CHAPTER 7

NEOCOLONIALISM, IMPERIALISM, UNDERDEVELOPMENT and HEALTH

INTRODUCTION

From the earliest times, human society has organised itself around the relations of the economy. Writing in the nineteenth century, Karl Marx defined certain stages in the historical development of European societies. After the initial stage of the ‘hunters and gatherers’, society was organised on an egalitarian basis. This was the stage of communalism. There was common ownership of land and property and the benefits from the labour of the people were shared out equally. In time, and following the domination of some groups by others, slavery came into existence. Slaves were the personal property of their masters. Initially, the main function of the slaves was to produce food, although some performed other tasks for their masters.

In the next stage, feudalism, the ownership of land became concentrated in the hands of a few, who derived their power from this. The workers on the land, the serfs, were tied to the land, as agriculture remained the principal mode of production. The serfs kept enough of the products of their labour for their own basic needs and the rest (the ‘surplus’) went to the landlord. With the onset of capitalism, industry became the principal mode of production. Ownership of the means of production, again, was concentrated in the hands of a few, the bourgeoisie, who themselves had originated in the class of merchants and craftsmen, but who now became the new industrialists and financiers.

Following on the system of enclosures (i.e. exclusion) in land tenure, peasants and serfs became landless and took to the new burgeoning industrial centres to become the new industrial proletariat. They now sold their labour for wages which hardly covered the cost of their basic needs. The remainder of the true price of their labour was expropriated by the owners of the factories and the mines as the ‘surplus value’. The owners made large profits out of the labour of the workers, and the chief contradiction in capitalism is between the workers and the bosses. In the last stage, socialism, the principle of economic equality would be restored as in communalism. There would be common ownership of the means of production, distribution and exchange.

EXPLOITATION AND THE DEVELOPMENT OF UNDERDEVELOPMENT

It is a widely held misconception that today’s underdeveloped countries are at a historical stage in their development which the developed countries have long since passed. The fact of the matter is that the countries that are currently described as being developed were never underdeveloped, though at some stage in their history they were undeveloped. The underdeveloped status of the countries of the Third World is the historical product of past and still continuing economic and other relations between the ‘satel1ite’ underdeveloped countries (the periphery) and the now developed metropolitan countries (the centre). These relations, between the centre and the periphery, are an essential part of the structure and development of the capitalist system on a world scale.

An erroneous view is that the development of these underdeveloped countries can only be stimulated by the diffusion, of capital and capitalist values, to them from the international and national capitalist metropolitan centres (1). A historical analysis suggests that a break with underdevelopment in Third World countries can only be achieved independently of the exploitative economic and other relations with the metropolitan capitalist centres. As Walter Rodney wrote: “All of the countries named as ‘underdeveloped’ in the world are exploited by others; and the underdevelopment with which the world is now pre-occupied is the product of capitalist, imperialist, and colonialist exploitation. African and Asian societies were developing independently until they were taken over directly or indirectly by the capitalist powers. When that happened exploitation increased, and the export of surplus ensued, depriving these societies of the benefit of their natural resources and labour. That is an integral part of underdevelopment in the contemporary sense” (2).

WESTERN CAPITALIST DEVELOPMENT

The following stages in Western capitalist development (concurrent with underdevelopment in the countries of Africa, Asia and Latin America) can be distinguished (3):

It is necessary to distinguish between colonialisation (where colonies were exploited -‘exploitation colonies’), and colonisation (where colonies were settled by white populations from the metropolitan centres ‘settlement colonies’). In the ‘exploitation colonies’ under colonialisation, the mode of production, low wage levels and unequal exchange, led to the development of underdeve1opment and a position of subordination and dependence within the world capitalist order. In the ‘settlement colonies’, on the other hand, protection against, and benefit from, unequal exchange, high wage levels and a differing mode of production permitted economic development. The two different types of colonies were intended to serve two different purposes in the world capitalist system. As far as Britain was concerned, settlement colonies and imperialism abroad were necessary, in the words of arch-imperialist Cecil Rhodes, to export Britain’s surplus population and thus ensure social peace at home. But the exploitation colonies were obliged to yield their human and natural resources for the benefit of ‘civilization’, i.e. for profit.

The mercantilist stage of world capital accumulation lasted nearly three centuries. There was, during this period, a marked increase in European mercantile activity and of colonial production for export, which was exploited by European metropolitan capitalist interests. Further, as the ‘Cambridge Economic History of Europe’ states, “.....the technological advantages of the sixteenth century Europeans, combined with their adventurous outlook, would go far to explain why they secured immediate dominance. But the long term subservience to the markets of Europe in which the colonial economies (of the North American states and the Caribbean sugar islands) were maintained, was the result not only of economic conditions, but also of the military power, exercised by the white races at the moment of impact and during the period of consolidation” (4).

With the development of the world capitalist system and the establishment of the colonial relationship with Latin America, the southern states of the North American continent and the Caribbean, which were dependent on imported slave labour as the principal productive power in their plantation economies, and, where needed, in their mines, large parts of Africa, from the Guinea coast to the Congo, were brought into the world capitalist order, and were an integral part of the historical process of the development of the world capitalist order. Africa’s enforced contribution was the export of its healthy young men and women.

Africa’s population loss was highly relevant to the question of its socio-economic development (5).African economic activity was affected both directly and indirectly by population loss. Not only was there a loss of economic units, but the reduced population found it increasingly difficult to tame and harness nature. Furthermore, the social violence between different African communities induced by the slave trade and which took the form of raiding and kidnapping resulted in a great deal of fear, uncertainty and insecurity. On the Gold Coast, slave raiding made it unsafe to mine and to travel with the gold; besides, kidnapping for slaves was more profitable.

The orientation of large areas of the continent towards the slave trade meant that other positive interactions were ruled out. Agriculture, in particular, was severely affected as conditions became unsettled and labour was drawn off. The slave trade had a ‘multiplier effect’ on European development, that is to say, the benefits extended to many areas of European life and equipped society for its own development. In Africa, on the other hand, there resulted disruption and disintegration. The African economy was diverted from its previous line of development and became dependent on external forces based in Western Europe. The majority of the goods imported into Africa from Western Europe were worthless consumer goods, cheap gin, gunpowder, beads and cooking utensils full of holes (6).

A study of the most ultra-underdeveloped regions in Asia and Africa, regions characterized by exceptional poverty, will reveal that they are all regions in which an earlier period of primary products (including mining) production for export was followed by pauperization after their soils, mines or market were exhausted by colonial and class exploitation in the course of world capitalist development. Examples of these former economically active areas are the mining regions of Central Africa, the cotton-export Nile valley, Bengal, Bihar and the plantation states of Southern India, Madras and Kerala. Those parts of the Indian sub-continent which experienced the longest period of contact with Britain are also those parts which are now the poorest, viz., Bengal, Bihar and the former Madras Presidency.

COLONIAL EXPLOITATION

The part played by colonial exploitation in the process of world capital accumulation and its concentration in the European metropolitan centres is described by Mandel: “It can be stated, unhesitatingly, that the contribution made by this stolen capital was decisive for the accumulation of the commercial and money capital which, between 1500 and 1750 created the conditions which proved propitious for the industrial revolution.......It can be concluded without exaggeration that, for the period 1760-1780, the profits from India and the West Indies alone more than doubled the accumulation money available for rising industry in Britain” (7).

Williams has said that “by 1750 there was hardly a trading or a manufacturing town in England which was not in some way connected with the triangular (slave) or direct colonial trade........ The profits obtained provided one of the main streams of that accumulation of capital in England which financed the Industrial Revolution.......The development of the triangular trade and of shipping and shipbuilding led to the growth of the great seaport towns. Bristol, Liverpool and Glasgow occupied, as seaports and trading centres, the position in the age of trade that Manchester, Birmingham and Sheffield occupied later in the age of industry. It was the slave and sugar trades which made Bristol the second city of England for the first three-quarters of the eighteenth century............

“When Bristol was outstripped in the slave trade by Liverpool, it turned its attention from the triangular trade to the direct sugar trade. Fewer Bristol ships sailed to Africa, more went direct to the Caribbean......The growth of Manchester was intimately associated with the growth of Liverpool, its outlet to the sea and the world market. The capital accumulated by Liverpool from the slave trade poured into the hinterland to fertilize the energies of Manchester; Manchester’s goods for Africa were taken to the coast in the Liverpool slave vessels. Lancashire’s foreign market meant chiefly the West Indian plantations and Africa...........It was this tremendous dependence on the triangular trade that made Manchester” (8).

With the loss of the American colonies, after the American War of Independence, the displacement of the French after the Peace Treaty of 1763 and the British victory over the Indians at the Battle of Plcrssey in 1757, the attention of the British was turned from the New World to the Old World and Asia. In the second half of the eighteenth century, the capital contribution of the East Indian trade increased quantitatively and qualitatively. “Very soon after (the Battle of) Plassey, the Bengal Plunder began to arrive in London, and the effect appears to have been instantaneous, for all authorities agree that the ‘industrial revolution’, the event that has divided the nineteenth century from all antecedent time, began with the year 1760........At once, in 1759, the bank (of England) issued £10 and £5 notes (for the first time) (9).

During the second (and third) stages of world capital accumulation and capitalist development, there was a great expansion of world trade with important changes in the international division of labour. There were far-reaching changes in the modes of production in both the metropolitan centres and in Asia, Africa and Latin America. World market prices were determined by the metropolitan centres in Europe and the U.S.and this resulted in the undervaluing of the exports of the colonial primary goods producers and the overvaluing of the metropolitan manufactured exports. The end result was an unequal exchange based on equal values.

At the end of the eighteenth century, Britain was not producing sufficient manufactured goods to cope with the increasing trade with Latin America for its raw materials. Britain got around this by re-exporting Indian Oriental textiles to Latin America and also to Africa where they paid for slaves used to increase raw material production in the Americas. India was, at this time, a major manufacturing nation. Following its own industrial development and, later, pre-eminence over France and Spain, Britain was able to de-industrialise India in the first half of the nineteenth century and transform it into an importer of manufactures and then an exporter of raw materials. The growth of the British textile industry, at the expense of the Indian one, permitted the development of the iron, steel and machinery industries in Britain.

THE COLONIALISATION OF INDIA

Frank(10) describes the rapid domination and transformation of India following the British victory (through treachery) over the Indians at the Battle of Plassey in 1757, which victory paved the way for the physical occupation of the sub-continent and led to the development of underdevelopment in. India. Following the destruction of Indian industry, the socio-economic connections between manufacturing and agriculture were disrupted and the social fabric of the nation destroyed. The population of Dacca (the Manchester of the sub-continent) fell from 150,000 to 30,000 between 1815 and 1840, "and the jungle and malaria fast encroached upon the town”.

The ‘free traders’ of the British East India Company and their allies in the British metropolitan heartland, who ruled India at this time, destroyed the Indian textile, iron and steel industries by imposing duties on Indian imports into Britain that were “five to twenty times higher than the duties they permitted in the name of free trade - on imports from Britain into India, and they ended by destroying Indian industry physically where necessary”. The ‘zamindari’ system, whereby the zamindars administered local districts and collected revenue on behalf of the Moghul Emperor, was corrupted into one of tax collectors for the development of British capitalism, as was the system of ‘ryotwaris’ or smallholders in Bengal.

The introduction of a profuse system of tax collecting and money lending disrupted the social structure in the villages and transformed it into one dependent on capitalism. Southern India was converted into a plantation economy where the production of raw cotton, tea, rice and wheat for export increased at the expense of the production of basic foodstuffs for local consumption and contributed to the frequent terrible famines when one and a half million people died during 1800-50 (11) and fifteen million people died between 1875 and 1900 (12).

In the third stage of world capital accumulation and capitalist development, i.e. imperialism, (in its colonial form), the development of underdevelopment in India was strengthened. The railways were built linking the hinterland to the ports to facilitate the carriage of primary products for export to the metropolis, and of metropolitan manufactured goods in the reverse direction. The population of the sub-continent was obliged to pay for all the costs of the British colonial administration. According to Jawaharlal Nehru(13) : “The techniques of British rule, which had already been well established, were now clarified and confirmed, and deliberately acted upon. Essentially these were: the creation and protection of vested interests bound up with British rule; and a policy of balancing and counterpoising different elements, and the encouragement of fissiparous tendencies and divisions amongst them. The princes and the big landlords were the basic vested interests thus created and encouraged. But a new class, even more tied up with British rule, grew in importance. This consisted of the Indian members of the services, usually in subordinate positions”.

Nehru wrote on: “Indians so employed were so dependent on the British administration and rule that they could be relied upon and treated as agents of that rule.........Nearly all our major problems today have grown up during British rule and as a direct result of British policy: the princes; the minority problem; various vested interests, foreign and Indian; the lack of industry and the neglect of agriculture; the extreme backwardness in the social services; and, above all, the tragic poverty of the people...........A significant fact which stands out is that those parts of India which have been longest under British rule are the poorest today. Indeed, some kind of chart might be drawn up to indicate the close connection between length of British rule and progressive growth of poverty...........there can be no doubt that the poorest parts of India are Bengal, Bihar, Orissa and parts of Madras Presidency; the mass level and standards of living are highest in Punjab (which was colonised last)”.

Describing India as the most classic case history of the development of underdevelopment, Frank(14) wrote that, “India exemplified all of the major structural factors in the capitalist development of underdevelopment that we also encountered in Latin America and elsewhere: the development of an export economy with an excessively unequal distribution of income, the drain of economic surplus to the metropolis, the transformation of the national and local economic and class structure as a function of world capitalist development and metropolitan developmental needs, the natural alliance between the metropolitan colonial power and local reactionary interests, and their underdevelopment policy, the close connection between the length and intensity of capitalist colonialisation and ultra-underdevelopment, which we have observed regionally in the New World and domestically in India, and which further examination of Asia will demonstrate internationally there as well”.

THE COLONIALISATION OF SOUTH EASTASIA

Under colonialism, societal structures in South East Asia were disrupted. Trade relations with the area’s largest trading partner, China, were replaced by unequal capitalist trade relations with the European metropolitan centres, Britain, France and the Netherlands. Buchanan(15) wrote: Most disastrous of all, the impact of capitalism created a new class - the colonial middle class; this was largely administrative and commercial in its functions and actively collaborated with the colonial power in the government and the economic exploitation of the dependent territory......... .. it was little interested in economic progress but was largely a parasitic group”. Capitalism and capitalistic relations penetrated into the very heart of village life not only in the Asian colonies, but also throughout Africa and Latin America.

Although China was not colonialised in the formal sense of the word, it was penetrated to some extent, especially in the south, by the forces of world capitalist development, and could not avoid the development of underdevelopment, as evidenced by the presence of a collaborating Chinese comprador class, the opium trade, the treaty ports and courts, special privileges and favoured nation status to foreigners and the open door policy.

The only country in Asia, Africa and Latin America together, which did not suffer the development of underdevelopment, was Japan. Seeing at close quarters the underdevelopment that was enveloping parts of China, the Japanese ruling class rejected foreign investment and undertook capitalist development on its own. Already engaged in inter-imperialist rivalry at the end of the nineteenth century, the great North Atlantic imperialist powers desisted from taking on Japan (16).

THIRD WORLD ELITES. LUMPENBOURGEOISIE.

There has been a revived interest of late in the phenomenon of the elite, due to a large extent, to the increasing attention given to the problem of socio-economic underdevelopment in the Third World. The elite here play a crucial role in the changes that are taking place throughout society. As it is the political elite that is dominant under civilian rule and still wields considerable power under a military government, we shall concern ourselves with the groups that wield political power.

THE ELITES IN THE DUTCH EAST INDIES

Kerstiens(17) described the administrative system that operated in the East Indies under the Dutch indirect system of colonial governemnt. (According to Kerstiens, in the indirect system of government only the top echelons of power were held by officers from the metropolis. In the direct system, all posts were held by recruits from the metropolis.)

In the Netherlands East Indies, the administrative build-up was as follows:

During the Second World War, the Netherlands East Indies was overrun by the Japanese, who held it for three and a half years. This was an important period for the developmentof the Indonesian political elite. During this period, the Japanese:

POLITICAL ELITES IN THE GOLD COAST - GHANA

Kerstiens wrote that in Ghana(18), just before independence, there was also, in addition to the political elite coming up through the political parties, a functional elite consisting of civil servants, professional people and well-to-do merchants who helped in the transition of the country from the colony of the Gold Coast to the independent Ghana without too many changes in the socio-economic and cultural life of the country. This functional elite never manifested itself on the political plane.

In the Gold Coast, it was the chiefs who, until independence, had generally been loyal to official government policy and, consequently, came increasingly into opposition with the new Western-educated elite. Again, in Ghana, the political elite formed a relatively small group which had come forward from a lower middle class background and had received a Western-style education; again, most of its members held university degrees or had been at university.

And so we see that the new elite in the ex-colonial countries at the beginning of independence was the political elite which itself was the outcome of the social changes that had taken place during the colonial era. With the growth of the cities, the development of trade and commerce with the metropolis which, as we saw, led to the development of underdevelopment in the colonies, the growth of the liberal professions and of administration, there developed a new group, the middle class, which supplied the recruits to the political elite.

Western in orientation and nationalist in sentiment, the new political elite installed, after the granting of independence, governments based on a parliamentary democratic system, and turned against the old indigenous aristocratic elite which held great power during the colonial period. This new Western-educated elite was, however, menaced by a newer group, which was composed of the leaders of mass movements and were, themselves, headed by charismatic national heroes such as Soekarno and Nkrumah. The mass leader was in closer contact with the people and was neither so highly educated, nor was he so Western in outlook. The mass based leaders, were revolutionary in outlook and came out strongly against the European elite, European economic power and Western hegemony. They were suspicious of international aid and took non-alignment as their doctrine. In many ways, they differed from the post-independence Western-educated political elite who, although they had a vested interest in breaking the European elite’s political strength, were, nonetheless, still willing to let it hold on to considerable economic power and, in fact, imitated its lifestyle and many of its cultural values. This struggle for power in many Third World countries between the Western-educated elites and the leaders of mass movements takes place against the background of international relations and competing philosophies.

In any case, the elite in the non-socialist Third World country considers itself a privileged class which owes it to itself to demonstrate its power and influence in society through a high standard of living, large residences, big limousines and membership of exclusive clubs, as well as ties with the metropolitan centre. This is often combined with nepotism, a disdain for those less fortunate than themselves and corruption. Because of its dependence on the national bourgeoisie of the metropolitan centre, Frank terms this Third World elite the ‘lumpenbourgeoisie’ (19), in preference to words and phrases like ‘dominant class’, ‘oligarchy’, or ‘middle class’.

Frank(20) quotes from the United Nations’ Economic Council for Latin America thus: “In general, it may be assumed that external support (from the metropoles) must tend to strengthen those groups whose sources of power are assuming greater strategic importance; but it should not be forgotten that external pressure cannot be controlled and may make certain activities strategic merely by giving them support.........(It is important to note) how much support specific groups receive from abroad, a factor which has always had some influence, and is becoming even more important with the increasing degree of dependence on the external (metropolitan) sector.......If the behaviour, unity or disunity of the upper classes has always depended on circumstances, this is truer than ever today.....

“......It is not surprising that it is the most traditional sectors of the upper classes which insist on strengthening the ideologies in defence of the status quo; these ideologies enable them to maintain a pact which could not be broken without harming their interests.......the middle classes........improved their social status by coining to terms with the oligarchy.........So long as the lower strata supported and at the same became integrated in the system they were welcome, but the concessions stopped there. It must be admitted that middle class governments sometimes gave their trade unions more than they could have obtained for themselves, but it is impossible to disregard the fact that those same middle class governments were also responsible for the most violent repression of the lower strata”.

The dependence of the neo-colonial Third World bourgeoisie on the metropolitan centres have led them to break with their old alliances with workers’ representatives, to support policies that further the unequal distribution of wealth, and to become the junior partner of the imperialists and thus perpetuate dependence and underdevelopment. Economic dependence ensures that the lumpenbourgeoisie policy of underdevelopment will exacerbate the economic, social and political problems in the Third World and result in lumpendevelopment. This is because the cause of lumpendevelopment lies in the system of world capital accumulation and capitalist development; the remedy lies in the revolutionary destruction of bourgeois capitalism and its replacement by socialist full development. The immediate tactical enemy of national liberation in the Third World is the bourgeoisie itself, in spite of the fact that, strategically, the principal enemy is imperialism.
To quote from Dos Santos(21): “In reality, we can understand what is happening in the underdeveloped countries only when we see that they develop within the framework of a process of dependent production and reproduction. This system is a dependent one because it reproduces a productive system whose development is limited by those world capitalist relations which necessarily lead to:

OTHER THEORIES OF UNDERDEVELOPMENT

Bourgeois sociologists and economists, have attempted to portray underdevelopment, as a failure to assimilate more advanced models of production and to modernize. These bourgeois attempts have been described as “ideology disguised as science”. Other attempts which analyse the international economy in terms of relations between units in free competition do no more than justify the inequalities of the world economic system and conceal the relations of exploitation on which it is based.

In his “The Stages of Economic Growth” (23), Rostow declared: “It is possible to identify all societies, in their economic dimensions, as lying within five categories:

“We now come to the great watershed in the life of modern societies: the third stage in this sequence, the take-off. The take-off is the interval when the old blocks and resistances to steady growth are finally overcome. The forces making for economic progress, which yielded limited bursts and enclaves of modern activity, expand and come to dominate society. Growth becomes its normal condition. Compound interest becomes built, as it were, into its habits and institutional structure”.

According to Rostow, the third stage, the stage of take-off, was the critical stage in the evolution of a traditional society towards full socio-economic development.

Having described the stages of evolutionary change, Rostow went on to define the agents of change. The first agent of change was the DIFFUSION OF VALUES from the developed societies of the metropolitan centres to the under developed societies, initially to their national capitals, then their provincial capitals and, finally, to the rural hinterlands.

The second agent of change was the DIFFUSION OF CAPITAL. Rostow and the bourgeois sociologists and economists expounded the view that the underdeveloped countries are poor because they lack capital. They believed that it was essential for the development of the poor countries that the rich developed countries should diffuse capital to the underdeveloped countries to stimulate economic development. Foreign capital would create a market entrepreneurial economy in an enclave in the underdeveloped country which would function not unlike that in the developed metropolitan centre and which would evolve first in the underdeveloped country’s national capital and then spread to its provincial capitals and, finally, to the hinterland.

The bourgeois sociologists concluded that there are dual economies in the underdeveloped countries: one, the enclave, which is the urban, developed market economy, enjoying, the benefit of the diffusion of both values and capital; and, the other, the marginal economy in the rural areas which have the majority of the nation’s population. The bourgeois sociologists and economists, therefore, explain the poverty and underdevelopment of the underdeveloped countries as being entirely due to their lack of progressive values and of capital; an example of ‘blaming the victim’.

Navarro(24) states that these Western bourgeois concepts (inappropriate in regard to the Third World) are also reflected in the health services’ literature. In keeping with the concept of ‘cultural diffusion’, emphasis is placed on the need to train different types of personnel in underdeveloped countries in the curriculum and medical priorities prevalent in the developed countries. The theory of the ‘scarcity of capital in the Third World’ is extended to mean that poor countries cannot afford to provide health to the whole population, only to the industrial urban based sector, mainly. Investment capital is needed elsewhere to produce the economic conditions necessary for progress to the take-off stage of socio-economic development. The third Western bourgeois concept of the ‘dual economies’ is reflected in the unequal distribution of health resources between the urban and rural areas, with Western, hospital-based, curative medicine in the cities and indigenous as well as inadequate and intermittent Western-type health care in the rural hinterlands. This dualism in health care has come about allegedly, as a result of the lack of diffusion of Western, developed medicine to the rural areas, as well as the lack of investment capital in those areas.

A CRITIQUE OF THE BOURGEOIS THEORIES

Navarro(25), Baran(26), Griffin(27) and Frank(28) have shown the Rostowian model to be invalid and inadequate to explain underdevelopment. With regard to the supposed lack of diffusion of cultural values, there is, in fact, a dominance of Western cultural values in developing societies. The press and television in Third World countries are influenced by Western values to a very great degree. Furthermore, cultural diffusion also operates through institutional education, when it is realised that the system of primary, secondary and university education is patterned after that of the former colonial power or, in the case of Latin America and Thailand, that of the United States. These individualistic, entrepreneurial and urban orientated values are instilled, when a spirit of co-operativeness is more appropriate in a rural and agricultural enviroment (29).

In the field of medical education, a hospital based, high-tech, individual, acute episodic type of medical care, with an emphasis on individual organ pathology, is expounded almost to the exclusion of preventive medicine, community health programmes and the study of the enviromental and socio-economic causes of ill-health. Far from there being an absence of the diffusion of cultural values from the metropoles to the periphery, there is, what was described by Candau, a one-time Director-General of the World Health Organisation, a situation of Western ‘cultural imperialism’. Further, there is technological diffusion resulting in high-tech care in the Third World, which is inappropriate and harmful in these situations for many reasons. The capital intensive technology contributes to the creation of unemployment; it diverts much needed resources from less prestigious but nevertheless more important services and, finally, provides the type of care that is really not needed (30).

As for the argument that there is a lack of capital in the countries of the ‘Third World’ and that there is a need for developed countries to pour in more capital investment, it has been shown that, far from this being the case, there are adequate resources in the underdeveloped countries, the sad fact being that these are misused. Fucaraccio states in relation to Latin America: “(a) a large part of the income is concentrated in a minority of the population......which generates the savings subsequently converted into capital goods; and (b) at least 50 per cent of the population not only do not have the ability to save but lack sufficient income even to satisfy their most basic needs which are estimated at about $ 190 per annum per capita......

“......the construction sector accounts for between 40 and 50 per cent of gross domestic investment, depending on the year and the country concerned. A considerable part of such construction represents residential units which do little to solve the low-income housing shortage in Latin America and in no way helps to increase productive capacity. The remainder comprises construction related to productive capacity and to public works. Equipment accounts for between 50 and 60 per cent of investment, of which half is for transportation and the remainder for machinery and spare parts” (31).

Navarro(32) argues that “the emergence of the highly controlled economy in the international.....economic spheres has resulted in strong links between domestic and foreign capital and this has constituted a relationship that has meant an external decapitalization”. He then goes on to quote the Foreign Ministers of Latin America who indicated in 1969 that:

“...........and now means, that the sums taken out of Latin American countries are several times higher than the amounts invested. Our potential capital is being reduced. The profits on investment grow and multiply, not in our countries, but abroad. So-called aid, with all the well-known restrictions attached to it, means markets and further development for the developed countries, but it does not compensate for the sums which leave Latin America as payment for external indebtedness or as profits produced by direct private investment. In a word, we know that Latin America gives more than it receives”.

Frank in describing how, contrary to what Rostow wrote, the diffusion of capital is, in reality, from the underdeveloped to the developed countries wrote : “..............available statistics show exactly the same pattern of net capital flow from the underdeveloped countries to the developed ones. The only trouble with these data is that they very much understate the actual flow of capital from the poor underdeveloped countries to the rich developed ones. First of all, they understate the capital flow from poor to rich on investment account. Secondly, they obscure the fact that the largest part of capital which the developed countries own in the underdeveloped ones was never sent from the former to the latter at all but was, on the contrary, acquired by the developed countries in the now underdeveloped ones” (33).

HUMAN HEALTH RESOURCES

It has been shown that the pattern of health services in the underdeveloped countries of the capitalist periphery is hospital based: high-tech, specialised, curative medicine which, besides benefiting the donor country’s balance of payments, caters to the wants of the lumpenbourgeoisie rather than to the needs of the majority of the population. Navarro(34) has shown how the pattern of diffusion and flow of human resources from Latin America to North America represents a savings for the North American economy. For example, the inflow of 5736 physicians from the underdeveloped countries, in 1971, was equivalent to the yearly output from fully half of the 120 U.S. medical schools. The figure quoted represents only those who were permanent U.S. residents. When all categories of physicians are included, then the annual inflow of foreign physicians who entered the United States in 1970, 1971, and 1972 was far greater than the number the country produced in each one of those years. Of all the foreign physicians who became permanent residents in the U.S. during the decade 1960-1970, 35 per cent came from Latin America, representing an annual direct and indirect savings during that period of approximately $400 million, which is much more than the annual aid in medical care and hospitals that went from the U.S. to Latin America in the same period, estimated to be $20 million.

Similarly, other figures quoted by Navarro show that the annual loss for the whole of Latin America due to the flow of physicians to the United States is $200 million, a figure which is equal to Chile’s education budget for 1970, or to the total medical aid given by the United States to Latin America throughout the decade of the 1960s. This decapitalization of human health resources is particularly disastrous in the Dominican Republic where “one-half of that nation’s newborn children die before reaching the age of five, and from which country 30 per cent of medical school graduates emigrate to the U.S. each year”.

From what has been said so far about the genesis of underdevelopment, it will be seen that the cause of underdevelopment is the control of the economy by a small lumpenbourgeoisie dependent on international capital, with formal and informal ties to the national bourgeoisie of the metropoles of the capitalist centre, and with a marked affinity for the values, tastes and forms of consumption typical in the developed countries. The lumpenbourgeoisie establishes, determines and moulds a pattern of production and consumption that is inimical to the overall development of the underdeveloped societies of the capitalist periphery. Stimulated by the value systems of the Western consumer society, which divert capital from potential investment, the lumpenbourgeoisie and the middle class of the capitalist periphery which, themselves, often make up less than a fifth of the population, then induce the majority of the population to aspire to ‘more’, where ‘more’ is always unattainable. Furthermore, as Frank(35) demonstrated, the regions that are most underdeveloped and that, today, seem the most feudal “.......are the ones which had the closest ties with the metropolis in the past. They are the regions which were the greatest exporters of primary products to, and the biggest’ sources of capital for, the world metropolis, and were abandoned by the metropolis when, for one reason or another, business fell off......these regions, like Bengal in India, once provided the life blood of mercantile and industrial capitalist development in the metropolis. These regions’ participation in the development of the world capitalist system gave them, already in their golden age, the typical structure of underdevelopment of a capitalist export economy. When the market for their sugar or the wealth of their mines disappeared and the metropolis abandoned them to to their own devices, the already existing economic, political and social structure of these regions prohibited autonomous generation of economic development and left them no alternative but to turn in upon themselves and to degenerate into the ultra-underdevelopment we find there today.........This hypothesis also contradicts the generally held thesis that the source of a region’s underdevelopment is its isolation and its pre-capitalist institutions”.

PATTERNS OF HEALTH CARE CONSUMPTION

Not only is there an imbalance in the production of human health resources (36) in underdeveloped countries, but there is also an imbalance in the type of health care delivered. We have seen how the medical curriculum borrowed from the developed countries exacerbates the maldistribution of human health resources by replicating the curative hospital-oriented medicine prevalent in developed societies. There is, furthermore, within the hospital sector, an inappropriate distribution of medical specialities that is very similar to that which obtains in the metropoles. There is often an oversupply of surgeons and an undersupply of paediatricians and public health doctors in situations where there is a high infant mortality, nearly half the population is under 15 years of age and the high overall mortality and morbidity is mainly the result of enviromental and nutritional causes.

Such a state of affairs is dictated by the wants of those who control the health care delivery system (the lumpenbourgeoisie) and who desire for themselves the same type and standards of care that are available to the national bourgeoisie of the developed countries of the metropolitan centre, with the consequent economic and social dependency. In fact in a central capitalist country such as the U.S., the patterns of production and consumption of health care, like that in an underdeveloped peripheral capitalist country, does not benefit the majority of the population either. The decapitalization of human health resources, in underdeveloped countries, by the emigration of doctors does not necessarily benefit the majority of the population of the developed metropolis, since most immigrant doctors, in the U.S. at least, tend to congregate in the overserviced areas of the country.

The health resources of an underdeveloped peripheral capitalist country are controlled by the lumpenbourgeoisie. As this group is based in the city, which is the enclave, in the poor country, of the foreign dominated and oriented economy in the world capitalist system, most of the health resources are also situated in the city. Whilst economic production, viz., agriculture and mining, occurs in the rural areas, consumption of services occurs in the cities.

Navarro(37) states that “the lumpenbourgeoisie influences the distribution of resources by:

Bourgeois theories of economic development (e.g. the enclave theory) are utilized to explain away inequalities in the distribution of health resources in the underdeveloped countries where the lumpenproletariat in the urban areas and the peasantry in the rural areas, who, together, constitute the overwhelming majority of the population, are catered for by a grossly inadequately financed public medical sector, whilst the urban-based lumpenbourgeoisie and middle classes are serviced by private and insured health care.

Putting the case for bourgeois economists, who believe that, in the process of development, the underdeveloped country, slowly imbibing the values of, and capital from, the developed countries, moves forward to achieve the features of the developed countries, Roemer(38) had this to say:

“............the economic development of a country depends on industrialization. Even the improvement of agriculture depends largely on the production of farm machinery, transport, fertilizer and other items requiring industrial processes. Thus, it is reasonable for a developing country to give priority in health resource allocation to its industrial workers. A skilled industrial worker represents a social investment; that is, the attainment of the skill ordinarily requires long training and experience.......Thus it seems to me that in countries of all types - industrialized and developing, capitalist and socialist the social insurance (i.e. health insurance) mechanism is virtually an inevitable stage in the political and economic process of attaining effective distribution of personal health services to a total population.

“In the course of this evolution, there may well be temporary inequities, favouring certain social groups as compared with others, but this is in the very nature of, social progress. It is realistically not a great price to pay for the advantages of stability, planning, the achievement of a higher priority for health, and all the advantages of the social insurance (health insurance) approach.......

In reality, and contrary to the opinions of the bourgeois economists in the metropolitan centres of Western Europe and the United States, the low level industry in the urban enclaves of underdeveloped countries, which is geared to the production of luxury and consumer goods for the local lumpenbourgeoisle and middle classes and to the production of super-profits for the Western-based transnational corporations, is hardly the motor and driving force for the nation’s economy. It is not only static, but, more than that, it diverts capital from true development projects. It is worth noting that, in the historical development of the present capitalist metropolitan centres, industrialization did not precede, but, instead, followed the structural changes, mainly in agriculture, that led to internal needs that called for industrialization. The main obstacle to industrialization and development, in Latin America, for example, is the system of land ownership and the absence of genuine land reform which would lead to internal demands that could sustain the process of development (39).

The distribution of health resources in an underdeveloped and subordinate peripheral capitalist country then reflects the priorities ordered in the economy generally by the country’s lumpenbourgeoisie. The only section of the proletariat who benefited from a ‘comprehensive’ health care programme was that privileged segment which sustained the industries and services of the consumer-oriented lumpenbourgeoisie and their profit-oriented foreign counterparts.

THE ALMA ATA DECLARATION - 1978

Tha Alma Ata Declaration followed a World Health Organisation (WHO) sponsored International Conference on Primary Health Care in 1978 (40). This conference was held against a background of increasing absolute poverty and exploitation world wide, with a lack of personal health services, enviromental health services, clean water supplies and sanitation for a great proportion of the world’s population.

The Western development and aid agencies’ response to increasingly vocal and critical protests from individuals in the underdeveloped countries was predictable, and an extension of the arguments and theories offered by the bourgeois economists a decade previously. The Western response was to advocate population control, ‘appropriate’ technology and self-reliance. They argued that too many people and too few resources made for poverty. ‘Appropriate’ technology meant all things to all men; in general, it could be taken to mean ‘ labour-intensive’ for small scale industry. In any case, the West argued that although changes were needed in the way the world’s resources were being distributed, this should be done in a spirit of co-operation rather than confrontation. Pious calls were made to the higher moral values of all concerned. Western responses and arguments conveniently leave out the basic causes for the maldistribution of the world’s resources.

The poor countries are poor not because they do not have resources. They have resources in large quantities, but these are being consumed by the rich countries. As a result there is a profound structural conflict not only between the rich and the poor countries, but also between the rich and the poor within each country.

In the system of world capitalist accumulation, the capitalist classes of the developed and underdeveloped countries play a vital role. Petras(41) states that the capitalist classes of the metropolitan centres organise the world capitalist system in a manner intended to perpetuate their world hegemony; the capitalist classes of the underdeveloped periphery are, in the main, collaborator classes “whose function is to organise the state and the economy (in their own countries) in accordance with the core definitions of the international division of labour”.

The creation of an international political economic order based on the inequalities of nations is rooted in the existence of an expanding centre of capitalism and a set of classes within the periphery whose own expansion and position is enhanced in the process. The insertion of particular social formations within the world capitalist market and division of labour is largely the product of classes which combine a double role - exploitation within their society and exchange outside their society.This dual process leads to the expansion of production relations and antagonistic class relations within peripheral society, growing exchange relations, and competition with the core.

Navarro(42) states that the real gap is not between North and South, but between the capitalist metropoles and the dominant classes of the periphery, on the one hand, and the poor of the capitalist periphery, who constitute the overwhelming majority of the population in their own countries, on the other hand. It is this which is at the root of the underdevelopment, poverty and disease in those poor societies. The class position of the various national representatives on the World Health Organisation’s decision-making body, the World Health Assembly, and of the personnel on the staff of WHO itself ensure that the dominant ideologies of Western academics and of the development establishment are predominant in WHO thinking.

That this is indeed so is reflected in the Alma Ata Declaration. The Declaration describes a world divided between the ‘have’ and the ‘have-not’ nations, and, within each nation, of ‘have’ and ‘have-not’ individuals. The development that the Declaration describes is capitalist development which, it says, “undoubtedly brings about improvement in health”. The Declaration recommends technological and organisational change within the current distribution of societal, national and international power. Women bear the double burden of work, work for wages outside the home in addition to household duties. Appropriate technology should be utilised to lighten their work load and increase productivity. Women require full knowledge about nutrition, pregnancy and lactation.

The Alma Ata Declaration recommends the recruitment of the co-operation of the medical profession and of the multinational drug companies by pointing out the benefits that would accrue to them from the change in priorities in health care delivery. The Declaration states “.....physicians and other professionals will need to be persuaded that they are not relinquishing medical functions but gaining health responsibilities........... Opposition from the medical industries can be diverted into positive channels by interesting them in the production of equipment for appropriate technology to be used in primary health care. Any losses from the reduced sales, of limited amounts of expensive equipment could well be more than counterbalanced by the sale to large untapped markets of greater amounts of less expensive equipment and supplies for primary health care” (43).

The Declaration thus reassures the medical elite of the capitalist centre and periphery as well as the multinational drug companies and medical supply industries that the profits made out of the misery and suffering of the poor and the sick need not be diminished in the process of changing the emphasis in health care delivery towards primary health care.

The Alma Ata Declaration calls for every community’s participation in its own health and welfare, but makes no comment on how this can be achieved against the background of the set of power relations that obtain in a capitalist society, where the primary commitment of the medical profession, for example, is to the safeguarding of their own class and race interests rather than to the health of the people. Furthermore, when the Declaration speaks about health for all by the year 2000 A D, it considers the primary health services as the key to achieving an acceptable level of health throughout the world, failing to understand that, historically, most improvements in health have been due to changes in economic, social and political structures rather than to changes in the health sector. Even when the Declaration goes on to recommend a number of interventions, viz., in food production, education, public works, communications, housing and water supplies, it fails to describe them with reference to their structural relationships in society.

Navarro(44) states that the WHO Declaration takes a clear ideological and political position which, really, is mistaken. He suggests that WHO break with the medical ideology that sees health mainly as an outcome of medical care and that it embrace the systemic view of health that sees health in the world of underdevelopment, today, as primarily an outcome of politically determined structural, economic and social changes. According to Navarro, “......the new understanding of what health and health struggles are, should lead the WHO of the future to focus on:

According to Hayter(47), the development establishment sees, firstly, extreme poverty as a threat to the stability of the neo-colonial regimes in the Third World and to the world capitalist system itself and, secondly, an urgent need to solve the current crisis in the world economy. Hence, the setting up of the Commission, and its predictable assumptions.
Summarising his opinions on the Brandt Report, Navarro(48) stated that, in its ideological and political position, the Brandt Commission was blind to conflict, exploitation and expropriation. Instead, co-operation, sharing and collaboration are put forward as the solution to today’s world poverty.

OCCUPATIONAL HEALTH IN UNDERDEVELOPED COUNTRIES

With new developments in the world political economy and the export of expensive, illegal and hazardous work processes to the Third World, the populations of Third World countries, and their workforces, especially, are increasingly at risk from new, dangerous and often hidden occupational hazards. Elling is of the opinion that the occupational health problems associated with industrialization, previously encountered in the developed world and now largely legislated out of existence, are likely to become more prevalent and serious in the underdeveloped countries for two reasons.

The first reason “lies in the general pattern of human and enviromental exploitation observed in the relations between the developed and underdeveloped countries, including a vast depopulation (extermination?) of indigenous peoples, much of it in the nineteenth century” and the second reason lies “in the special labour, and living and health conditions frequently encountered in underdeveloped countries”. He continues:......(this) theory of a worldwide division of labour is simply a euphemistic way of identifying human exploitation on a massive scale...it would appear that economic growth to some has meant expropriation from the underdevelopment of others” (49).

Although the multinational corporations (MNCs) operating in the underdeveloped countries frequently offer their workers better wages as well as better benefits than the local employers do, the MNCs encourage the development of single, special skills amongst their workers. As the livelihood of such workers depends on the fortunes of the MNC and on the capitalist decisions of its profit-seeking board of directors, they constitute a vulnerable section of the workforce. They remain notoriously weak and will accept low wages.

In countries where a neocolonial government is in power or where a military clique has been installed by Western agencies acting covertly and in collusion, the threat of force to maintain compliance is ever present in the background or a repressive police state may already be operating openly. The U.S. National Emergency Civil Liberites Committee stated in 1976 (50) "......in Guatemala, Iran (under the Shah), Brazil, as in Chile, the close relation, between the CIA and specific U.S. business interests determined to maintain domination of local economies, has been quite clear. An examination of the record, including the Pentagon Papers, demonstrates that control by American interests of the “rich natural resources” of South East Asia was no minor goal in our initial intervention in Indochina. But the people could not be told this. Hence the myths of the cold war were used as cover for the initially secret operations of the CIA, and the later open military expansion, when this was not enough to bend the Vietnamese to our will”.

HEALTH HAZARDS AFFECTING THE POPULATION IN GENERAL IN UNDERDEVELOPED COUNTRIES

The vulnerability and susceptibility of the population and its workforce in the industrialization process is accentuated by poorer nutritional levels, higher rates of intercurrent debilitating diseases, absence of union organisation, lack of governmental action in relation to occupational health hazards, unfamiliar industrial environments, lack of industrial health services and personnel, and the impact of rural to urban migration.

In considering the environmental and health impact of modern industry on the community at large in industrializing societies, Commoner(51) wrote:

“Similarly, chronic, low level exposure to radiation, mercury or DDT may shorten a wage earner’s life without reducing his income or even incurring extra medical costs during his life-time. In this case, the cost of pollution is not met by anyone for a long time; the bill is finally paid by exacting the wage earner’s premature death, which apart from the incalculable human anguish - can be reckoned in terms of some number of years of lost income. In this situation, then, during the ‘free’ period, pollutants accumulate in the ecosystem or in a victim’s body, but not all the resultant costs are immediately felt. Part of the value represented by the free abuse of the enviroment is then available to mitigate the economic conflict between capital and labour”.

One of the hazards to the community that Elling(52) identifies is the commercialization of infant feeding. This results in unsupportable expense to the family, infectious disease (due to making up the infant’s bottle formula with contaminated water), undesired parity for the mother (breast feeding delays conception), and greater economic burdens on the family as a whole. The dumping of pharmaceutical products, which have been banned in the metropolitan countries, on to Third World populations is discussed elsewhere. Foreign-owned agribusinesses exploit the most profitable lands for single cash crop production, turning, in the process, farmers into low wage earners; the country then has to import food to feed itself, setting the seal on the development of underdevelopment, and shifting from a position of self-sufficiency to one of dependence. As a considerable portion ‘ of the family’s income is spent on food to sustain the overworked breadwinner, the children and their mother have to do with less. Malnutrition is the result (53).

The introduction of pesticides consequent upon the industrialization of agriculture damages the ecology and poisons the workers and their families. Unplanned industrialization leads to mass migration from the rural to the urban areas, where job insecurity and shanty town housing with inadequate sanitation and poor housing lead to mental and physical stress (54). There has also been an increase in the incidence of diseases, including certain forms of cancer, associated with urban pollution (55).

HAZARDS TO INDUSTRIAL WORKERS IN UNDERDEVELOPED COUNTRIES

Turner described the situation in the 1970s (56):

“Work conditions in the Third World can be atrocious. Wages in South Korea, currently about the lowest in the runaway economies, are about a dollar a day, or around $ 7 a week. Hours are worse in Hong Kong, where 60 per cent of its male workers work a seven-day week, while 52 per cent of all employees work ten hours a day or more. Each year some 34,000 children between twelve and fourteen are forced to find work, and a case in which a ten year old girl started work at 6.00 a.m. and was still working at 8.50 p.m. is not exceptional. Official estimates are that at least one in four factories in Hong Kong uses child labour...........”

Although the hazards in the older industries and factories, e.g. mines, lumbering, and textile mills have been well documented, little has been written on the newer hazards, viz., pesticides and agricultural chemicals, new air pollution problems in the steel and auto industries, radiation hazards, the combined effects of individual hazards (e.g. smoking, urban air pollution, and dusty occupations), problems of socio-cultural background and the industrialization process, and industrialization-related mental disorder. The most researched of the newer problems are those related to the manufacture of asbestos and vinyl chloride.
Both asbestos and vinyl chloride are carcinogenic and the production of these materials has been transferred to underdeveloped countries with weak industrial health regulations.

For example, before 1969, the U.S. did most of its own manufacturing of asbestos, obtained from mines in Quebec, Canada. With the recognition of the hazards of cancer from work with asbestos, the asbestos mined in Canada is shipped to Mexico or Taiwan, and, later, also to Brazil and Venezuela, for manufacture, and then shipped to the U.S. for use. Vinyl chloride is a chemical used in the manufacture of rubber, and the producers of this substance are all large multinational corporations dealing in chemicals, oil and rubber. Following industrial health legislation by the U.S. Department of Labour in 1974, the corporations cut down on production in the U.S. and moved out to unregulating countries such as Iran (under the Shah), India, Mexico, Venezuela, the Philippines, and Spain (57).

Diseases with long latency periods, e.g. the development of cancer from work associated with asbestos and vinyl chloride, may not become evident if workers die prematurely from one of the more quick-acting causes of death so common in underdeveloped countries. There is a need, therefore, to assess the early signs of long-acting disease processes as well as to unravel disguised hazards. Active occupational health programmes, backed by legislation and with an adequate number of trained staff carrying out surveillance and affording protection to the workers, are necessary.

Finally, “.....the workers themselves (should) develop an awareness, concern and consciousness which will lead them to build the kind of economic system and society that will enhance, not simply exploit, human potential.............experiences in Yugoslavia, Tanzania, Cuba and China suggest that there is a greater awareness, concern, and mobilization of efforts to protect workers and provide adequate medical and health services in such conditions. When we look at the rape of countries like Brazil, one cannot help but hypothesize that real protection lies in this direction” (58).

DIFFERENCES IN MORTALITY RATES BETWEEN THE CAPITALIST CENTRE AND ITS PERIPHERY

Essential to the understanding of inequality and mortality is the concept of the unity of international capitalism and the organic ties that bind the underdeveloped countries of the capitalist periphery to the advanced metropolitan social formations of the capitalist centre. Fundamental, to this discussion, is the theme of the struggle of the working class (the proletariat in the urban enclaves and the peasantry in the agricultural hinterland) for improved health, working conditions and enviroment versus the interest of capital to maximise profits and extract the surplus value.

Bourgeois sociologists identify two causes for the observed decline in mortality in the metropolitan centre, viz., the standard of living of the population and the quality of public health programmes. But this does not take into account the significance of underdevelopment for public health and mortality in the Third World and fails to make the connection between public health and mortality and the political economy. In the comparative study of mortality levels, two important differences are observed: the higher mortality of the working class as compared with that of the bourgeoisie, and the higher mortality in the peripheral regions as compared with that in the areas of capitalist development. These inequalities result from differences in accessibility to services and benefits. The provision of health care, better working conditions, adequate food and housing as well as a clean water supply all represent costs which must be paid directly or indirectly by capital.

INEQUALITIES IN THE METROPOLITAN CENTRE

In advanced capitalism, the working class has a higher mortality than the bourgeoisie or even the petit-bourgeoisie. Mortality is significantly and dramatically lower for the privileged classes of society, and this is true for infant and adult male mortality in England and Wales (59). Patterns of inequality in mortality rates have existed for centuries (60). However, recent levels of mortality for the working class in the industrialized countries of Europe and North America are lower than those in most countries of the Third World. It is also likely that the capital-owning class in some Third World countries may enjoy lower mortality rates than the proletariat in industrialized capitalist countries (61).

Capitalism has to reconcile its aim of maximisimg profits with its need for a productive labour force. Writing on the situation in Britain in the years after the Second World War, Navarro(62) observed that capitalism often benefits from labour’s struggles. He wrote: “History shows that concessions won by labour in the class struggle become, in the absence of further struggle, modified to serve the interests of the capitalist class”.

Gregory and Piche(63) go even further: “For some analysts, the health care industry in advanced capitalism, and in the United States in particular, is an excellent example of capital’s ability to transform hard-won improvements in the social wage into an arena for accumulation. The list of health-related institutions through which capital accumulates is a very long one: clinics, hospitals, nursing homes, drug companies, medical supply and equipment companies, construction firms, laboratories, insurance companies and management consultants, for example”. Contradictory pressures in advanced capitalist social formations may induce capital to invest in the health of certain groups of workers, viz.,

INEQUALITIES IN THE CAPITALIST PERIPHERY

Labour is cheap at the periphery of international capital. In the initial stages of capitalist penetration of what is now the periphery (i.e. the Third World), precapitalist relations permitted the indigenous populations to reproduce themselves without selling their labour power to the foreign capitalists. Slavery and forced labour had, therefore, to be used by capital in order to obtain adequate labour. Now, the surplus of labour at the periphery permits capital to hire and fire at whim with scant regard to the problems of the reproduction of labour which occurs, in any case, within the household economy, outside of capitalist relations of production. Capital does not feel obliged to pay social wages to its labour force. The struggle of labour is hindered by a lack of proletarianization and of class consciousness, feelings of powerlessness, and the size of the relative surplus population. Many of those engaged in waged labour in the dominant capitalist mode of production are also engaged in non-capitalist subordinate household production.

As the organic composition of capital is low in the peripheral economy, only a low skill labour force is required. Low wages only are paid and there is a constant circulation of labour between productive activities in the capitalist and in the non-capitalist spheres. The dangers to health are high in such a scenario.

High levels of unemployment oblige workers to accept dangerous employment and the effects of occupational diseases are compounded by those due to poor nutrition and bad sanitation. Inadequate provision of health services and the inaccessibility of those services that do exist contribute to the high mortality in much of the Third World. There are situations, however, where this does not apply. The lumpenbourgeoisie in the underdeveloped states experience much lower mortality; in the cities and large provincial towns (the capitalist enclaves), improvement in the mortality figures obtains as a result of the increased services that tend to be supplied primarily to serve the interests of capital and to aid capital accumulation.

Cleaver(64) stated that: “An examination of the current crisis suggests that it is a long term repressive strategy of capital to control and restructure the international working class whose struggles in the 1960s ruptured its (capital’s) development plans and threw its survival into jeopardy”.

Turshen(65) suggests that improvements in the standard of living, including the health of the working class in advanced capitalist societies, have been achieved not only through class struggle, but also on the back of this very cheap labour in the peripheral economies. Futhermore, ideology plays a role as an instrument of social inequality in matters of health. “(The) social ‘representation’ of illness and health implies, for example, that even in cases of equal physical and economic accessibility to health services, members of the working class will perceive their health and illnesses differently from members of the bourgeoisie. Therefore, differences in the use of a health care system will occur, reinforcing differences in morbidity and mortality between social classes” (66).

INFANT MORTALITY IN THE THIRD WORLD

That there is a causal relationship between the infant mortality trend and changes in the purchasing power of the urban poor is illustrated by the experiences of the poor in Sao Paulo, Brazil, in the sixties and seventies. In 1964, the Brazilian Armed Forces seized power from the constitutionally elected President, Joao Goulart, and put into effect aggressive economic policies to control inflation, attract foreign investment, encourage the accumulation of capital and stimulate the economy. Between the years, 1968 and 1974, the industrial sector reached an annual growth rate of 12.2 per cent. Dubbed the ‘Brazilian Miracle’ and an unqualified success of economic planning, it was effected by a set of government priorities that included subsidies and incentives to capital in specified regions of the country and sectors of the economy, the stimulation of technologically advanced forms of production, and economic and political measures to enhance the accumulation of capital by lagging wages behind increases in productivity (67). What was achieved was done at heavy social and political cost.

The distribution of income is the result of competing claims on the economy’s output. The workers’ struggle for higher wages and the power of the labour unions was weakened by direct and indirect political pressures, legislation and the occasional use of military force.

Income is an important determinant of the infant mortality rate. Poor diets and a low standard of living result from low purchasing power. Associated with this are poor housing in high risk areas, reduction of reserves that could be utilized during periods of sickness or in an emergency and poor sanitary arrangements. Studies of mortality and family income demonstrate that the death rate is more responsive to income changes at the lower end of the income range than to income changes amongst more affluent families. An identical change in income across population subgroups, therefore, has a disproportionate effect on the mortality of the poor (68). One study from Brazil concluded that a 10 per cent increase in the income share of the bottom 40 per cent of the labour force is associated with infant mortality declines of 11 to 12 per cent (69).

There is an inverse relation between fluctuations in real wages and the trend in infant mortality. As a result of the economic stress in low wage families, households placed additional members into the labour force, especially women and children, as secondary workers and as sources of supplemental income. Although the employment of secondary earners softened the fall in household income when the income of the head of the household declined, real family income amongst the poorest in Sao Paulo still fell (70). Householders responded to a decline in income by changing their consumption patterns, allocating a greater proportion of their income to food, consuming less meat and more of the cheaper and less nutritive foodstuffs (71).

Malnutrition reduces the resistance to diarrhoeal diseases and respiratory infections to the point where an attack of one of these conditions that would be trivial for a healthy child becomes fatal. An inadequate diet is the single commonest cause of child mortality in underdeveloped countries (72). An inadequate diet can cause serious debilitation and death through a predisposition to recurring relatively mild illnesses. When malnutrition is widespread, diarhoeal infections and parasitic diseases are responsible for much of the mortality.

Wood(73) concludes that the Sao Paulo experience (1963-1979) showed that “the inverse relationship between real wage trends and changes in the level of infant mortality in San Paulo is attributed to three interrelated factors: the large proportion of the population earning a salary that is close to, or below the officially established minimum wage (and the impact of this on the aggregate mortality rate); the high income elasticity on the mortality of subgroups at the low end of the income range (who experience a high incidence of infant deaths); and the precarious nutritional status of substantial sectors of the urban population..........The findings suggest that the infant mortality rate is responsive to specific government policies designed to contain inflation and stimulate capital accumulation through the control of wage levels in the country”. The influence of other factors (viz., clean water supplies, sewage disposal, rural to urban migration, improvements in data collection, etc.) could not explain the rise and subsequent fall in the level of infant mortality in the city of San Paulo during the 1960s and the 1970s.

NEOCOLONIALISM AND TH