The United Kingdom Council for Human Rights

AMERICAN (FLEXNERIAN) MEDICINE AND
U.S. MEDICAL AID PROGRAMMES

THE HISTORY OFAMERICAN MEDICINE

The licensing regulations for the practice of medicine, such as they were in the United States at the beginning of the nineteenth century, collapsed in the 1830s and 1840s as a result of the erosion of traditional roles by the new urban industrial society and the changing face of America. There was then virtually no control over the training, standards of practice and licensing of physicians, and this state of affairs persisted till the 1880s (1).

Young men from poor families could set themselves up as physicians and thus improve their position in society, by entering any one of a number of proprietary medical schools, paying the requisite fees and then collecting their M.D. degrees at the end of the course. The M.D. degree was in itself a licence to practise. Upto the beginning of the American Civil War, the sons of the wealthy pursued further medical training usually in England or France; from the end of the Civil War to the beginning of World War I, they proceeded, instead, to Germany or Austria for further training. Their poorer brethren, of course, were unable to do this and this helped to differentiate the ‘ elite’ of the profession from the rank and file.

Before 1910, medical care in the U.S. was organised very much as a cottage industry(2). Doctors practised on a ‘solo’ basis and it was not unknown for payment to be in kind. The education of a physician often followed the apprenticeship model of the time and medical training sometimes took as little as one year. The doctor’s little black bag contained all the instruments that he was ever likely to use.

The end of the nineteenth century in America was characterized by violent social upheavals directly as a result of the growth of industry and the emergence of large conglomerates. The urban proletariat reacted to the exploitation at their place of work, their poor wages and their squalid living conditions, by unionising and, sometimes, by physical violence. The small farmers organised themselves against the financial power of the conglomerates. The new middle class comprised the new skilled workers, entrepreneurs and managers, as well as the merchants and artisans who had had an established role in the old order. Subject to the same unhealthy environs as the working class, they reacted by taking over political control of urban local governments and highlighting the corruption and excesses of the system. The capitalist class continued the process of capital accumulation and detracted public attention from the inevitably ensuing social problems by transforming these problems into technological problems whose solution could only be effected by science and technology, not, though, through political striving. Scientism thus became the prevailing ideology (3).

The end of the nineteenth century saw the predominance of the physical sciences and engineering over the humanities in the institutions of higher learning, and science was beginning to be seen as the agent that was capable of solving all of society’s problems(4). In industry, scientific management was seen as a means of increasing productivity (and thus wages) by a more efficient control of the production process(5). Scientific agriculture produced more food at lower prices for the urban working class. It increased the income of the farmer but put him in debt to the finance corporations and the agro-industry(6). Scientism was manifested in the professions by reforms which required periods of advanced study in college and/or university, which, again, tended to perpetuate the new class divisions in American society. Only the wealthy could afford to send their sons for prolonged periods of study in order to enter the professions of law, medicine, theology or engineering. Only middle class women could benefit from the new scientism that manifested itself as the domestic science movement(7).

For this reason the latter half of the nineteenth century, which saw the emergence of a new industrial and occupational structure in the United States, has been termed ‘the progressive era’. “In consequence, a primarily small town agrarian society bacame transformed into an urban industrial one. As a result of this confrontation with a rapidly changing society, many new occupations emerged. Among them were what we have called consulting or ‘helping’ professions whose special area of concern was the social problems of the new society. These new problems e.g. heavy drinking, juvenile delinquency, prostitution, political rackets, all manner of crime, mental illness, etc., were attributed to the disintegration of traditional family and community life, and, therefore, to the disintegration of traditional means of socialization and social control Social control and efficiency became dominant themes in the writings of the reformers of the Progressive Era” (8).

Herbert Croly, the first editor of ‘New Republic’ and an exponent of Progressivism wrote: “The automatic fulfillment of the American national promise is to be abandoned, if at all, precisely because the traditional American confidence in individual freedom has resulted in a morally and socially undesirable distribution of wealth” (9). According to Berliner, “‘. . . . this scientism tended to produce three results:

(a)social conditions were somewhat ameliorated, (b) due to the elimination of inefficient and marginal producers, the corporate organisation of society became the norm; and (c) the capitalist class, by virtue of its financial dominance, was able to structure these trends so as to maintain its control over them and thus keep them from upsetting the existing social structure; and, in fact, it used them to maintain and further entrench the existing social structure........ Medicine was also subject to scientism (and) came to be known as scientific medicine... New contradictions emerged, in a dialectical way, from these band-aids applied to the system” (10). The Flexner report was an attempt to deal with these contradictions.

ABRAHAM FLEXNER

Flexner, hinself, was not a medical person. He received his Bachelor’s degree in 1886 from John Hopkins University which was, also, at that time pioneering graduate education. Flexner later did graduate work in education at Havard and in Germany. At the beginning of this century (1908-1909), the American Medical Association’s (AMA’s) Council on Medical Education approached the Carnegie Foundation with the suggestion that the Foundation fund a study on medical education in the United States. The study would also make representations as to the future of medical education in the country. The Foundation chose a layman and educator, Abraham Flexner, for this important work. To allay any fears that the general public might have had about sectarianism and vested interests at work in the report, the AMA chose to go to the Carnegie Foundation instead of the Rockefeller Foundation which was already associated with scientific medicine. In its turn, the Carnegie Foundation picked Flexner, an educator with no direct ties to the medical field, whose remit was to study not just medical education but professional education. The Carnegie Foundation was already engaged in a similar enterprise in regard to the entire educational system.

At the beginning of his study, Flexner went to visit the pioneering medical school at John Hopkin’s in Baltimore. He wrote later that he went to visit “others (in John Hopkins) who knew what a medical school ought to be, for they had created one. I had a tremendous advantage in the fact that I became thus intimately acquainted with a small but ideal medical school embodying in a novel way, adapted to American conditions, the best features of medical education in England, France and Germany” (11). The system at John Hopkin’s at the time was later extended to the other medical schools in the country. John Hopkin’s had raised admission requirements, lengthened the course of study and, by placing the pre-clinical teachers and the heads of the clinical departments on salary, had made careers in full-time academic medicine possible.

THE FLEXNER REPORT

In the now famous Report (1910) which bears his name(12), Flexner wrote: “The (state) boards of (medical examiners) touch at three points the problems with which this report has dealt: for they deal

(1) with the preliminary education requirements,
(2) with the facilities of medical schools,
(3) with the examination for licensure

In regard to (1), Flexner recommended that the state boards require minimum educational standards for entrance to medical schools. Physicians’ apprentices without high school diplomas could not apply. In regard to (2), Flexner, not desirous of advocating the policing of medical schools, nonetheless recommended that the state boards refuse to license the graduates of medical schools “scandalously defective in teaching facilities”, adding, however, “only so long as an entrance requirement cannot be enforced or a proper examination arranged, do the state boards need power to close schools obviously and notoriously defective”. In regard to (3), Flexner wrote: “The examination for licensure is indubitably the lever with which the entire field may be lifted; for the power to examine is the power to destroy”.

The support given to the Flexner Report and its implementation by the American Medical Association was an attempt to maintain ideological hegemony over the other sects in the medical field at the time (e.g. homeopathy and naturopathy), to secure an alliance between the AMA and the capitalist class, and, finally, to establish the dominance of the medical researcher and scientific medicine over the practitioner and his solo fee-for-service medical practice (13).

Between 1904 and 1920, the number of medical schools, students and graduates was cut by half; and the scientific content of medical education was greatly increased in the remaining schools (14). The reorganisation of American medical education, that followed in the wake of the Flexner Report and that benefited the wealthy and privileged groups in society, also resulted in the closure of six of the eight all-black medical schools then in existence, sparing only Howard University Medical College (founded in 1868) in Washington D.C., and Meharry Medical College (founded in 1866 as part of the Central Tennessee College). As a result of the racially exclusivist policies of the AMA and of the medical profession generally, these medical schools had been founded in the second half of the nineteenth century (15).

The adoption of the Flexner Report by state boards and the medical profession in the U.S. had profound effects on the whole practice of medicine in the country. In practice, only those students who could afford four years of college and four years of medical school would consider a career in medicine; this had the effect of limiting the field to upper middle class white males.

The engineering approach to the practice of medicine was developed which emphasized research and therapy on machine breakdown and repair. i.e. individual pathology and cure and which de-emphasized the socio-economic basis of illness and disease. This can be seen as a need to legimate the existing social structure in the light of the prevailing scientism, and to subordinate the means of reproduction of the productive sector of society (i.e. medical care institutions) to capital accumulation. The recommendations of the Flexner Report were implemented by the nine largest philanthropic foundations which granted over $150 million to certain medical schools in the U.S. in the 20 years following the publication of the Report and set the stage for the introduction of a system of medical practice beset with conflicts and contradictions (16).

Whilst the quality of medical education and the standard of health care were given as the reasons for instituting the study that led to the Flexner Report, the data offered by Stevens (17) suggests that economic considerations were predominant. The medical profession were concerned about an overcrowded profession and about competition from homeopathy and naturopathy The major thrust for an investigative study came from the organised medical profession. The Flexner Report was also quite clear about limiting the total output of physicians: not more than one medical school per city, no more than 70 graduates per medical school and a specific graduate to population ratio. The schools which were already in the worst financial status, largely attended by the poor, women, blacks, and part-time working students, were largely ignored by the large foundations during the distribution of grants; the foundations, instead, directed their wealth to those schools already having the largest endowments, i.e. to those schools attended by the sons of the wealthy (18).

Navarro(19) states that “scientific medicine received priority because it represented a means of aiding the efficient reproduction of the most appreciated commodity; the labour force”. Proletarians have to be kept in optimal condition because their productivity is a basic ingredient in the process of capital accumulation. The technological nature of Flexnerian medicine required the development of a complex infrastructure of hospitals, medical centres and research institutes which generally diverted service funds to research work related more to the heeds of productive expansion than to social benefit. The contradictions that have resulted in the operational crises of Flexnerian medicine have never been more visible than in the current crisis of capitalism. Although the great masses of the unemployed and subemployed are not strictly part of the productive labour force, the dominant classes cannot leave them unattended. At the same time, it is not possible to extend coverage of costly services because that would reach the the financial limits of a system exhibiting an irrational concentration of resources.

U.S. MEDICAL AID PROGRAMMES

Educational and public policy formulation in underdeveloped areas reflects the interests not only of the national elite, but also those of the policy makers in the economically dominating (neocolonialising) nations. The absence of an analysis and a perspective has led to a blind transfer of structures and policies from the neocolonialising metropolitan countries which are often ill-suited to the needs of underdeveloped areas (20). The recommendations of the Flexner Report, for instance, which themselves were based on the John Hopkins Medical School model, have been widely and uncritically introduced into the Third World where U.S. medical aid programmes are at work(21), with a number of deleterious results.

Not only has the development of primary care and the achievement of other urgent health goals been impeded, but the emphasis on full-time attendance by both staff and students and the increasing specialization in both medical education and research have prevented the enrollment of students from poorer families who would have to take up part-time employment in order to support themselves at college and have contributed, in general, to the isolation of the university teaching hospital and medical school from the community. In these countries with U.S. aided health programmes, a significant portion of the health budget is diverted away from urgent and equitable primary care medicine (and its substitution by ineffectual, inadequate and low cost ‘community medicine’) towards high cost, hospital-based, research-oriented, and framentation-by-speciality medicine, which caters to the non-urgent wants of the consumption-oriented urban elites, rather than to the urgent needs of all the people, However, issues such as these are never raised.

Describing the organisational pattern of health services in dependent countries, Navarro spoke of “a system of health services that is highly oriented toward


(a) specialised hospital based medicine as opposed to (primary care]/ community medicine,
(b) urban, technologically intensive medicine in contrast to rural, labour intensive medicine,
(c) curative medicine as different from preventive medicine, and
(d) personal health services as opposed to enviromental health services” (22).

ROCKEFELLER FOUNDATION PROGRAMMES AT HOME AND ABROAD PUBLIC HEALTH PROGRAMMES

The development of the public health field in the world today owes much to the impetus it received from the needs of colonialism and neocolonialism. Tropical diseases took their toll of the ranks of the early colonisers. Vaughan wrote in an early textbook of tropical medicine: “Disease still decimates native populations and sends men home from the tropics prematurely old and broken down............To bring large tracts of the globe under the white man’s rule has a grandiloquent ring; but unless we have the means of improving the condition of the inhabitants, it is scarcely more than an empty boast” (23). The schools and research institutes of tropical medicine, which were founded around the turn of the century to apply the medical sciences to the needs of imperialism, were successful in reducing the death rate among Europeans working in the tropics.

The Rockefeller public health philanthropies continued the imperialist tradition; the Foundation’s programmes were based on solid political considerations. U.S. control of the markets and resources of the Third World countries was considered a priority for the health of the U.S. economy; some control of their political institutions, in addition, was considered essential for the profitable investment of that portion of U.S. capital that was surplus to the current needs of the metropolitan capitalist centres. An infrastructure, e.g. roads, railways, and other essential services, had to be constructed in the underdeveloped country to facilitate its maximal exploitation.

Tropical diseases, esp. hookworm, malaria and yellow fever, could interfere with the processes of exploitation and, therefore, had to be eradicated or, at least, controlled. The application of health programmes, which could be seen by the inhabitants to actually bring obvious benefits, could thus cause the population to be more receptive to Western values, economic penetration, and domination by the giant multinational and transnational companies. The way would then be open for the entrenchment of U.S. (or other Western) hegemony.

In their desire to develop the field of public health, the Rockefeller Foundation professionalized public health work, helped develop local public health departments, founded schools of public health and employed full time qualified public health officers.

THE ROCKEFELLER SANITARY COMMISSION FOR THE ERADICATION OF HOOK WORM DISEASE

The earliest major public health scheme undertaken by the Rockefeller philanthropies was in the U.S. South itself. Doubtless, it helped pave the way for other schemes in underdeveloped areas further afield. The remit of the Sanitary Commission (founded in 1909) was to aid, over an initial 5 year period, in the integration of the backward U.S. South into the capitalist economy of the industrial North by increasing the productivity of Southern agricultural and industrial workers through an improvement in their general health. Stiles, a zoologist, had suggested that the hookworm was the cause of one of the important diseases of the South. The ‘germ of laziness’, it was alleged to be the cause of part of the proverbial laziness of the poorer classes of the white population (24). Hookworm anaemia, the condition that resulted from heavy infection with the parasite, was particularly severe amongst those who existed on low protein, low mineral diets(25) and was thus common amongst the blacks and the poor whites.

Although the hookworm campaign was valuable to the poor people it reached (it failed to eradicate the disease but helped to bring it partially under control and reduce its incidence), it also helped towards the commercial organisation of the South’s agrarian economy, placing it under the control of the local banks and merchant class. It cemented the position of the blacks and the poor whites as the agricultural and industrial labourers of the South, and helped integrate the Southern economy into that of the North and under the control of the Northern capitalists. For the capitalists of the North, their philanthropy was an extension of their capital into the social superstructure, where educational institutions, the economy and public health were to be made more supportive of the new capitalist industrial order (26).

ROCKEFELLER PUBLIC HEALTH PROGRAMMES IN UNDERDEVELOPED COUNTRIES

In 1913, the Rockefeller Sanitary Commission was incorporated into the newly chartered Rockefeller Foundation, one of the first acts of which was to create an International Health Commission. Hookworm programmes were started abroad in 1913; in 1914, a campaign against yellow fever was commenced, and in 1915 a campaign against malaria. The Foundation considered missionaries valuable allies in the pursuance of the foreign public health programmes. In 1905, Frederick Gates, a former Baptist minister, who created the Rockefeller philanthropies, wrote to Rockefeller, Snr. (who had already been donating generously to Baptist and Congregational missions) in the following vein:

“Quite apart from the question of persons converted, the mere commercial results of missionary effort to our own land is worth, I had almost said, a thousand fold every year of what is spent on missions Missionary enterprise, viewed solely from a commercial standpoint, is immensely profitable. From the point of view of the means of subsistence for Americans, our import trade, traceable mainly to the channels of intercourse opened up by missionaries, is enormous. Imports from heathen lands furnish us cheaply with many of the luxuries of life, and not a few of the comforts, and with many things, indeed, which we now regard as necessities....our imports are balanced by our exports, to these same countries, of American manufactures. Our export trade is growing by leaps and bounds. Such growth would have been utterly impossible but for the commercial conquest of foreign lands under the lead of ‘missionary endeavour’ “. Brown described the missionaries as “the velvet glove of imperialism frequently backed up by the mailed fist” (27).

The Rockefeller Foundation programmes were promoted with the intent of raising the productivity of the workers, subvert their autonomy, transform them into an industrial workforce, induce an acceptability of U.S. cultural and economic values and undermine the underdeveloped country’s economic and political independence.

The Rockefeller Foundation’s International Health Commission financed hookworm programmes in China, the Philippines, Latin America, the West Indies, Ceylon, Malaya and Egypt. In China also, the Foundation took over the control of the Peking Union Medical College from the missionaries. The Foundation identified health as the capacity to work and measured qualitative improvements in health by quantitative increases in productivity.

A 1918 hookworm programme in Costa Rica resulted in such an improvement in health that productivity increased dramatically. Each labourer was paid less per unit of work, but, with his health improved, was able to work harder and longer with the result that his take home pay was increased. The Foundation also soon discovered that medicine was an irresistible force in the colonization of non-industrialized countries, and that, for the purposes of placating primitive and suspicious peoples, medicine had some advantages over machine guns (28).

However, the Foundation insisted that they have direct control over their own health programmes, since productivity and efficiency were a high priority for them. They saw the governments of receptor countries mainly as the means by which U.S. political, economic and cultural penetration could be effected. The Foundation donated funds to help set up schools of public health at John Hopkins, Harvard and other medical schools in the U.S. and abroad, and spent several million dollars on the training of foreign medical personnel in the public health services. The Foundation’s programmes were mainly in regions where Rockefeller investments were concentrated. For example, the medical education programmes were begun in China and Turkey, where the Standard Oil Company were engaged in major operations.

Brown writes: “Once the programmes were launched by the Foundation’s top officers, the internal logic and historical conditions assured that the imperialist ends would be served, even if mid-level officers, field directors and professional personnel did not consciously promote imperialism through their programmes...... Acceptance of European and American medical theories and practice implied submission to the authority and superiority of these foreign cultures.. "(29). The U.S. philanthropic foundations received their wealth from the giant commercial corporations, that operated under the imperialist umbrella; their managers and officers are part of the corporate capitalist class. The health professionals associated with these programmes share in the material advantages that accrue to the capitalist metropolis, as well as, not infrequently, the racist and ethnocentric ideologies that justify imperialism.

U.S. INTERVENTION IN THAI MEDICAL EDUCATION

Arriving in Bangkok in 1835, Dr Dan Bradley was one of the most well known of the early American missionaries who introduced the Western system of health care to Thailand (30). Dr Bradley’s work covered surgery, obstetrics and vaccination against small pox; he died in 1873. The first hospital was opened in Thailand in 1888, and named the Siriraj Hospital after a Thai prince; a medical school was opened in relation to the Siriraj hospital the following year. From all accounts(31), standards were far from acceptable, in Western eyes, at the school until the intervention, in the early twenties, by the Rockefeller Foundation. This was not only the beginning of foreign aid to Thailand, but also the first major intervention in medical education in the country, although Americans had already been working on a hookworm campaign there.

In 1921, Thai health officials, Rockefeller Foundation representatives and local and expatriate doctors met in Bangkok to discuss the form that medical education, in the country, should take (32). The Thai government’s senior representative at the negotiations with the Foundation was Prince Mahidol, a half-brother to two Thai kings, who, himself had received degrees in both medicine and public health from Harvard University and was a practising physician in his own country. The Foundation made it clear that it would be concerned only with a high grade school for the preparation of properly qualified physicians receiving a degree, basing its insistence on the Flexner Report.

As has been shown, the Flexner Report, with its emphasis on scientific quality and specialised medical practice, led, in the U.S., to the closing down of numerous medical schools, a development that was supported by the Rockefeller Foundation and its sister organisation, the General Education Board. In the underdeveloped world, the Foundation’s support of the highest standards of medical education was based on the experience of its Sanitary Commission, International Health Board and Division of Medical Education, who concluded that public health activities in a country would never be sufficient without well-trained indigenous physicians (33). The Foundation ensured that, in the case of the re-organised Thai medical school, expatriate Americans would have control over the character of the courses, type of examinations, passing qualifications, and graduation.

From 1924 onwards, the medical school began to function much like a U.S. school; after Foundation monies arrived, new buildings were built and the Rockefeller professors went into post. However, right from the beginning, there was some concern whether the small number of highly qualified graduates, that would be turned out by the medical school annually, would be sufficient to deliver, or, at least to organise and supervise, a uniform system of basic medical care for the whole population. Over the years, as the medical school delivered its products, it was increasingly seen as being inappropriate for the needs of the population. In 1928, Prince Sokol, Director-General of the Thai Public Health Department told the Foundation’s Paris Office that half a dozen high level medical graduates annually had made little impression on the national health scene and that what the country really needed, and, urgently, at that, was a large number of reasonably competent men for a state medical and public health service. A system of ‘junior doctors’ was proposed by some in Bangkok. Here, there would be a reduction in the time spent in training, with the training itself emphasizing the commoner diseases. These ‘junior doctors’ would be supervised by provincial medical officers and regional hospital doctors who would themselves have been trained according to the Flexnerian model.

A further suggestion was that of an additional lower type of medical training that would establish ‘health assistants’ who would be public health nurses, with a little more instruction in the management of medical emergencies, the recognition of common diseases, and the administration of drugs such as quinine. The Foundation, however, saw each of these proposals as a Thai Trojan horse that would undermine their Flexnerian model of medical education, and, therefore, rejected them. The Thais, however, went ahead with the scheme to train ‘junior doctors’ in addition to the high-level Siriraj graduates. The Rockefeller Foundation made its last grant in 1930, pulled out of Thailand and turned its attention elsewhere.

Donaldson(34) made two points in regard to the Rockefeller Foundation’s intervention in Thai medical education. Firstly, the Western model of the professional became dominant in Thailand because the Thai thought that it had practical applications. When the Thai became disillusioned with this model, the Foundation was still able to push for its acceptance because of the Foundation’s own wealth and influence at a time in Thailand’s history when the country was open to Western models and the Westerners were aggressively advocating them. Secondly, the fact that Thai doctors were concentrated in the urban areas is not just because of their socialization to a role introduced by the Roskefeller Foundation, but because the Thai elite had not encouraged doctors either to move out of the urban areas or to tailor their medical services to cater for the needs of the population as a whole (35).

In 1963, the Rockefeller Foundation became involved in another assistance programme at a second Thai medical school, viz., that at the Ramathibodi hospital. Again, the Foundation did not support a programme to train urgently needed medical assistants.

Instead, the Foundation, later, helped build, and staff, a graduate programme in the life sciences at the Mahidol University Faculty of Science and involving six new departments in anatomy, biochemistry, microbiology, pharmacology, physiology and pathobiology. Emphasizing Ph.D. level training, it turned out its first Ph.D.s in 1973 (36).

Studying in these six departments, and separate from the graduate students, were an equal number of medical students obtaining pre-clinical training prior to entering the University’s Faculty of Medicine. The life sciences programme thus served as part of the system of (Flexnerian) medical education, and it was soon viewed with some misgivings by many Thai (37). As Donaldson put it: “The shortcoming of these programmes is not they create the inequality associated with professional services throughout the developing world, but that they so neatly serve those who maintain it” (38).

U.S. AID PROGRAMMES IN COLOMBIA
THE COMMUNITY SYSTEMS FOUNDATION ( C.S.F.)

Following on the abolition of slavery in Colombia in 1851, the ex-slaves took to working for themselves on some of the plentifully available land and grew large quantities of plantains and cocoa, and raised livestock. The end of the civil wars of the nineteenth century led to the development of a centralized, dictatorial state in Colombia which created just the conditions that American investors felt were ideal for capitalist economic penetration. Between 1913 and 1928, loans larger that those given to any other Latin American country were made by U.S. investors to the Colombian government for the building of the necessary infrastructure (39).

With the construction of a railway to the Pacific and the opening of the Panama Canal, the region of the Cauca Valley was opened to economic exploitation. As land now became valuable, the peasants were forcibly dispossessed by any number of means, e.g. by direct force, by the flooding of plots, and by the aerial spraying of herbicides. Recorded as well as unrecorded history provides evidence of the violent struggles waged by the peasants in the thirties, forties and fifties against the progressive concentration of land into haciendas (40).

Established in 1963, the Michigan-based Community Systems Foundation (CSF) described itself as a non-profit making corporation working and researching in the field of community self-help. Amongst its advisers were professors and graduate students from the University of Michigan in Ann Arbor. CSF described its operational strategy as one in which planning, implementation and management are integrated as a learning process through practical work rather than through formal learning; emphasis was placed on self-help, local and personal self-sufficiency, intermediate technology and the incorporation of the women’s movement. With funds from the United States Agency for International Development (USAID), CSF intervened in Chile, Zaire, and other Third World countries, as well as Colombia (in the Cauca Valley).

In the Cauca Valley, the small amount of peasant land remaining was very unequally divided into private property plots; 30 per cent of the population was, in fact, landless, while another 50 per cent lacked the two hectares necessary for subsistence. In the first report(41) on its Cauca Valley operations, CSF made no mention of the oppressive nature of existing economic conditions, class relations and land tenure, and their relationship to income and nutrition. After stating that 50 per cent of the children under six years of age in the area were malnourished, the report opined that the peasants were misusing their resources. Instead of selling all their soya, if they only retained 7 per cent of it for their own nutritional needs, they could close the ‘protein gap’.

The CSF report failed to take note of the fact that these folk were continuously confronted with the stark necessity for cash. In an individual family’s food priorities, the chief breadwinner’s caloric requirements must remain an important consideration. The workers were aware that wage labour on the plantations was an enormous energy drain, in comparison with peasant labour, and made the labourers thin and prematurely old. When their land shrank below subsistence size, the peasants were forced to intensify their labour and energy output by going to work on the plantations.

THE ROCKEFELLER FOUNDATION IN COLOMBIA

The Rockefeller Foundation became involved in Colombia for the first time in 1913 with its hookworm eradication programme. Although this was a failure due to a lack of co-operation from the rural poor, the Foundation went on, in the 1920s, to found scholarships for promising young physicians; in the 1930s, to reorganise the country’s public health system; in the 1940s, to help the government’s institute of agronomy; in the 1950s, to influence Colombian medical practice through its patronage of the medical school at the University of Valle; and, in the 1960s, to influence higher education through the Foundation’s new University Deve1opment Programme’s work at the University of Valle. Colombia was second only to Thailand in the number of Rockefeller scholarships and grants that its citizens received.

In 1963, U.S. academics, under the Foundation’s auspices, were involved in birth control projects, and, by 1970, were offering consulting services to government, business and industry.

But a widespread reaction against overt U.S. domination in many fields resulted in the Foundation’s expulsion from the country in the seventies. The Foundation now channels its grants through agencies such as the Foundation for Higher Education (FES) and the FES’s Department of Research and Education which operate under the Colombian flag, and disguise the U.S. presence whilst preserving its influence.

As Taussig wrote(42): “..............health services can be recruited for political...............goals in a large number of complicated and interacting ways. Medicine is a specially privileged tool in that its humanitarian image allows for the penetration of forces that might otherwise be unacceptable. The fact that the research and its application are constrained by the interests of the powerful, and it is so tied to economic incentives that knowledge and creativity become market commodities like any other, adds to the erosion of scientific values and the stifling of critical thought. The inability, to raise popular support for health programmes, severely restricts the gathering, interpretation and application of data. The fact that appearances are what count - the appearance of real aid instead of self-interested aid and Machiavellian manipulation completes this erosion, so that the projects are little more than a triple play in desperation - the desperation of the poor, the desperation of governments to act in a way that does not threaten their power, and the desperation of the local and foreign professionals for the grants and international connections by which their careers can be furthered - leaving rational social change an empty promise”.

THE POLITICS OF MALARIA CONTROL

After several years of increasing success, in the attempts to control malaria, in the post-World War II era, it is now realised that malaria has made a major comeback in the seventies and eighties. It has been shown that the widespread, de-facto and intentional de-control of malaria is part of capitalism’s strategy of underdeve1opment and repression to save itself through a process of global restructuring of international economic relations.

Not only is the resurgence of malaria widespread, causing the deaths of millions in Asia and hundreds of thousands in Latin America, but the steps taken to counteract it have been far from adequate and, moreover, demonstrate a lack of commitment on the part of officialdom, governments and foreign aid donors. Indeed, the implications would appear to be that the de-control of malaria may be permitted to become much more serious. The most serious resurgence of malaria had been in Southern Asia, with India, and Pakistan being the countries most affected (43). There had also been increases in Afghanistan, Sri Lanka, Nepal, Bangladesh, Burma and Indonesia (44), as well as in Central America (Honduras, El Salvador, Costa Rica and Haiti) and sub-Saharan Africa.

In the post-World War II period, the global attack on malaria had been so successful that the World Health Organisation (WHO), which had initially set its sights on malaria control only, declared in 1955 that the eradication of malaria globally was technically, at least, achievable. The anti-malarial programmes in this period consisted of the treatment of malarial patients with specific drug therapy and the interruption of the transmission of the disease by spraying walls, for example, with DDT, to kill the mosquitos. The progress achieved could be assessed thus: the total eradication of malaria from the U.S., Europe, most of the Soviet Union, and some Third World countries; a major degree of control on the Indian sub-continent; and, some control in the malarious areas of sub-Saharan Africa.

The resurgence of malaria was officially-acknowledged by the WHO when its Director-General, H. Mahler, wrote of a generally worsening global situation of malaria decontrol with a hard core deterioration in Asia (45). The studies financed by the World Health Organisation spoke of the increasing resistance of the parasite and its vector to drugs and chemicals, of the poor administration of anti-malarial programmes, of inadequacies in all the factors associated with a successful anti-malaria programme, such as research, training, supplies and infrastructure, and of poor socio-economic conditions generally. All of these could be interpreted as being due to a lack of adequate funding, it being well known that parasite and vector resistance is often due to inadequate or incomplete control.

Not only did the countries affected make an inadequate response to WHO’s findings, but the funds from the United States Agency for International Development (USAID), the United Nations International Children’s Emergency Fund (UNICEF) and the Pan-American Health Organisation all began to tail off prior to all this. Cleaver wrote that the reasons, offered by national governments and international agencies, reasons such as the prohibitory cost of the programmes or administrative mismanagement, were inadequate and unconvincing explanations for abandoning or underfunding programmes when previously malaria eradication or control efforts had been shown to be generally successful (46).

Cleaver(47) believes that the programmes of the Rockefeller Sanitary Commission in the U.S. South were part of a much larger development strategy by Northern U.S. businessmen which formed the basis of subsequent U.S. strategies in China in the years preceding the Second World War and in much of the Third World in the years subsequent to the war. The Populist Revolt in the U.S. South in the 1880s, and the 1890s, when large numbers of small family farmers and sharecroppers rose up against their systematic exploitation by Northern merchants, bankers and industrialists was seen by the Rockefeller philanthropists as demonstrating a need to develop Southern agriculture, restructure Southern education and transform Southern government. The Rockefeller Foundation’s hookworm campaign in the South also led to health campaigns in schools, the foundation of schools of public health, the de-fusing of farmer antipathy and rural unrest by appearing to improve the health, and thus the productivity, of the farmers, and, finally, led to the involvement of government funding and to government takeover of the programmes.

Hard on the heels of the hookworm campaign in the U.S. South came the malaria campaign(48) when it was realised that the efficiency of the military personnel on the bases in the U.S. South was seriously hampered by malaria(49). It can be seen that the decision to undertake public health campaigns in this region was not based so much on the presence of longstanding poverty and disease but on the need to resolve to further the cause of ruling class hegemony.

Throughout the capitalist world, both in the metropoles and at the periphery, the development of medical care and public health services was brought about by economic and political factors, viz., the need for private enterprise and capitalist dominated governments to increase productivity and defuse worker and peasant unrest through improved health. The imperialist strategy, of importing workers from healthier rural pools to replace those made ill by the poverty and overwork of underdevelopment, failed to make good the losses in productivity resulting from the constant renewal of the labour pool.

The underdevelopment of rural societies following the arrival of colonialism destroyed traditional social structures and forced peasants off the land. The local ecology was destroyed, and poverty, hunger and ill-health used to force the indigenous populations to work on the plantations and in the mines (50). The result was a rise in the level of endemic disease, together with recurrent severe epidemics which interfered with successful colonial exploitation (51). The high mortality led to the depopulation of whole towns during epidemics. The anti-malarial measures undertaken by colonial administrators, however, were piecemeal and fragmented and not designed to increase the health and productivity of the whole of the colonised population. Instead they were restricted to the area where the white expatriate population was concentrated and where the plantations and mines were sited.

In fact, the differential development of health programmes was a feature of colonialism, with better services for the immediate employees of the colonial export industries and the surrounding populations, and worse, or non-existent, services for the more underdeveloped hinterland. It was a vice-president of the American United Fruit Company who, when giving the reasons for setting up hospitals for the company’s workers in Central America, said: “The work that has been done was done for a very practical hard-headed reason - that of self-interest..............sick people cannot work.........It may have been an enlightened self-interest, but it was done largely because (the American companies) could not get out the ore, or raise the bananas or pump the oil unless these fundamentals were taken care of” (52). As labour was scarce in Hawaii, plantation medicine was given top priority on the islands (53).

Furthermore, a good deal of the scientific research and foreign public health work done by Americans and Europeans was directed not just towards the needs of commerce, but also to those of military strategy. The high mortality from malaria amongst American soldiers in Cuba during the Spanish- American War provided the impetus for the discovery of a vaccine against yellow-fever. In addition, health care and public health were presented as the kindly and humanitarian face of imperialist penetration.

In China, the Rockefeller Foundation’s public health work was part of private efforts to save China by stemming peasant revolution and undermining socialist fervour. The Foundation’s support for public health measures in the country included building and supporting the renowned Peking Union Medical College (whose curriculum was organised according to the Flexnerian model), co-operating with the police department to establish a municipal public health station and supporting the public health component of Jimmy Yen’s anti-communist community development programmes. These health programmes were complemented by others in agriculture, education and elite-building (54).

The philanthropic organisations’ vision of investing in health and productivity as a basis of stability and capital accumulation influenced strongly the approach which dominated U.S. foreign aid and development policy and the character of bilateral and multilateral aid programmes in the post-World War II period. The Rockefeller Foundation, by standing outside and above the interests of individual multinational companies, helped to build an international public health movement, which aimed at widespread public health measures, focussed on the causes of particular diseases, co-operated with established governments, and elite institutions and individuals, and ignored poverty, inequality and exploitation.

THE POST-WORLD WAR II PERIOD

In the years after the Second World War, the approach towards developing public health services as a guarantee for a more productive labour force became institutionalised as a ‘human capital’ investment component of capitalist development strategies. This concept, initiated by the Rockefeller Foundation years before, was developed more fully at the national and international level in the 1950s and the 1960s (55). The use of public health became an ideological weapon in the fight against industrial and peasant revolt by increasing not just the physical ability to work but also by increasing the willingness of workers and peasants to work.

To take the example of Dr Tom Dooley: whilst working as a U.S. Navy doctor in Haiphong in 1954, Dooley helped Catholics from North Vietnam to escape to the South and, later, whilst still liaising with the Central Intelligence Agency, worked inremote areas in Laos, near the Chinese border, persuading people to identify with the government rather than with the guerillas.

In 1950, a conference was held at the Harvard School of Public Health when the representatives of twenty-three-multinational corporations met with public health experts to discuss how health work could be brought to bear in the fight against communism. The Dean of the Harvard School of Public Health had this to say:

“Powerful Communist forces are at work in this country and throughout the world, taking advantage of sick and impoverished people, exploiting their discontent and hopelessness to undermine their political beliefs.......Health is one of the safeguards against this propaganda. Health is not charity, it is not missionary work, it is not merely good business - it is sheer self-preservation for us and for the way of life which we regard as decent. Through health we can....prove, to ourselves and to the world, the wholesomeness and rightness of Democracy. Through health we can defeat the evil threat of Communism” (56).

Shortly after, the Rockefeller Foundation began to limit its operations, as the World Health Organisation (WHO) and its associated agencies and the various U.S. bilateral aid programmes entered the scene. In the years after the Second World War, there was a re-organisation of the U.S. governmental international health projects. Those in the Western Hemisphere were co-ordinated under Nelson Rockefeller’s Institute of Inter-American Affairs (IIAA) (57), and the government public health programmes were intended to play an important role in fighting social unrest and agrarian revolution.

In Europe, the public health activities of the American Economic Cooperation Administration (ECA) under the Marshall Plan and of the United Nations’ Relief and Rehabilitation Administration had the remit to undermine socialist politics. In IndoChina, the ECA’s public health programmes attempted to counter France’s weakening position (58), and a number of projects were launched, e.g. a trachoma control project, an anti-malaria DDT team and other technical assistance programmes employing American public health specialists of all kinds: health officers, sanitary engineers, nurses, laboratory technicians, and health educators. It is alleged that public health programmes financed by U.S. foreign aid played a political role in the following situations: Iran, during the 1953 overthrow of Mossadegh, Thailand, during the counter-insurgency campaigns of the early fifties, and the Philippines, during the fight against the Hukbalahap guerillas in the late forties and early fifties (59).

In 1956, President Eisenhower threw U.S. support behind WHO’s world wide malaria eradication programme. He announced a new anti-malaria programme and described it as another example of American humanitarianism. Funds were to be channelled through the ECA and WHO. It had been noted that the U.S. would reap the same benefits indirectly when the funds were channelled through international bodies and multilateral programmes since the multilateral agencies were closely interrelated with American programmes. Decisions as to whether or not to support anti-malaria programmes have been influenced more by considerations of a political nature than by those of welfare or common humanity.

Just as the development of public health programmes leads to increased work and profits for capitalism, so, depending on the circumstances and events affecting international capitalism at a given period, the underdevelopment of public health can lead to capitalist profitability. In this context, development and underdevelopment are different strategies by which capital seeks to control the working class, although, as a result of the hierarchical relations that necessarily exist under capitalism, as well as to maintain that hierarchy, development for some is accompanied by relative or absolute underdevelopment for others. Therefore, development and underdevelopment are not just opposites, but are two different socio-economic strategies. In a situation of development, working class income and health are raised for more work; in the circumstances of underdevelopment, income is reduced and public health programmes undermined.

Historically, these alternate strategies have been employed in the following situations, as when agriculture was underdeveloped in early capitalism in order to induce labour to migrate and serve the needs of developing industry in the early conurbations, or when the ‘zamindari' system was developed on the Indian subcontinent by British capitalism in order to facilitate the underdevelopment of the land. When the development of a land and its people is judged to be inimical to the interests of capitalism because, for example, increased income would result in less work (in a situation of back-breaking work and super-exploitation), then coercion (in the form of the hut tax, the poll tax or the destruction of the means of livelihood) is utilized to force more people into labour and to extract more labour out of the workers.

Cleaver(60) explains that the self-destruction of capital, although apparently irrational, is not unusual, and is one of the means by which, in a capitalist crisis, the conditions of profitability are restored. Such a scenario is usually associated with monetary or commodity capital; in the case of ‘human capital’, the self-destruction of capital has meant the destruction of working class power and a reduction in the level of working class health. Disinvestment in health has occurred previously under capitalism, as during the period of super-exploitation and vast primitive accumulation associated with early colonialism, and also during later colonialism when a mixture of development and underdevelopment was utilised in the differential investment in improved health for some (in the urban industrial enclave) and none for others (in the rural hinterland). If disinvestment in health has occurred previously under capitalism, then there is the possibility that that is what is happening in regard to public health programmes and to malaria control today.

The working class struggles for higher wages in the 1960s ruptured the link between production and income and undermined capital’s control over labour. In the Third World, the demands of the super-exploited have erupted, time and again, into revolutionary violence. The response of capital has been long term austerity and long term restructuring. There has been a development of capital intensive sectors like energy, and the collective strength of the working class has been undermined by the establishment of new hierarchies and by the fragmentation of the class. In areas of increasing underdevelopment, there has been a decrease in the income of the working class. In the Third World, the strategy of letting nature take its toll has led to absolute starvation in parts of Asia and Africa. The manipulations of the giant transnational companies have resulted in rising food prices and lower standards of living in the metropolis.

One of the results of capital’s re-structuring of the world economy has been the underdevelopment of public health and medical care through a reduction in government support. In the metropolitan centres, this has taken the form of cutbacks in government expenditures for medical care and the closing of some hospitals. In some of the peripheral capitalist countries of the Third World, this took the form of reduced funding for malarial control allowing the disease, which had previously been largely under control, to spread.

The change in policy from expanding malaria control to underdevelopment through disease was part of a set of repressive measures undertaken by the lumpenbourgeoisie in the peripheral capitalist countries (61). In the Philippines. for instance, there was a shift in policy from the expansion of malaria control to the intentional withdrawal of control for political reasons. In a few Third World countries which were becoming new centres of peripheral capitalist development, as in Brazil, Saudi Arabia and Iran under the Shah, malaria eradication programmes were hurriedly enforced.

Arguments, that propose that, at a time of ‘fiscal’ crisis, improved health for some can only be possible at the expense of deprivation for others, must be seen not only as part of a strategy of ‘divide-and-rule’, but also as an exhortation to the poor to manage their own poverty.

SELECTIVE PRIMARY HEALTH CARE

The health culture of a community is a component of its overall culture and, as Banerji noted(62), is formed by:

(a) the cultural meaning of health problems;
(b) cumulative health practices, derived from various systems of medicine, home remedies and non-professional: sources, that are acquired by the community as its social inheritance;
(c) diffusion of health practices from outside;
(d) active efforts to acquire health practices from outside; and,
(e) cultural innovations by the current generation to deal more effectively with the prevailing health problems. The International Conference on Primary Health Care (PHC) held in Alma Ata, in the Soviet Union, under the auspices of the World Health Organisation (WHO) in September 1978, revealed an important shift in the thinking about the nature of Third World underdevelopment(63). Primary Health Care, which was defined as the basis for achieving the ultimate goal of health for all by the year 2000, was to include at least the following:
(a) Education concerning prevailing health problems and methods of preventing and controlling them;
(b) Promotion of food supply and proper nutrition;
(c) An adequate supply of safe water and basic sanitation;
(d) Maternal and child health care, including family planning;
(e) Immunization against the major infectious diseases;
(f) Prevention and control of locally endemic diseases;
(g) Appropriate treatment of common diseases and injuries;
(h) Provision of essential drugs.

The Declaration of Alma Ata was a recognition of the reasons for the unsatisfactory results in many health programmes and of the necessity for a basic needs strategy in which the Declaration should be used as a guide for planning. From the end of the Second World War to the seventies, the dominant, Eurocentric, GNP-based view of development was the theory of diffusion or ‘ trickle-down’ of which Rostow is probably the best known exponent. This has been discussed in a previous chapter.

By sponsoring the basic needs strategy, the Declaration has stimulated a reexamination of the best way to create health whilst attacking disease The creation of health would also depend on:

(a) The creation of a good standard of nutrition,
(b) Access to adequate social services, such as education in addition to health,
(c) Full employment,
(d) The opportunity for the whole population to participate in the social and political decisions and processes: which influence their daily lives (64).

The Conference at Alma Ata gave new impetus to the movement (which had been gaining in strength) that argued, with an eye on the changes in health care delivery in China and Cuba, that the improvement in the health of the people could and should be achieved with the resources that the community already possessed. It should not be made dependent on the growth of the national product as development could be delayed, postponed or cancelled even in the presence of economic growth, and a healthy, educated and socially involved population is a necessity for true development. However, whilst, in theory at least, many governments support the idea of primary health care as spelt out in the Declaration, the fact of the matter is that, in practice, they continue with the fragmentary allocation of individual disease control programmes and remain opposed to the integration of such programmes into a system of comprehensive primary health care.

The sequelae to the Conference at Alma Ata have once more brought to the fore the difference between the two classic approaches to disease control and health care delivery, viz., the verticalist and the (more progressive) horizontalist (or integrationist) approaches. The verticalists sponsor specific, hierarchically organised disease control programmes and are rebuked by the integrationists for their narrow approach to the whole aspect of health care, for failing to appreciate the social causation of most disease, for imposing solutions from above rather than working with communities, and for obstructing improved and integrated health care systems. In the realm of primary health care, the verticalists have surfaced as supporters of selective primary health care and have the ear of many Western governments and aid agencies, and even, as will be shown later, UNICEF. In the field of primary health care, their views have been crystallised by Walsh and Warren (65).

The verticalists argue that health for all by the year 2000 (the message of the Alma Ata Conference) is a noble goal, but one that is unattainable through a comprehensive primary health care approach aimed at the total coverage of the population. Instead they argue for a policy of selective intervention to deal with the most serious public health problems; they consider the primary health care, as advocated by the Alma Ata Declaration, and which they re-name ‘comprehensive primary health care’, too costly for underdeveloped Third World countries and requiring a large number of trained staff.

Walsh and Warren advocate a system of selective primary health care which gives priority to certain diseases according to their prevalence, the level of morbidity or disability they cause, their mortality rate, and the feasibility and effectiveness of control measures and the cost of intervention (66). The selective approach, they suggest, should be aimed at children less than 3 years old and women of childbearing age, and this would result, they go on to claim, in a significant decreases in the mortality rates. The five components of their selective approach are:

(a) Measles and DPT vaccination for children over 6 months of age;
(b) Tetanus toxoid to be administered to pregnant women to prevent neonatal tetanus in their infant children;
(c) Encouragement of long term breast-feeding;
(d) Chloroquine treatment during febrile episodes for children under 3 years of age in malarious areas; and,
(e) the provision of oral rehydration salts and instructions for their use in the treatment of diarrhoea.

This is in contradistinction to the broad concept of primary health care agreed upon at the Alma Ata Conference This model of selective primary health care would be provided either by fixed units or by mobile teams visiting every four to six months. Health care delivery would be restricted to proven low-cost methods of intervention in a minimum number of health problems affecting large numbers of people. Walsh and Warren suggest that until a country has reached that level of socio-economic development, when it can afford a system of comprehensive primary health care, an interim strategy will become necessary. Resources should be concentrated on the research and development of less costly and more efficacious methods of prevention and treatment. The large scale treatment of chronic illnesses such as leprosy, tuberculosis and onchocerciasis. would not be attempted.

In an example where the selective approach was applied to a health project in an underdeveloped country, viz., the Haiti Project (67), it is claimed that by targeting diseases such as diarrhoea, tetanus, measles, diptheria, pertussis, poliomyelitis, tuberculosis and malnutrition, the overall mortality rate was reduced by 40%.

Boland and Young(68) disagree with the view that comprehensive primary health care can be achieved with an annual expenditure of as little as US$6 per capita. When the costs of labour, supplies, food, supervision, logistical re-organisation, depreciation, travel expenses, training, safe water supply and proper sanitation ara taken into account, the figure is much higher, and too expensive for most underdeveloped countries to implement. Boland and Young claim that in the three countries. where primary health care has been successful, viz., China, Cuba and Tanzania, the governments exercise central political control over their peoples and have the necessary strength and stability to effect radical changes in their health systems. They conclude, therefore, that because of the prohibitive costs of comprehensive primary health care and current political structuring, an approach of “selective primary health care for all by 1990”, providing nutrition, immunization, the control of endemic diseases and health education would be more appropriate.

Evans and his colleagues (69), who also support the selective approach, state that primary care can only be delivered to a population at low cost if the programmes are carefully selected according to prevailing needs. According to them,maximum improvement can be obtained by concentrating scarce resources on maternal and child health services and the control of the major infectious and parasitic diseases in children under the age of five. In 1982, none less than UNICEF endorsed the selective approach to primary health care by introducing a system aimed at pregnant women and children and entitled GOBI - FF as follows (70):

G = mass use of growth charts to monitor child development,
O = widespread availability of oral rehydration salts,
B = promotion of breast-feeding,
I = immunization of all children, against measles, diptheria, pertussis, tetanus,tuberculosis and polio-myelitis,
F = food supplements for pregnant women and young children, and
F = family planning, emphasizing birth spacing.

This programme is intended to reduce, dramatically, the high infant mortality and morbidity rates in underdeveloped countries. It must, however, be seen as another one of the vertical approaches to primary care favouring categorically specific, hierarchically organised, discrete disease control programmes.

THE COST EFFECTIVENESS OF PRIMARY HEALTH CARE PROGRAMMES

Gish(71) suggests that the concept of primary health care can be related to health programme planning in terms of three types of objectives: effectiveness, equity and efficiency. Effectiveness or the outcome of objectives refers to the changes in health status and related conditions resulting from the health programmes. Reductions in disability and discomfort are measured in addition to the reduction in mortality; furthermore, the Alma Ata strategy includes other outcomes more difficult to assess such as self-reliance, local participation and control, and client satisfaction. A sympathetic consideration of these other outcomes, as well, increases the acceptability of these programmes by clients. Equity objectives represent a strategy for the distribution of services broadly throughout the whole community. Some services, e.g. immunization do not require a wide coverage in order to be effective, but the introduction of high technology must take into account the need for equity in the distribution of resources. Efficiency implies more services from available resources. Other things being equal, selection of the most efficient programme alternatives will bring the greatest benefits, although, theoretically, efficiency could conflict with equity and effectiveness. Choices will be limited by historical, financial, technical, managerial and social factors.

COST-EFFECTIVE CRITERIA

Owing to the fact that it is not easy to assess health benefits in dollars, or pounds, or monetary terms, cost-effectiveness (C-E) techniques are being increasingly used instead of benefit-cost analyses(72). The methodology is explained by Levin(73). A ratio is formed to give an average or unit cost per unit of outcome (e.g. dollars per death averted) or units of outcome per dollar. The investment option with the lowest C - E ratio maximises benefits or minimizes costs.

Gish(74), however, believes that the technique of C-E analysis involves several critical simplifications which make it inappropriate for evaluating general primary care activities. Projects can only be compared, he says, if their outcomes are measured in similar units or if only one type of outcome is being compared. In programmes which produce a broad mix of benefits, C-E comparisons tend to undervalue interventions that produce important outcomes other than the one being considered. A further problem is the tendency to confuse efficiency with increased coverage. Coverage is determined not only by efficiency, but also by accessibility and acceptability.

Finally, C-E analysis has been used to compare different mixes of services, and alternative delivery systems. Differences in the mix of services and delivery systems will affect both the cost and effectiveness in the calculation of C-E ratios. Valid comparisons, therefore, should hold all other factors constant, except the one being measured. In comparing C-E ratios for different countries and for different periods in time correction must be made for inflation and exchange rate differences. C-E analysis, therefore, is not a method for evaluating complex medical care programmes, or for developing a multifactorial primary care programme. It is more appropriate for choosing amongst alternative health care technologies with single outcomes.

Analysing primary health projects based on the selective approach, such as:

(a) the Haiti project, which was based on the Albert Schweitzer Community Health Project, and built around a 140-bed hospital,
(b) the Lampang project in Thailand,
(c) the Danfa project in Ghana, and
(d) the ambitious India Population Project I,

Banerji(75) concluded that the results of selective or partial interventions within a system do not live up to expectations. He opined that the lessons of these projects did not seem to have been considered by those favouring the selective approach as an alternative to comprehensive primary health care.

Banerji goes on: “The whole concept of primary health care is based on a philosophy of health service development that is quite different from the selective approach. Primary health care is based on a people, rather than on a pre-determined system. It emphasizes social control over health services, involving people at all stages of health service development, namely problem identification, programme formulation, and programme implementation and evaluation. Selective primary health care is thus a contradiction in terms because it adopts an authoritarian or paternalistic approach in “selecting” for others a number of limited vertical health programmes and leaves the other causes of ill-health untouched...........It would need very convincing evidence to prove that a package of a few selected programmes provides an approach that is epidemiologically and socially more effective than a programme of comprehensive primary health care services. Certainly, there have been major shortcomings in the implementation of primary health care in most countries of the Third World. But those who claim that the selective approach is a more cost-effective alternative have failed to prove their case. The promotion by outside agencies of a selective approach (essentially a simplistic solution to a highly complex problem) may turn out to be dangerously counter-productive”.

HEALTH CARE DELIVERY AND THE BRAIN DRAIN

Health problems in the underdeveloped countries are related to their poverty rather than to their tropical or subtropical climates; reductions in morbidity and mortality are more likely to be accomplished through the equitable distribution of health resources rather than from further advances in medical science as such. Planning for health care in rich and poor countries has to be different; the levels of available resources are different not only with regard to finance but also with regard to skilled manpower. The differences in the availability of financial resources are reflected in the differences in the statistics for hospital beds in the developed and underdeveloped countries.

The disparity in the levels of skilled manpower is reflected in the differences in the number of available medical workers between the two groups of countries. In the United Kingdom, for example, there is one doctor for every 860 people, but in India, on the other hand, there is one for every 5,000; in Haiti, there is only one doctor for every 13,000 people, and in Nigeria, only one for every 30,000. Furthermore, doctors are much less evenly distributed in the underdeveloped countries.

The differing structure and location of populations will require a different emphasis on health planning. In an underdeveloped country, a much higher percentage of the population will be found to be under the age of 10 and while the population may be increasing, say, at the rate of 0.5 to 2 per cent per year in the developed countries, in the underdeveloped countries this increase may be 2.5 or even 3 per cent. In underdeveloped countries, the rural areas may hold between 50 and 90 per cent of the population, whereas in the United States only 10 per cent of the population are described as living in rural areas, and in Britain this figure is said to be 5 per cent.

In the underdeveloped countries, the rapid rate of urbanization related to the development of enclaves characteristic of dependent peripheral capitalism results in the growth of shanty towns. Lastly, in underdeveloped countries, disease patterns differ drastically from those in the developed world. Half or more of all deaths occur in children under the age of 5, whereas, in the United States, more than half of all deaths are caused by diseases of the heart and blood vessels amongst people between 50 and 70 years of age. In the underdeveloped countries, children die mostly from diarrhoea, pneumonia and malnutrition. Infant mortality (0-1 year olds) may be four times as high, and childhood mortality (1-4 year olds) may be forty times as high as in the developed world. The diseases of the developing countries are largely the result of poverty (76).

HEALTH CARE FACILITIES

In underdeveloped countries, the introduction of the kind of high-tec hospital-based medical care system that has been developed in the industrialised countries means that it is possible for a single regional type teaching hospital in a capital city in a Third World country to absorb the greater portion of that country’s annual budget, and thus making impossible an equitable distribution of health resources. Furthermore, these large teaching hospitals in the capital, with their contigents of specialists and super-specialists, although supposedly serving as the peak of a curative medical care system for a wide geographical area, if not for the whole country, in practice, turn out to be functioning as the district general hospitals for the immediate geographical areas, viz., the industrial urban enclaves and their elite groups.

For underdeveloped countries concerned with reaching the whole of their populations with an adequate health care delivery system, the alternative is the health centre with its outlying aid stations or dispensaries and mobile clinics which reach large rural populations at the lowest possible level. The health centre would provide the entire health requirements of a family, in both preventive community and curative medicine, except those which can only be provided in a hospital. Gish(77) has calculated that a country with only 50p per capita to spend on health care could still provide basic health care services for its entire population. Gish has also calculated that, for 50p per head, it would be possible to run a network of district hospitals to cover an entire population, serving them with certain specialised services. In large cities, a number of district type hospitals can be located in the same city to provide facilities for teaching and research. In a country with a per capita income of, say, £40 per annum, a health expenditure of £1 per head would amount to 2.5 per cent of the G.N.P.

HUMAN HEALTH RESOURCES

The type of health care delivered is critical in determining the type of manpower employed. Large hi-tech city hospitals require highly specialised medical personnel to carry out specialised medical research, the teaching of future highly skilled manpower and the care of patients suffering from exotic diseases. In many underdeveloped countries, there are not sufficient staff to man the large hospital facilities which already exist, in spite of the concentration of medical personnel in the capital cities.

Health centres, on the other hand, can be staffed by men and women with middle level skills(78), viz., medical auxiliaries and para-medical staff, such as registered nurses, pharmacists, laboratory technicians and health inspectors.

The education of medical students in the non-socialist Third World is similar to that of those in the West, and prepares them for employment in a large city. This trend is likely to remain unchanged. Although medical schools in the Third World have been rapidly increasing their output, there is no significant increase in the number of doctors outside the capital cities and large towns. When these become oversupplied with doctors, medical emigration occurs, benefiting the developed countries, mainly the United States, Great Britain, Canada, Australia, Germany and France(79).

Medical education in non-socialist Third World countries is organised after the pattern found in Western models, and turns out graduates socialised into Western medical attitudes. Doctors are trained not so much to service the needs of the mass of the population who are rural dwellers and who have a low effective demand, but more to cater to the wants of the few urban dwellers who have a high effective demand. As the doctors cannot all compete successfully for the patronage of the urban middle and upper classes, many seek emigration.

Such a situation can only be corrected by tailoring medical education to service the type of health problems faced by the population of the country as a whole. For this purpose, the creation of new social and professional attitudes is just as important as the creation of new medical curricula to combat illness, disease and death in rural areas. Doctors should have part of their training in the circumstances of a district hospital in the rural hinterland. The overt policy in some Third World medical schools of turning out medical graduates for the very purpose of emigration should be halted. They are accepted in the receipient countries only because they fill a demand for a greater number of health workers than the receipient countries are able to turn out from their own institutions, as well as functioning in the role of a medical subproletariat.

Gish(80) describes the international migration of doctors as primarily the result, as well as the measure, of the maltraining and related malutilization of medical manpower, and of graduates in particular, and states that this is equally true in the case of the United Kingdom as it is of India. In the capitalist countries of the centre, medical care has developed as part of the market system, and most medical services have had a price attached to them. This has been part of the process of the social and economic development which has characterized the progress of today’s industrialized centres. Those who accept the dominant role of market forces in the process of the allocation of health benefits suggest that there is no such thing as a brain drain, but only a redistribution of health manpower that obeys the laws of the market, i.e. that it is all a question of supply and demand. These persons would reduce health care to the status of a commodity.

Doctors are trained in keeping with the values and requirements of those with incomes sufficient to purchase private medical care, and there is increasing pressure from these groups in the population for the training of even greater numbers of doctors. The expensive training costs of doctors means that the level of effective economic demand of the great majority of the population cannot meet the expectations and requirements of the medical graduates, who then emigrate to those parts of the world where demand is greater. The existence of this overflow by emigration stimulates the production of still greater overflow as doctors begin to be trained specifically for overseas demand. Where emigration has not reduced the glut of doctors in a Third World country, health planning becomes centred around the need to employ the high status doctors, which further distorts the health care delivery system.

Medical migration is the result of the national and international inequalities in the distribution of income both within and between countries. The same conditions that result in the concentration of human health resources in the industrial enclaves and capital cities of the Third World are also responsible for the international movements of these resources. Also as long as countries continue to produce, and produce in surplus, inappropriate types of medical graduates, medical migration from poorer to richer countries will occur.

International medical movements distort the educational and health care systems of underdeveloped countries. They are, however, the logical extension of the kinds of health care systems to be seen in most underdeveloped countries. So long as the availability of health care is determined primarily by market forces, it is inevitable that an oversupply of doctors in any area relative to economic demand will overflow into the world market. The occurence of these movements will prevent market forces from bringing the supply of doctors into line with demand. The solutions to these problems can only be effected by changes within the framework of individual national health care systems and the social, class, political and economic structures within which they exist.

REFERENCES

KUNITZ, Stephen J. “Professionalism and social control in the progressive era: the case of the Flexner Report”, in ‘Social Problems’, Vol. 22 (1), 1974. p 21.
KELMAN, Sander. “Toward the political economy of medical care”, in ‘Inquiry’, Vol. 8 (3). p 31.
WASSERMAN, H. “Harvey Wasserman’s History of the United States”. Harper and Row, New York. 1973.

- WILLIAMS, W.A. “The Contours of American History”. Quadrangle, Chicago. 1968.

- WIEBE, R. “The Search for Order”. Hill and Wang, New York. 1968.
RUDOLPH, F. “The American College and University”. Vintage Books, New York. 1962
BRAVERMAN , H. “Labour and Monopoly Capital”. Monthly Review Press, New York. 1974.
POLLACK, N. “The Populist Response. to Industrial America”. Harvard University Press, Cambridge, Mass. 1962.
EHRENREICH, B. and ENGLISH, D. “Complaints and Disorders”. Feminist Press, New York. 1973.
KUNITZ, S.J. “Professionalism and social control in the progressive era”. Op. Cit. pp 17-18.
CROLY, H. “The Promise of American Life”. E.P. Dutton and Co., New York. 1963. p 22.
BERLINER, H. “A larger perspective on the Flexner Report”, in ‘International Journal of Health Services, Vol. 5(4), 1975. p 575.
FLEXNER, A. “I Remember”. Simon and Schuster, New York. 1940. p115.
FLEXNER, A. “Medical Education in the United States and Canada”. Carnegie Foundation for the Advancement of Teaching, Bulletin No. 4, New York. 1910.
BERLINER, H. “A larger perspective on the Flexner Report”. Op. Cit. p 589.
RAYACK, Elton. “Professional Power and American Medicine: The Economics of the American Medical Association”. World Publishing, Cleveland. 1967. pp 66-72.
CURTIS, James L. “Blacks, Medical Schools and Society”. University of Michigan Press, Ann Arbor. 1971.
BERLINER, H. Op. Cit. p 590.
STEVENS, R. “American Medicine and the Public Interest”. Yale University Press. 1971. pp 55-74.
KLEINBACH, G. “Social structure and the education of health personnel”, in ‘International Journal of Health Services’, Vol. 4(2), 1974. p 312.
NAVARRO, V. “Social Class, Political Power and the State, and their Implications in Health and Medicine”. John Hopkin’s University, Baltimore. 1976.
MYRDAL, G. “The Challenge of World Poverty”. Pantheon Books, New York. 1970. pp 164-207.
BOWERS, J., (Editor). “Medical Schools for the Modern World”. John Hopkin’s Press, Baltimore. 1970.
- PURCELL, E., (Editor). “World Trends in Medical Education: Faculty, Students and Curriculum”. John Hopkin’s Press, Baltimore. 1971.
KLEINBACH, Grace. “Social structure and the education of health personnel”. Op. Cit. p 313.
VAUGHAN, G.E.M. “A School of Tropical Medicine. The World’s Work”. 1907. Chapter 14, pp 8898-8901.
WILLIAMS, G. “The Plague Killers”. Charles Scribner and Sons, New York.1969.
MAY, J.M. “The Ecology of Human Disease”. M D Publications, New York. 1958.
BROWN, Richard E. “Public health in imperialism: Early Rockefeller programmes at home and abroad”, in ‘American Journal of Public Health’, 1976, Vol. 66, No. 9,p 899.
Ibid., p 899.
VINCENT, G.E. “The Rockefeller Foundation -A Review of its War Work, Public Health Activities, and
Medical Education Projects in 1917”. Rockefeller Foundation, New York. 1918.

-The Rockefeller Foundation, “Hospital Ship for Sulu Archipelago”. New York. 1916. Chapter 1. pp 13-14.
BROWN, Richard E. “Public health in imperialism: Early Rockefeller programmes at home and abroad”. Op. Cit. p 902.
LORD, D.C. “Mo Bradley and Thailand”. W.B.Eerdmans and Co., Grand Rapids, Michigan. 1969. pp 85-90.
MENDELSON, R.W. “I Lost a King”. Vantage Press, New York. 1964. p 139.
DONALDSON, Peter J. “Foreign intervention in medical education: a case study of the Rockefeller Foundation’s involvement in a Thai medical school”, in ‘International Journal of Health Services’, Vol. 6, No. 2, 1976. pp 251-270.
PENFIELD, W. “The Difficult Art of Giving: The Epic of Alan Gregg”. Little Brown, Boston. 1967. p 143.
DONALDSON, P.J. “Foreign intervention in medical education, etc.” Op. Cit.

AMERICAN (FLEXNERIAN) MEDICINE AND U.S. MEDICAL AID PROGRAMMES