadvantaged groups, such as the blacks and women, in recent years; but class mobility into professional positions remains limited.

MONOPOLIZATION AND PRIVATE CORPORATE PROFIT

Monopoly capital, a prominent feature of most capitalist health systems in the advanced capitalist nations, has certain manifestations. Since the implementation of the Flexner Report, medical centres have burgeoned, in the U.S., usually in affiliation with university medical schools. With their emphasis on advanced technology, they have contributed in no small way to the maldistribution of health workers and facilities throughout the country, as medical graduates are reluctant to practise in areas without easy access to high-tec facilities. Capital is highly concentrated in commercial insurance companies, and corporate investment in health maintenance organisations (HMOs) is increasing.

THE ‘MEDICAL-INDUSTRIAL’ COMPLEX

The exploitation of illness for private profit is a primary feature of the health systems in advanced capitalist countries. Strong criticisms have been levelled against the pharmaceutical and medical equipment industries for their advertising and marketing practices, price and patent collusion, marketing practices in the Third World, ‘dumping’, and promotion of expensive innovations without proof of effectiveness. These innovations are linked to the expansion of medicals centres, the penetration of finance capital into the health system, and the promotion of new drugs and equipment by the medical supply industries. Attempts at cost-effectiveness analysis, therefore, should consider the broader political and economic trends that result in irrationalities in the health system.

POWER POLITICS IN HEALTH CARE DELIVERY

The political power of the dominant groups in society is determined by their class position and their economic resources. Their viewpoints and proposals, therefore, reflect their own political and economic interests rather than the honest concern for improving the health service. In this scenario, three interest groups can be defined (17). Firstly, the professional monopolists include physicians, specialists, and research workers in medical schools and universities, mainly, who produce a continuous proliferation of programmes and projects that provide a symbolic screen of legitimacy while maintaining power relationships in the health system. Secondly, the corporate rationalisers hold top positions within health organisations as hospital administrators, medical school deans and public health officials, and go on to complicate and elaborate the bureaucratic structures of the health system. The third interest group is the community population which requires health care facilities and which is affected by the quality and type of the health services provided. This interest group has the least power and its leaders are more often than not co-opted to serve in symbolic positions in the medical bureaucracy. The institutional and class structure creates and sustains the power of the professional monopolists and corporate rationalisers. As such change is unlikely “without the presence of a social and political movement which rejects the legitimacy of the economic and social base of pluralist politics” (18).

STATE INTERVENTION IN HEALTH CARE DELIVERY

The state in Western-style capitalist democracies consists of the coercive institutions of the executive, legislative and judicial branches of the government, the military and the criminal justice system, as well as the non-coercive institutions, such as the educational, public welfare, and health care systems. Although the latter convey ideological messages that legitimate the capitalist system, all these interconnected public institutions act to maintain the capitalist economic system and the interests of the dominant groups of the capitalist class (19).

In regard to the health care delivery system, socialists argue that the private sector, based in private practice and companies that manufacture medical products and control finance capital, drains resources, to the detriment of patients, from the public sector operating through public expenditures and public institutions. As public hospitals face cutbacks or closure, as low income patients find it difficult to obtain adequate health care, and as private hospitals dump low income patients on to public hospitals, the contradiction between the private and the public sector becomes more acute.

The functions of the state with regard to health care are threefold. Firstly, the state functions in a general way to legitimate the capitalist economic system, based in private enterprise, through its support of the private sector. State expenditures usually increase during periods of social protest and decrease as unrest becomes less widespread. Secondly, the state takes a more direct role in protecting and reinforcing the private sector. In those states that operate a national health insurance scheme, continued profits are also assured for the private insurance industry for their role in the book-keeping and administration of the scheme. The corporate sector also profits in the new state sponsored health initiatives, such as the health maintenance organisations (HMOs) in the U.S. (20). A third function of the state is the provision of generous support and funding for research that stimulates the search for the unifactorial rather than the multifactorial origin of disease and which thus obscures important sources of illness and disability in the capitalist work process and industrial enviroment.

By the suppression of alternative health approaches that might be threatening to the system, the state reinforces dominant frameworks in scientific and clinical medicine that are consistent with the capitalist economic system. It has been estimated that, in Western industrialised societies, enviromental factors are involved in the aetiology of approximately 80% of all cancers (21). Such findings are threatening to the organisation of capitalist production, and are subject to indifference and active criticism from the state and its agencies.

Under capitalism, state intervention will be restricted to policies and programmes that will not conflict with capitalist economic processes or the interests of the capitalist class. ‘Negative selection mechanisms’ are forms of intervention that exclude activities that challenge the capitalist system (22). Reforms never reach a level strict enough to interfere with profitability. Similarly, government regulation of the pharmaceutical industry is erratic and rules out public ownership of the industry. ‘Positive selection mechanisms’ promote policies that strengthen the private enterprise system and the interests of capital. The positive selection of reforms like health insurance, for example, is in sharp contrast to the exclusion of structural changes that threaten the broader political and economic aspects of the present system (23).

MEDICAL IDEOLOGY

Ideology refers to the complex of ideas and doctrines that form the perspective of a social group. In his “Contribution to the Critique of Political Economy”(24), Marx put forward a concept of society as functioning on two structural levels. The infrastructure, or the economic base, consists of the concrete relations of economic production. The primary feature of the infrastructure is social class which itself is determined by the ownership or control of the means of production. The superstructure includes the governmental and legal institutions and their dominant’ ideologies. Economic forces determine the events of history and this economic determinancy gives primary importance to class conflicts and the sphere of production in the shaping of historical events.

The infrastructure determines the nature of the superstructure which itself together with its ideology helps reproduce the social relations of production and patterns of domination. The beliefs that support the status quo are promulgated by the ideological hegemony and the ideological apparatuses that the dominant groups use to maintain state power, and by the ideological dimensions of modern science that legitimate decisions which enhance the interests of the capitalist class. Together with the educational system, the mass media and organised religion, medicine promulgates an ideology that maintains patterns of domination and which itself has social ramifications beyond medicine itself (25).

Viewing the human body as a machine with component parts that may become diseased or malfunctioning, modern medical science detracts from the multifactorial origin of disease and the causative factors that lie in an unhealthy environment, conditions of work and social stress. The mechanistic view of the human body supports an ideology that values industrial technology and control by scientists and “experts”. Using a reductionist approach, the unifactorial view of disease focuses, not on the illness-generating conditions of society, but on the individual and his /her lifestyle. This is also known as victim-blaming. The responsibility for disease and cure rests not at the collective level of class structure and the relations of production, but on the individual. Medicine contributes to the rational governance of society by supporting the economic interests of capitalism and by helping industry meet its need for a reliable workforce (26).

HEALTH CARE AND SOCIAL CONTROL

As a radical analysis developed in the sixties, it became clear that the schools, the welfare agencies, the mental health and other social service systems were agencies of social control (27). However, the medical system was criticised more for what it did not do than for what it did. It was criticised for not caring equally for the poor.

Briefly, a capitalist health care system operates to maintain and reinforce capitalist social relations. The medical profession and the public in general consider the medical system as a means of intervening technically in the interest of improved physical fitness. In this system of social relations, sociologists consider ‘sickness’ a social role. (‘Disease’ is a biological state.) Doctors define sick roles and control entry into them. Parsons(28) describes the characteristics of the sick role as follows:

Freidson is concerned that the system of medicine is expanding its jurisdiction to cover areas that were once the province of law or established religion, and is emerging as a vast, expansionist and uncontrolled regulatory apparatus.

The Ehrenreichs(30) recognise two different forms of social control exerted by the medical system, which forms they describe as disciplinary social control and cooptative social control respectively.

Disciplinary Social Control is exerted by the exclusionary sectors of the medical system; these sectors of the medical system present high barriers to entry (e.g. financial or geographic obstacles, or discourteous or inconvenient treatment). Medical services encourage people to maintain their social responsibilities. The company doctor, in the interests of capital, pressures the injured worker to return to work. A certificate of illness is required from a doctor before a worker can register as being too ill to work. In the eighteenth and nineteenth centuries, the dreaded poorhouses and insane asylums in France and Britain were maintained as public spectacles as a warning to those who might be tempted to escape from their social responsibilities by taking on the mantle of pauperism or madness. Similarly, constant publicity surrounding the conditions inside our overcrowded prisons, and long stay psychiatric institutions (and even old people’s homes) discourage entry into these institutions (31).

The Cooptative Type of Social Control is exerted by the expansionary sectors of the medical system. Unlike disciplinary control, cooptative control is exercised on those who enter into the medical system, and it has a significant ideological content. Characterized by low barriers to entry and sympathetic treatment, the expansionary sector of the medical system encourages people to enter into sick roles and also to seek help for a number of other situations not associated with the sick role (e.g. preventive care, contraceptive services, marital difficulties).

In the everyday situation, a given sector of the medical system or even an individual physician may exhibit both exclusionary and expansionary tendencies, with the different forms of social control being exerted differentially on different groups in society.

THE HISTORY OF SOCIAL CONTROL THROUGH MEDICINE

Historically, the experience of the poor was, in the main, with the exclusionary system of medicine. In the late nineteenth century, when the American medical profession was beginning to appear in its present form, the urban, mainly immigrant poor had to be content with a health care delivery system that consisted of a few ghetto dispensaries and a few, even more forbidding, municipal hospitals where nursing care was minimal and standards of hygiene pretty well non-existent. The scant medical system for the poor meant that the diseased went on working; the effect of the system on the poor was that of enforcing industrial discipline. The wealthy, urban upper classes, on the other hand, wallowed in a medical system that was grossly expansionary. There was such an excess of doctors serving the wealthy that, according to the American Medical Association, doctors were obliged to resort to dubious advertising practices in order to drum up business.

Since the turn of the century the medical system has undergone great changes. The enormous overall expansion of the system led to an expansion of the cooptative social control exercised by the medical system. The rise in the class position of the medical profession led to changes in the ideological content of the social control exerted by the medical system. The expansion of the medical system occurred along three parameters. The jurisdiction of the system was expanded to include new services, e.g. family planning, abortions, in-patient obstetrical care, long term care of the aged and disabled, community mental health services, marriage and sex counselling, and cosmetic surgery. There was an expansion in the numbers, varieties and efficacy of previously existing services, e.g. antibiotics for infections and radiotherapy and chemotherapy for cancer. There was an expansion in the availability of medical care, with Medicaid and other programmers in the U.S., and the National Health Service in Britain, putting medical care within the reach of the poor and working class people. These changes in the medical system have led to a profound public dependency on the system, a dependency that extends to all strata in society. The public are enjoined to seek medical help for the most minor symptoms. Medical miracles such as heart transplants and the transplantation of foetal brain tissue, are given wide publicity, and death becomes regarded as a failure of the doctors. The medical system now replaces lay sources of help in the community (relatives, neighbours and clergymen), with doctors themselves increasing the dependency by discrediting lay advice and labelling it as “old wives’ tales”. The political power, organisation, and autonomy of the doctors have enabled them to provide an increased volume of services without an increase in their numbers. Within medical institutions, more and more of the doctors’ tasks are being transferred to administrators, nurses, and technicians as well as to the marginalised group of immigrant doctors without career prospects in West European and U.S. hospitals. Nonetheless, doctors have retained their monopoly over communication with patients; only doctors can reveal to patients the results of X-ray and laboratory tests and the nature of the illness from which the patient is suffering. As a result, doctors have improved their incomes and class position.

As a result of the expansion of medical services, more and more people now come into contact with doctors over more problems than ever before. It would do, therefore, to examine the features of the doctor-patient relationship. Firstly, patients are required to submit to a visual and manual examination of their bodies and to confide in their doctors. The patient may, as a result, develop a psychological dependence on the doctor. Secondly, patients are required to submit to the authority of the doctor and to treatment without too many questions being asked. The authoritarianism in the relation between doctor and patient increases as the social (class) distance between doctor and patient increases. The degree of authoritarianism demonstrated by the doctor is greater when the patient is female, working class or black. The Ehrenreichs say: “A relationship of dominance and dependency, of intimacy and authority, between a person and a member of the upper class can only act to promote acquiescence to a social system built on class- and sex-based inequalities in power” (32).

In this relationship, ideological messages are communicated by doctors. Firstly, these may be messages unrelated to medical matters, e.g. in regard to elections or other public issues. Secondly, these messages may be related to medical matters, but are quite gratuitous. When a black woman complained of weakness and tiredness, for example, she was told by her doctor that “coloured people are always lazy” (33). Thirdly, a message may be concealed as a medical communication, e.g. doctors may ‘advise’ young mothers not to put their small children in day care centres on the grounds (quite unfounded) that the children might catch infectious diseases. The intention is to discourage mothers from working (34).

For too long the radical approach to health has been to ask for “more of the same”, viz., that high quality medical services should be freely available to all, but free of racism or sexism. Radicals have failed to free themselves from the mystification of medicine and failed to question the content of medical care which itself is treated as a ‘commodity’ by the medical system. What is needed is a truly democratic medical system which is sensitive to the needs of, as well as accountable to, the community it serves (35).

MEDICINE AS AN INSTITUTION OF EXCELLENCE

Since medical science includes a body of advanced knowledge, the top professionals here come to hold elite positions; ordinary people become dependent on these expert decision-makers for the application of the benefits of this advanced knowledge. Since the quality of much medical care is poor, the ideology of excellence in medicine has been termed a fraud, viz., ‘the excellence deception’ in medicine (36). Socialist countries, on the other hand, have gone on to develop a ‘people’s medicine’.

HEALTH CARE AND IMPERIALISM

Under imperialism, capital has gone on to expand beyond national boundaries. Whilst this has brought many advantages to the economically dominant nations, the expansion of capitalism has had major social, political and economic repercussions in the dominated countries. Health care has played a major role in the march of imperialism (37). Navarro has shown how much the underdevelopment of health in the Third World has followed on the depletion of natural and human resources under imperialism, when raw materials and human capital have been extracted from Third World nations and exported to the metropolitan countries of Western Europe and North America (38).

Health care systems in Third World countries remain underdeveloped as the result of the extraction of their wealth for foreign benefit. Workers in the Third World who are employed by multinational corporations suffer from a high incidence of occupational disease (39). Under imperialism, multinational corporations exploit the cheap labour of workers in the Third World. Through public health programmes in the Third World(40), sponsored by U.S. philanthropies whose wealth is derived from the profits of imperialism and who in turn support the imperialist exploitation of the Third World, attempts are made to improve the health of the workers of multinational corporations. Through population control programmes, attempts are made to increase the labour supply by recruiting more women into the regular labour force (41).

Under imperialism, new markets are created in the Third World for products manufactured in the metropolitan centres. The monopolistic character of the pharmaceutical and medical supply industries has hindered the development of local technology in Third World countries; a few of these countries have reacted, however, and gone on to design their own pharmaceutical formularies. With Western cultural penetration reinforced by imperialism, doctors in Third World countries ally themselves with the capitalist class of their own countries, and support links with the national bourgeoisie of the metropolitan centres. Doctors in Third World countries tend to come from upper-middle class, higher-income families and view medicine as an economically and socially secure profession and a means of upward mobility. They therefore, tend to resist social or political change that would threaten existing socio-economic structures either in their own countries or in the outside world. Medicine contributes to the reinforcing of international class relations (42). In recent years, health workers have assumed roles in direct support of imperialist military wars in Indochina and North Africa (43). In Latin America and Asia, counter-insurgency and intelligence operations have been mounted from health centres and hospitals (44).

HEALTH AND THE WORLD CAPITALIST ORDER

For many years, much of the morbidity and mortality in the Third World, especially that related to parasitic and infectious diseases, was classed as problems in ‘tropical medicine’ by Western health experts. This medical ideology laid the blame for the poor state of health of the inhabitants of these lands on climate and geography (45), and on the biology of the natives which made them ‘lazy’ and ‘shiftless’ (46). The usefulness of ideology to the established order was that it detracted from the conditions of poverty and disease that resulted from the exploitation, social and political destabilization, and ecological devastation that followed on colonialism and the scramble, for possessions, by the Western Powers in Africa and Asia. Instead, this ideology permitted the misery, and suffering, in these occupied lands, to be viewed as somehow ‘natural’ to tropical climes. Similar levels of parasitic and infectious disease are present in underdeveloped communities in northern climes, e.g. the Eskimos and Laplanders (47).

Other authors have demonstrated, quite convincingly, the relationship between poverty, suffering and disease, on the one hand, and underdevelopment, on the other. Underdevelopment of the Third World is the reciprocal of development of the capitalist world. Underdevelopment is not a passive process and does not occur as though by default; it is an active process in which the core nations (or metropolitan centres) in the capitalist world-system exploit the peripheral and semi-peripheral nations and expropriate their wealth. National and international health problems, including public health problems, problems of the development and use of health resources and problems of medical ideological hegemony, are not discrete problems but are all intimately related to the evolving structure and functioning of the capitalist political-economic world system (48).

Marx wrote that “the veiled slavery of wage-workers in Europe needed, for its pedestal, slavery pure and simple, in the New World” (49). He saw that capitalism, and its exploitation, were, from their beginnings, a world-system. Being amongst the first of the European societies to develop a strong central state, Portugal was able to graduate from primitive capital accumulation (profit) (from trade and plunder), to the expropriation of surplus (profit) from her vast plantations and mines, worked by slaves, in the New World. The advantages, which Portugal initially possessed, passed, over the course of centuries, to the Low Countries, then to England, the U.S., and finally to Japan and Western Europe (European Economic Community).

Frank(50) defines, according to the mode of production and social formation, stages in world capitalist accumulation, as follows:

The world-system defines relationships, including health relationships, on a world scale as well as between nations. Agents of the world system affecting health relationships include international health agencies, foundations, bilateral aid programmes, multinational corporations and the medical cultural hegemony that supports these health relationships, and the agents mediating them, between nations. The multinational corporations that especially affect heath are the pharmaceutical firms, medical technology producers, food suppliers, industrial firms that pollute and exploit the enviroment, agribusinesses, commercial baby food suppliers, firms that sell chemical fertilizers and pesticides, and the sellers of population control devices.

Multinational corporations, sometimes backed up by political forces, armed forces or undercover agencies, e.g., in the case of Chile under Allende, extend the business of core nations. The phenomenon of cultural hegemony, by which a ruling class imposes its whole world view on workers and peasants, is best described by Genovese(52), a pupil of Antonio Gramsci, as follows:

“One concept of reality is diffused throughout society in all its institutional and private manifestations, informing with its spirit all taste, morality, customs, religious and political principles, and all social relations, particularly in their intellectual and moral connotations .......................It follows that hegemony depends on much more than the unconsciousness of such interests on the part of the submerged classes. The success of a ruling class in establishing its hegemony depends entirely on its ability to convince the lower classes that its interests are those of society at large that it defends the common sensibility and stands for a natural and proper social order”.

The media, in capitalist democracies, are potent agents of mind and thought control. Although there can be plenty of argument and discussion, certain basic assumptions must be upheld. All arguments are taken up, but within certain bounds. Thus it is that the U.S. has the right to make assertions about human rights anywhere in the World. Thus the media ignore the actual historical record of the U.S. which is one of aggression in Vietnam and in Grenada, and of support and training of police forces in Latin America to torture and violate the humans rights of prisoners and suspects.

Against this hegemony, struggle the forces of resistance with their alternate conceptions of ideas and events. Multinational corporations and the ruling classes of the metropolitan centres, (the U.S., Western Europe and Japan) manipulate national governments and officials, and carry the cultural hegemony of the core nations into the semi-peripheral and peripheral nations. The cooperation of the client elites (comprador bourgeoisie or lumpenbourgeoisie) is thereby gained whilst the working classes in the urban enclaves and the peasants in the rural hinterland are repressed (53). In the ‘neospeak’ and ‘doublespeak’ of Western capitalism, the ‘Free World’ comprises those countries where free investment and free trade favour the accumulation of surplus (profit) by the comprador bourgeoisie in the dependent countries and the bourgeoisie in the core nations (metropolitan centres). In the peripheral country, where rich natural resources exist, poverty is the lot of the majority of the population and a large reserve army of the unemployed is kept in check by a Western-supported repressive regime.

INEQUALITIES ASSOCIATED WITH CAPITALISM

The inequalities that exist under the capitalist world-system are increasing as a result of the continuing exploitation and the transfer of capital and resources from the periphery to the centre of the system. Describing the control of economic life in Latin America, Navarro says (54):

“The top 298 U.S.-based global corporations earn 40 per cent of their entire net profit overseas, with their rate of profit from abroad being much higher than their domestic rate. Actually this rate of profit for these global corporations is even higher in the underdeveloped world, resulting in huge net outflows of capital from these countries back to the U.S. American corporations, for example, made direct investments in the Latin American continent of U.S.$ 3.8 billion during the period 1950-1965, whilst extracting $11.3 billion, for a net flow of $7.5 billion back to the U.S.”

When describing the standard of living in capitalist countries both in the periphery and at the centre of the capitalist world-system, the average figures usually quoted say nothing of the current crisis of capitalism and do not reveal the growing inequalities within countries. During the so-called economic miracle in Brazil, the richer got richer and the poor got poorer, with the majority of Brazilians facing an actual decline in real wages, raging inflation and high unemployment (55). The President of Brazil, Geisel, was reported to have said: “Brazil is doing fine but the people are not” (56). In predominantly agricultural countries, gross inequalities in the distribution of land exist. In the Dominican Republic, for example, food production is hampered by semi-feudal land tenure. In 1971, less than 1 per cent of farmers owned 47.5 per cent of the land, while 82 per cent of the farmers farmed fewer than 10 acres (57).

THE UNDERDEVELOPMENT OF HEALTH IN THE CAPITALIST WORLD-SYSTEM

The problems in the health sector are interwoven with each other and with the world-system. They bear directly on (a) health levels and (b) health resources and conceptions (58).

HEALTH LEVELS

GENERAL HEALTH LEVELS

There is a strong negative correlation between infant mortality and overall resources of nations as measured by gross national product per person. Socialist China in 1972 had an infant mortality rate of 55 per 1000 whilst India, a peripheral capitalist unit, had an infant mortality rate of 139. Similarly, Kerala, a socialist-oriented state within India and with a more egalitarian distribution and control of its overall resources, had a low infant mortality rate (59). In Brazil, a peripheral capitalist unit, during the so-called economic miracle, when the real income of the masses actually fell, the infant mortality rate rose to become one of the highest in Latin America. Whilst cocktail party conversations in Rio focus on the latest advances, in plastic surgery, thousands of town shack dwellers eke out a living by scavenging junk, and, in Sao Paulo, 600,000 homeless children roam the streets and feed themselves by begging.

INDUCED MALNUTRITION

The buying up of fertile farming land by multinational corporations for single crop production and export to the world market has serious repercussions for the local population. There is less land available for the production of food staples with consequent shortages and price rises. Dispossessed small farmers are obliged to become wage earners at less than subsistence levels, food is imported from the U.S. and dependency is thus created. By promoting the use of non-indigenous hybrid seeds, fertilisers and pesticides, the dominance of international capital over local agricultural production is emphasized. Bourgeois scientific bodies define the problems of food production and of agriculture, according to their own cultural hegemonies and thus add to the creation of dependency.

In what became the baby bottle scandal of the baby bottle syndrome, certain multinational corporations, and Nestle in particular, promoted, in the Third World, artificial baby food formulas, as being superior to mother’s milk, with serious consequences for infants in certain countries. There are many serious disadvantages associated with these baby food products. The formula is expensive with the result that, not only do the other members of the family go hungry, but the mother is tempted to dilute the food formula, which, after all, continues to look white. The family’s living conditions, viz., the absence of refrigeration and of piped clean water, do not facilitate the safe and satisfactory preparation of the baby’s formula feeds. The baby may thus die from a sheer lack of adequate calories in his feeds or from the absence of antibodies, to the common pathogens, that are transmitted in mother’s milk. The mother is denied the not insignificant contraceptive benefits of breast-feeding. These benefits are of especial value in areas where rapid population growth can cause problems.

Although the multinational corporations have had the support of the cultural hegemonic and value laden arguments of U.S.A.I.D. (U.S. Agency for International Development), viz., that (imported) supplemental feeds are necessary when mother’s milk is not flowing freely, ordinary concerned citizens in Third World countries have fought back with worldwide boycotts (e.g. against Nestle’s products) and the recruiting of official support for these boycotts and against commerciogenic malnutrition (60).

PHARMACEUTICALS

Problems here relate to production, marketing and tax dodging. Production of drugs by multinational corporations in underdeveloped countries may be geared towards the world market, while local needs go unmet. Lower standards operate for the production of drugs for use in underdeveloped countries, so much so that their potency is unpredictable. Elling gives an example of tax dodging by a multinational pharmaceutica1 company (61): “..............it is said that a U.S.-owned pharmaceutical manufacturer in pre-Allende Chile shipped its product on paper to its own subsidiary in a tax haven in the Bahamas for 50 cents a unit; this subsidiary then shipped the drug back at 10 times the price, i.e. for $5.00, without having to pay taxes on the difference of $4.50; then the Chile-based firm sold the drug for $7.50 and paid tax only on the profit of $2.50 minus expenses, which were liberally calculated. In the meantime, the transport and handling costs were very low, since the drug had never left the plant in Chile”.

Problems are also associated with the marketing of Pharmaceuticals in Third World countries(62). These relate to inappropriate marketing, the sale of prescription drugs to untrained persons, and the sale of drugs without warnings as to side-effects or contraindications. Expensive versions or inordinately large quantities of drugs are sold. Dangerous, banned and time-expired drugs are often dumped onto underdeveloped countries. The advertised indications for the use of a drug in Third World countries often far exceed the advertised indications in the core countries. For example, Ovulen, which is recommended only for use as a contraceptive in the U.S., is additionally recommended, in some Latin American, countries, for use in regulating menstrual cycles, in premenstrual tension, and for menopausal problems. Even in the core countries, drugs are advertised to encourage the belief that “every quirk in the human spirit and every vague ailment can be smoothed out chemically” (63).

In the underdeveloped countries, a deep dependence is created for the products of the multinational corporations. Furthermore, the prices of the simplest drugs are higher than in the metropolitan centres and really useful drugs become unobtainable. The government of the People’s Republic of China has got round these problems by emphasizing the local manufacture of traditional as well as modern drugs (64).

DUMPING OF DANGEROUS PRODUCTS

In the early seventies, the fire resistant chemical TRIS was added to children’s pyjamas. In 1971, the U.S. Consumer Product Safety Commission banned the sale of garments containing this chemical on the grounds that it was carcinogenic. The manufacturers recalled the garments, then exported them to the Third World. Similarly, dangerous infants’ pacifiers and high tar cigarettes have been dumped onto Third World countries.

POPULATION CONTROL

There has been a historical shift in the ideological hegemony of the population economists in the capitalist core nations from the Malthusian social-evolutionary view that populations may grow faster than the increase in available food supplies to the mid-twentieth century view that the free world is in danger of a ‘population explosion’ (65). The socialist People’s Republic of China has demonstrated, however, that a planned economy based upon common ownership of the means of production, distribution and exchange can provide food and services in sufficient quantities whilst simultaneously abolishing unemployment and starvation.

In the new division of labour(66) that is emerging in the neo-imperialist base of the capitalist world system, high technology production is retained within the the core nations of the metropolitan centres whilst other productions are displaced to certain underdeveloped countries where a large army of the unemployed will perform high risk production tasks for starvation wages. Workers of different nations are played off against each other. Marginal groups amongst the populations of Third World peripheral states and native, aboriginal peoples in developed countries become victims of a policy of complete neglect. When marginal groups of a population are found to be sitting on land rich in oil, minerals or other exploitable resources, exterminaion and genocide follow.

In other instances, sterilization campaigns and population control programmes are effected, as happened during Indira Gandhi’s ‘emergency’in India (67). In Colombia, 40,000 women were sterilized, between 1963 and 1965, in Rockefeller-funded programmes having been coaxed by gifts of lipstick, artificial pearls, small payments of money and false promises of free medical care (68).

Under the guise of ‘population planning', equipment and drugs, banned or restricted in the U.S., because they were deemed unsafe, have been dumped onto Third World countries (69). With the complicity of the U.S. Agency for International Development (USAID), thousands of Dalkon shields (intrauterine devices) were exported to underdeveloped countries in the early seventies. Representatives of the U.S. government justified this action on the grounds that mothers in underdeveloped countries were at a much greater risk of dying at childbirth than mothers in the U.S. When, in 1973, the U.S. Food and Drug Administration advised physicians not to prescribe the high dose (80 microgram) oestrogen birth control pill, U.S.A.I.D.bought up, cheaply, large quantities of these high dose pills and distributed themin Bangladesh and other Third world countries. Senior USAID officials even suggesteda catchy slogan for rural pill promotion:
“It makes your breasts more beautiful and is good for everyone - including the tailorswho have to make bigger brassieres.”

Swollen breasts are a side effect of the high dose contraceptive pill.Depo-Provera is a dangerous long-acting, injectable contraceptive. Possible sideeffects are nodules in the breasts; it may also cause cancer in the reproductive tractsof test animals. After Depo-Provera was banned in the U.S. in 1978, themanufacturers (Upjohn) and USAID directed large quantities to Mexico throughthe Planned Parenthood Federation.The head of USAID’s Office of Population Dr Ray Ravenholt, is reported to havesaid:

“Population explosions, unless stopped, would lead to revolutions...(Population controlis required to maintain) the normal operation of U.S. commercial interests around theworld. Without our trying to help these countries with their economic and socialdevelopment, the world would rebel against the strong U.S. commercial pressure.The self-interest thing is the compelling element” (70).

It would appear that the role of international health, aid and population agenciesis one of laundering the programmes and projects, of imperialist countries, in theThird World in order that they might appear benign and acceptable.

EXPERIMENTATION ON HUMANS

As a result of rising levels of general awareness, medical researchers, in the U.S. at least, will no longer be able to use in clinical trials certain vulnerable sections of the U.S. population, viz., prisoners, the mentally handicapped, armed forces personnel, the young and the poor (71). It is unlikely that there will be a repetition of the infamous ‘Tuskeegee Trials’, in which poor black men were recruited, under false pretences, to go through the whole clinical course of syphilis, without treatment, for the purpose of studying the natural history of the disease.

Extrapolating from the operations of the capitalist world-system in other areas of health and medicine, it is likely that experimentation on humans will be exported from the metropolitan centres to the dependent peripheral countries whose populations are more vulnerable. Military sponsored research has been carried out in Bangladesh. After being banned in the U.S. in 1978, Depo-Provera was still being utilised in research projects, using large numbers of human subjects, in Mexico, Sri Lanka and Bangladesh, in much the same manner in which nuclear devices were tested on the lands of vulnerable local peoples (72).

HAZARDOUS INDUSTRY

There are serious international public health problems associated with the export of hazardous industry to the peripheral countries and the establishment of such industry in these countries. With an OSHA (Occupational Safety and Health Administration) ban on the working of asbestos in the U.S.(73), asbestos mined in Canada is exported to unregulating peripheral countries to be worked into finished products which are then shipped to the U.S. for final use. Similarly, pesticides banned in the U.S. are exported to peripheral and semi-peripheral countries. The position was summed up by a WHO official thus:
“The multinationals simply go into the less developed countries, give a banned pesticide a local name and then turn around and sell it all over the world under that new name. It is a real Mafia-type operation” (74).

Worn and dangerous capital equipment in core countries is refurbished and exported to subsidiaries in peripheral and semi-peripheral countries, without the ongoing transfer of knowledge on the control of hazards associated with such equipment and industry. Although the dangers of working with asbestos were known in Britain in 1924, with new regulations and changes in working conditions soon being effected in that country, British-owned companies in South Africa continued to run their asbestos mines with African labour and without health and safety precautions (75).

CULTURAL HEGEMONY IN MEDICINE AND PUBLIC HEALTH

The cultural hegemony in medicine works to maintain the dominance of the medical profession vis-a-vis the consumer and the public in general. The terms ‘consumer’, 'consumer movement’, and ‘consumer representation’ tend to put the idea abroad that the users of medical and health services have some control, at least, over the nature and quantity of services made available to them. They tend to give the receipients of services the illusion of power whilst actually maintaining them in a subordinate position.

The providers of services, viz., the medical profession, are surrounded and protected by a professional mystique which permits them to sell their knowledge in the medical market-place within the monopoly capitalist system. The ownership of medical technology is legitimated by the media, controlled by the upper classes, through the imagery of medicine promoted in the newspapers and on radio and television. Knowledge is not regarded as the property of the people; it is regarded as the proper preserve of the experts. Furthermore, as a result of the concentration of ownership of the media, certain subjects that threaten the status quo are kept out of the media (76).

THE BRAIN DRAIN

In the exchange between the centre of the world capitalist system and the periphery, dangerous drugs and industrial chemicals, e.g. pesticides, flow from the core to the periphery, and profits flow from the periphery to the multinationals based in the core. In the ‘brain drain’, expensive and scarce health woman- and manpower flows from the periphery towards the core. The outcome of this is that, in the periphery, inadequacies in the health services and in social structures are further exacerbated, whilst, in the core countries, the cheap supply of already trained health personnel permits inadequate systems to limp along without fundamental or structural change (77). Young doctors in the peripheral countries are influenced by the Western medical cultural hegemony and its ideas of ‘the good life’, and, especially, of ‘the good medical life’, in the metropolitan centres.

One method by which Western hegemonic values penetrate through to the periphery is the system of medical adoption programmes, sponsored by the large multinational corporations and U.S. foundations. In such a programme, medical lecturers from a Western medical school, seconded for a pre-determined period of time, to a Third World medical school, end up teaching inappropriate high-tec medicine to undergraduates who then go on to graduate into circumstances where most of their time and effort will be expended in helping the local population cope with hunger and the lack of basic public health conditions.

Advertising, as in the case of baby bottle-feeding and the sale of drugs, also aids the penetration of Western hegemonic values. Furthermore, the lumpenbourgeoisie (comprador bourgeoisie) and elites in peripheral countries demand Western hightec, curative medicine which they see on their visits to the metropolis and which they are pressured to accept by representatives of the pharmaceutical companies and the medical supply industries. These hegemonic values are perpetuated by Western-trained and -oriented medical representatives in the regional offices of the World Health Organisation.

IRRELEVANT MEDICAL HIGH TECHNOLOGY

The desires of the elites and the employees of multinationals in the Third World for Western high-tec medicine, at the cost of depriving the poor of these countries of adequate medical care, are encouraged by the high pressure salesmanship of Western medical equipment supply corporations such as American Medical International (AMI). AMI boasts of building, equipping and, if need be, running private hospitals the world over.

Dr Hafdan Mahler, the former Director-General of the World Health Organisation, had this to say in 1974 (78):

“The challenge is immense if the World Health Organisation’s definition of health is taken seriously; this definition considers health to be something different from the absence of disease and infirmity, and speaks instead of a state of physical, mental and social well-being. What is more, the definition considers health to be a right for everybody without discrimination. All this, though solemnly accepted by the member states of the World Health Organisation, may seem like a bad joke when set against the realities of the health scene today. On the one hand, we have the persistence in tens of millions of people of such diseases as cholera, malaria and onchocerciasis. On the other hand we have the gigantic modern machinery geared to the treatment of a whole range of diseases up to the point of obfuscating the distinction between life and death... Countries further down the developmental scale are busy imitating this kind of perversion. In a developing country, which constitutionally declares health a universal human right, you find in one province 80 per cent of the [national] health budget being used to support one teaching hospital, whereas in outlying parts complete coverage is supposed to be achieved by one general purpose dispensary for half a million people “The general picture in the world is that of an incredibly expensive health industry catering not for the promotion of health, but for the unlimited application of disease technology to a certain ungenerous proportion of potential beneficiaries and, perhaps, not doing that too well either”.

However, in countries that are somewhat independent of the capitalist world-system, like China and Cuba, the health care delivery systems are geared to solving the basic health problems of their peoples, not to profit from the sale of technology (79).

MEDICAL IMPERIALISM

The world views of a medical cultural hegemony, supporting Western imperialism have, in the past, aided in the annexation of whole lands (with their peoples), helped maintain the kinds of stability needed for the super-exploitation of colonised lands and cooperated in the social control of the nationalist elements amongst the subjugated populations. A certain kind of medical cultural hegemony is associated with a particular hegemonous and expansive political-economic system; it aids not only in maintaining that system but also functions, when and where necessary, as an active arm of that system (80).

A continuing dominance over the practice of medicine in underdeveloped countries is still exerted by Western medical cultural hegemonies in concert with Western philanthropic foundations and Third World elites (the lumpenbourgeoisie). This is illustrated, for instance, by the manner in which Western hospital-based curative medicine was exported to Thailand’s capital city. Furthermore, in India, a peripheral unit of the capitalist world-order, the divisions between traditional and modern forms of medicine continue to be maintained, whereas in socialist China the two systems have been merged (under the theme ‘China walks on two legs’) in order that valuable elements from each of the two systems of medicine might be recruited for the benefit of the people (81). Meanwhile, the ruling elites in dependent Third World countries may even fly to the metropolitan centres for the private medical treatment that is readily available in the urban enclaves of their own countries.

In its search for profitable markets for drugs, medical equipment, service industries, financial services and health centre and hospital construction, capital is aided by organised medicine. From its beginnings, scientific medicine has functioned in the service of imperialism in the following ways (Paul (82) ):

American doctors travel with soldiers and businessmen to a large number of underdeveloped countries. Although American medical aid has had some successes in these countries, the toll of casualties from American military support and interventions worldwide is as follows:

-    Six million dead and ten million refugees, at the minimum, in Indo-China;
-    Among civilians in South Vietnam alone, war claimed 1.5 million casualties, including half a million dead, 40,000 amputees, 20,000 brain injured, 30,000 blind and 10,000 paraplegics;
-    One million Indonesians were massacred in an anti-Communist crusade in 1965;
-    Tens of thousands have been killed, tortured, mutilated and jailed in campaigns in Guatemala and Chile (83).

In Third World countries, the diversion of resources towards one crop farming for export and the operations of American agribusinesses have resulted in famines in Africa and Asia. Also in Southeast Asia, the heroin traffic sponsored by the CIA pacification programme had devastating consequences (84).

MEDICAL DIPLOMATS

Many European government foreign service departments used doctors as diplomatic agents. Accepting these diplomatic assignments, the doctors used their medical role as the perfect cover. Working their way into the confidences of the ruling families of the different target countries, the doctors earned the gratitude of powerful rulers through acts of healing and curing. Taking advantage of this, they were able to arrange favourable commercial deals, obtain profitable concessions, pass on intelligence and, when needed, sow discord. It was for purposes such as these that the French Foreign Service successfully placed French physicians at the Moroccan Court. French interests in the country were protected until well after formal independence (85). An American Public Health Service doctor, Dr Kevin Cahill, who served as physician to government leaders in West Africa in the 1960s, related that he influenced policy during the periods of recurring coups and transmitted confidential information between American and African officials (86).

MEDICAL SPIES

Their class background and their privileged medical education imbues Western physicians with a belief in the benevolence of Western civilization in general and in Western medical science in particular. These medical- ideological attitudes makes doctors not only good advocates of Western ideologies but also good diplomats, propagandists and even spies.

British doctors from the Presbyterian missionary societies had become active in Morocco by about 1880. They were soon followed by the secular medical ‘missionaries’ from France and Germany. Doctors from all three West European countries gained access to, and sowed discontent among, the local tribes, gathered strategic military information, carried out political and social research, and prepared maps in anticipation of a colonial war. In other words, doctors were used as spies and propagandists amongst the native and indigenous peoples.

The United States Government has put medicine to similar uses. Captain Leonard Friedman(87), a staff psychiatrist in the Surgeon’s Section, Special Warfare Centre at Fort Bragg, North Carolina, argued in support of the importance of medicine as an instrument of national policy in Vietnam. He wrote:

“Experience has shown that American medicine has consistently been one of the most successful instruments to use in stability operations”, and went on to quote, as examples, the role of American doctors in support of U.S. foreign military adventures and counterinsurgency in Northern Mexico in the 1880s, Cuba in 1902, the Philippines in 1902 and 1921, Nicaragua in 1927 and Japan in 1946. Friedman argued that the commitment of American public health teams to Vietnam and “the training of medical sub-professional personnel can lead to further acceptance of Western ideas and ideals".

Writing in a later issue of ‘Military Medicine’(88), Colonel Spurgeon Neel who had previously served as Surgeon of the U.S. Military Assistance Command, Vietnam, had this to say:

“Stability operations have become a third principal mission of the United States Army. Variously known as ‘military operations in low intensity warfare’, ‘show of force’, ‘counterinsurgency’, or ‘civic action and nation-building’, these activities now command an equal priority with readiness for limited and general war missions...........Most emerging nations share the fundamental problem of a significant degree of medical deprivation.............. The shifting emphasis to the prevention of insurgency provides an arena wherein the Army Medical Service contribution to the attainment of this objective will be most manifest. Medical stability operations concentrate on the pre-insurgency phase of operations in order to produce maximum results with minimum resource investment........ in those countries where revolution is inevitable despite the best stabilizing efforts, [the potential of medicine to transcend distrust] offers a continuing, essentially apolitical avenue through which favourable influence may be maintained”.

In American-occupied South Vietnam, the U.S. Army Medical Service was, according to Spurgeon Neel, actively engaged in stability operations of both the counterinsurgency and limited war types. The Medical Civil Assistance Programme (MEDCAP) of the U.S. Army Medical Service in Vietnam had as one of their objectives the maintenance of the favourable image of the Central Government of Vietnam and of the United States in the minds of the general population. MEDCAP was closely integrated with the programmes of the U.S. Agency for International Development (USAID) and U.S. voluntary and non-governmental agencies providing health assistance in South Vietnam. U.S. military hospitals admitted selected Vietnamese civilians for ‘high impact’ surgical procedures during which Vietnamese children with serious defects, deformities and functional impairments were admitted for corrective surgery.

As a result of these operations, American surgeons were given the opportunity to practise and improve their surgical skills whilst, at the same time, American prestige was given a boost from the psychological impact on the inhabitants of the Vietnam villages to which the restored children were returned. Congressman Hugh Carey suggested in 1971 that U.S. overseas health programmes should be expanded as medical counterinsurgency successes in Vietnam and Latin America had demonstrated the value of medicine as a weapon of American foreign policy in an increasingly hostile world (89).

MEDICAL PROPAGANDA

Doctors have contributed to imperialist expansionist propanganda by endorsing calls for foreign, including medical, assistance. For example, prior to the colonial takeover of Morocco, European physicians made great play of the supposedly bad health conditions in the country. Their medical arguments help to form mass opinion in favour of colonial rule. So much so that when a medical spy, Dr Emile Mauchamp, was murdered in Marakesh, the French government used the incident as the excuse for intervening militarily, and imposing colonial rule. Colonial officials regarded physicians as apostles of colonialism who enobled the entire colonial enterprise and the doctors themselves boasted of their kindly deeds and their inspiration of native gratitude (90).

Medical propaganda was used to counter criticisms of the American war in Vietnam and to justify imperialism. The ‘New York Times’ medical editor, Dr Howard A. Rusk, wrote(91), in 1966, that “the national supply of physicians is being increased by about 150 graduates each year from the University of Saigon. Its school of medicine has new buildings provided by the United States, which is also strengthening the instructional programme..............South Vietnam’s medical services for its civilian population would be almost non-existent if it were not for the support provided by the United States and a few other free world countries ..........“When General Humphreys arrived in Vietnam [in 1965], most health facilities were in a deplorable state of repair. They were without power, water or waste-disposal systems. These situations are gradually being remedied... Vietnam has a long way to go before its complex problems are solved, but it has also gone a long way in moving toward their solution during the last year.”

In 1967, a distinguished team of American physicians, headed by the executive vice-president of American Medical Association, Dr F J L Blasingame, was requested by President Johnson to investigate Vietnamese health conditions (92). They attempted to play down the high incidence of burns amongst the civilian population from napalm bombing. The team wrote to President Johnson as follows:

“Prior to leaving the United States, the team was aware of the exceptional public interest in the number and type of civilian burns cases in Vietnam. Throughout our visit, individual team members paid particular attention to burns. The cases were relatively limited in number in relation to other injuries and illnesses, and we saw no justification for the undue emphasis which had been placed by the press upon civilian burns caused by napalm. A greater number of burns appeared to be caused by the careless use of gasoline in stoves which were not intended for gasoline. Probably most burns occurred from this source.”

The U.S. government continued to mask its war plans with a humanitarian and medical cover.

HEALTH AS AN INSTRUMENT OF FOREIGN POLICY

Herbert M. Singer, the chairman of the board of the World Health Foundation, was quoted by Congressman Jerome R. Waldie in the U.S. House of Representatives in 1968 (93). Singer had suggested that U.S. support of health programmes in foreign countries had assumed an increased importance because of its new potential as an instrument of foreign policy. He felt that foreign aid must find its justification in the self-interest of the aiding nation. In the past, U.S. support of health programmes had been founded on self-interest motivations such as:

Mr Singer felt that developing countries are, by their very nature, subject to powerful forces for public disaffection towards their governments. The programmes that are intended to counter these forces of disaffection are, he felt, slow in maturing, and are even slower in trickling down to the disaffected masses. Programmes for developing an economy, education programmes and programmes for improved housing are not geared, thought Singer, to produce an immediately effective impact on the disaffected masses. It was here that health and health programmes could play a profound role as a ready counter weapon to combat the forces of disaffection and as a generator of loyalty of the people to their government. Health programmes could purchase the necessary time for other programmes, slow moving in public benefits, to make themselves effective for the disadvantaged and the disaffected.

Singer wrote that health programmes were probably the least demanding upon the resources of the country for the impact achieved in terms of loyalty to government. Health and health programmes had a unique capacity to touch the lives of individuals and families and to do so more acutely and more dramatically than perhaps any other service of government. A health programme functioning on a personal level, would, if properly organised engender a warmth of appreciation and loyalty to the government from the receipient and his family. The feeling of personal and family security arising from such a government health programme could well earn for the government such goodwill as to convert a large segment of a community from unfriendliness and antagonism. Any disruption of the government which would threaten the continuity of a vital personalized health programme would be a matter of profound concern to the beneficiaries and potential beneficiaries of such a programme, Singer declared.

MEDICAL EXPERIMENTATION