CHAPTER 9

FAMINE
BIRTH CONTROL PROGRAMMES
THE ACTIVITIES OF THE MEDICAL SUPPLY INDUSTRIES FAMINE

With the onset of colonialism, the dominated areas. were transformed into suppliers of primary commodities (plant and mineral) for European consumption as well as into markets for European manufactured goods. Colonialism thus had the doubly detrimental effect of undermining not only the ability of the local populations to feed themselves, but also their self-sufficiency in manufactured goods. This was the beginning of “an intranational and international specialization that is so organised that one participant of the team specializes in starvation while the other assumes the white man’s burden of collecting the profits” (1).

With the colonialists expropriating most of the fertile lands, the amount available for the production of food for local consumption was reduced. For instance, the British colonial government in Kenya granted Lord Delamere 100,000 acres of the best land for the price of a penny an acre (2). In Africa, the local people were herded into native reserves, whilst, in the Caribbean, as well as in Latin America and Southern India, for example, the indigenous people were driven into the difficult and mountainous terrain of the hinterland. The intensive cultivation, often for subsistence farming, of the remaining land soon led to the exhaustion of the soil.

Numerous examples can be quoted from the history of the colonial world. In Senegal, it was intensive monkey nut cultivation; in Ceylon (Sri Lanka), it was the monoculture of coffee and tea and the associated deforestation; in Egypt, the continuous, instead of the previously periodical, irrigation then necessary for intensive cotton-growing; in Gambia, the extensive rice-growing for food, that was undertaken before the colonial epoch, was partly replaced by groundnut cash crop schemes, with the result that rice had to be imported to avert famine; Southern India was turned into a plantation economy just as much of Latin America was, raising cash crops for export to Europe, and thus laying the foundations for the occurence of recurring famines. Again, in Cuba, “the extensive plunder-culture of sugar cane meant not only the death of the forest, but also, in the long run, the death of the island’s famous fertility. With forests surrendered to the flames, erosion soon did its work on the defenceless soil and thousands of streams dried up” (3).

This process of the destruction of the ecology and the extension of the desert has been given a further impetus. With the advent of large scale refrigeration, the export of food items for the luxury consumption of ‘exotic’ foods in the metropolitan centres increased. The commercial production in S.E.Asia of pineapples, bananas and other tropical fruits for export has displaced local farmers, who then go on to seek employment as waged labour at $1 or $2 a day in atrocious surroundings (4). Although the production of seafood in Thailand has remained constant over recent years, exports have doubled with the result that the local consumption of fish has been reduced. Hayter(5) gives other examples: Africa is a net exporter of barley, beans, peanuts, fresh vegetables and cattle, whilst half of Central America’s agricultural land produces food for exports.

Many countries which are heavily exporting food and cash crop commodities to the metropolitan heartlands in Europe, North America and Japan have themselves become importers of food for the very survival of their populations. Towards the end of the seventies, essential food supplies constituted 40 per cent of the imports of Sri Lanka, 19 per cent of Mali’s, 30 per cent of Senegal’s, 23 per cent of Egypt’s, 17 per cent of Malaysia’s and 13 per cent of Mexico’s (6). Countries and individuals have been deprived of the fundamental right and basic security of being able to produce for themselves.

A factor that has been significant in producing hunger as well as an increase in the intensity, frequency and depth of famines is the unequal distribution of food and of the means to buy food. In the Bengal famine of 1943, there was no significant decline in the amount of food available. As people in the rural areas did not have the money to buy food, the food went to Calcutta and much of it was exported. Sen(7) relates stories of the hungry rural poor who had migrated to Calcutta in search of food, only to die in front of shop windows full of foodstuffs. The colonial powers established proxies in the subjugated areas from the ranks of the landlords, and, where there was not an established and collaborating landlord class, created one. In India, the peasants were beholden to money-lenders and middlemen and oppressed by a pernicious system of usury. The increasing inequality has resulted in a situation where the rich are getting richer and the poor are getting poorer, and food is disproportionately available to the rich in the towns and prosperous areas.

In the sixties and seventies, what has become known as the green revolution had been vigorously promoted by Western governments and aid agencies as a solution to the problems of underdeveloped countries. Although this consisted mainly in the development of high-yielding seeds, the aid projects were also accompanied by the sale or transfer of fertiliser, pesticides, and machinery which were beyond the reach of most small farmers. As agriculture becomes more profitable, the big landowners buy out the smaller ones. The resulting concentration in the ownership of land serves as a market for the major agribusiness firms which feature increasingly in the operations of the multinational corporations. The green revolution failed to solve the core Third World problems of distribution. Although there were increases in food production these were not distributed to those, who needed them. The rural poor were therefore worse off and the increase in poverty was associated with a rise in production of food cereals per head of population.

The impact of Western capitalism on traditional societies has been greatest in terms of land ownership and food production (8). The concentration of the ownership of land in England which followed the dispossession of smallholders and their replacement by capitalist farmers during the agricultural revolution has been repeated in a more drastic way. In Latin America, 17 per cent of the landowners control 90 per cent of the land and over one-third of the rural population uses only 1 per cent of the crop land. In Asia, 20 per cent of the landowners control 60 per cent of the arable land and their portion is increasing. In Africa, three-quarters of the population have access to only 4 per cent of the land. In 22 underdeveloped countries world-wide, one-third of the active agricultural population have no land at all (9). It has been calculated that vast areas of the world are potentially able to produce food crops. The potentially cultivatable area is 2-3 times the present, and could support 38-48 billion people, 1013 times the present world population, with the developed countries alone potentially able to feed 11.2 billion people. In the worst famine years of the early 1970s, enough food, in grain alone, was being produced world-wide to give everyone 3000-4000 kilocalories a day (10). And so whilst hunger and famine plague the Third World, grain, beef and butter mountains, and milk and wine lakes accumulate in the Western world.

THOMAS MALTHUS

Thomas Malthus (1766-1834) wrote extensively on the subject of population increase in England. He railed against what he felt was a tendency of the poor to have large families. He postulated that populations increased in a geometric way, viz., 2, 4, 8, 16, 32, etc., whereas food production increased arithmetically, viz., 2, 3, 4, 5, 6, 7, etc. To prevent poverty and starvation resulting from population increases out of proportion to increases in food production, he suggested that the poor should be persuaded to practise sexual restraint. Western aid agencies, Western governments and their client elites in Third World countries have taken up this argument, suitably modified, to promote family planning projects in underdeveloped countries. Using emotive language and speaking in terms of “population explosions”, they see population increases as the cause of disasters, famine, depletion of resources and disease, as development fails to keep up with increases in the number of persons to be fed.

Enlightened developmental theorists argue that the real problem is not inadequate food production, but inappropriate production and inequitable distribution. Because the best land in underdeveloped countries is owned and controlled by foreign and local capitalists who emphasize the production of cash crops for profit, these countries have to buy foodstuffs for their own consumption with the meagre payment they receive from Western countries in exchange for their cash crops.

The chairman of Booker McConnell, one of the largest multinational food companies in the world, stated the truth about relief for famines when he had this to say about starvation in the Sahel:
“The quantities of grain needed for the Sahelian relief were trifling in relation to the available supplies. The supplies could have been purchased and freight was readily available for shipment. Money and organisation, not available grain supply, seem to have been the problem in the Sahel zone” (11). The poor of the underdeveloped world, the poor whom Malthus described as dangerous, consume only one-tenth of the world’s resources. The U.S.A., with 6 per cent of the world’s population, consumes 35 per cent of the world’s total resources. The U.S.A. also consumes 25 per cent of the world’s oil and mineral resources and over 40 per cent of the world’s coal and natural gas (12).

THE PROPAGATION OF MYTHS ABOUT FAMINE

Jenny Hammond (13), in a seminal article on the myths that have been built up in the West around the origins and solutions to famine, criticises the partial diagnoses and oversimplified perceptions of the Western media and the Western aid agencies. Hammond goes on to describe NINE myths in detail:

Myth One : The Ethiopian famine.
At any one time, there may be not just one famine, say in Ethiopia, but severalregions in Africa (and Asia) may be suffering food shortages, famine and the effectsof migration.

Myth Two : Famine is a one-off natural disaster.
To regard famine as an Act of God is to absolve people from responsibility. This attitude obscures as well as entrenches the real problems. Famines should not be regarded in isolation from each other and from the long chain of economic and political causes and effects of which famines are the end product. The famines in the former colonial territories of Sahel, India and Ireland were the result of colonial exploitaion of the land for profit. During the Indian (Bengal) Famine and the Irish potato famine, ships, laden with food, were regularly leaving Calcutta and Dublin respectively for England. Hammond questions whether it is meaningful to distinguish ‘famine’ from routine starvation. Where disease and death are associated with very low routine nutritional levels such as obtains in countries with low average life expectancy rates, and where it is only the poor who die of famine, then there is an invisible famine going on all the time.

Myth Three : Famine is caused by drought. Hammond believes not. Rainfall has always been erratic in sub-Saharan Africa, but imperialist penetration, and the subsequent ecological damage, has disrupted traditional strategies for dealing with periods of decreased rainfall.

Myth Four : Famine is caused by enviromental degradation. Imperialist nations blame the poor peasant farmers and nomadic pastoralists for overtilling the soil and stripping the trees for firewood or forage. But enviromental degradation is not the cause of famine; it occurs during a famine. Having successfully managed their enviroment for centuries, the farmers and herders, impoverished by colonial domination, exploitation, confiscation of communal lands, hut, poll and animal taxes, and enforced labour, are now obliged to undermine their enviroment.

Myth Five : These African countries are overpopulated.
Famine is the result of an imbalance between food provision and population. The population density in sub-Saharan Africa is less than 16 to the square km (compared with 100/sq.km. in China). It is not so much the absence of food in these countries that is the problem, but the entitlement to the food that is available. The developed countries consume 80 per cent of the world’s resources, many of which are being exported from the Third World, including food from Ethiopia and the Sahel.

Myth Six : African countries have sunk into chaos since independence. Before independence and during colonialism, African agricultural production was disrupted by forcing peasant farmers into the cash crop economy for European profit. The best farm lands were switched from subsistence farming to the production of export crops, and Third World countries became dependent on the metropolitan buyers of their produce who also determined the prices. The situation remains unchanged in the present era of neo-colonialism or economic colonialism. The integration of Third World capitalist countries into the world capitalist order that is under Western domination ensures their continued exploitation and leaves them little room to manoeuvre for food self-sufficiency and, to effect radical change.

Myth Seven : Increased foreign aid will solve the problem. Bilateral aid (aid from a single, donor country to a single receipient country) is tied to goods, services, contracts, and fees to the donor country. Multilateral aid (e.g. from the World Bank) comes in the shape of large industrial investments which benefit only the small proportion of the population and the elite groups who live in the urban industrial enclaves. Food aid, by dumping Western grain surpluses, undermines local food production, destabilises internal markets and helps establish a taste, amomg the elite groups, for expensive imported foods, thus further adding to import bills.

Myth Eight : Development projects help. Many development projects have ignored traditional methods of socio-economic organisation and have had a disruptive effect on local societies. The emphasis placed by development agencies on land usuage has led to land passing out of the subsistence sector and into cash crop cultivation.

Myth Nine : The problems are insoluble. Africa has the resources and the land to feed all its people and more. However, until its rural farmers have access to their own land and control its management, food production will continue to be inefficient. Among the causes of food deprivation are the concentration of power in the hands of a small urban elite, with ties to the metropolitan centres and the multinational companies, who expropriate the country’s resources. A future for all of Africa will only be possible when the resources of her lands and of her people are restored to her.

AGRICULTURE IN THE UNDERDEVELOPED NON-SOCIALIST COUNTRIES

Agriculture is a source of capital accumulation itself and must, therefore, be examined in relation to the economy at national level and to the economy as part of international capitalism. The relation between agriculture and industry is a close one. Food prices determine the wage level since food is the basic element of consumption in these countries. Agriculture provides industry with raw materials, such as foodstuffs and fibres. Mechanised agriculture is a market for many industrial goods, e.g. machinery, fertilisers and pesticides. The agricultural sector is a source of transient labour looking for periodic work in small scale industry. In countries with little industrial development, agriculture is the principal source of capital accumulation.

From the middle 1960s, the changing relationship between the underdeveloped countries and the metropolitan centres has resulted in a rapid process of transformation of the agricultural sector. The increasing penetration of multinational agribusiness companies into the rural areas of the Third World countries has resulted in a shift of production from subsistence crops to cash crops for export, with resulting changes in the labour force and in property relations (14). With the fall in the production of subsistence crops, there is an increasing dependence of the underdeveloped countries on the grain-exporting countries, viz., the United States, Australia and New Zealand. It is estimated that 30 per cent of the population of the Far East suffers from malnutrition, 25 per cent in Africa, 18 per cent in the Middle East, and 13 per cent in Latin America (15). With the penetration of capital, either foreign or local, into the agricultural sector, there is an increasing concentration of land in a few hands. The peasants are displaced from the most fertile lands and end up either as waged labour in the cash crop producing, capitalist agricultural sector or as part of the industrial proletariat in the urban enclaves.

In the rural areas, then, there are two types of agricultural workers. These two groups are not strictly separable, however, for some workers in each group may perform roles associated with the other group of workers at different periods in their lives. One group of workers is occupied in subsistence agriculture and/ or small scale cash crop cultivation, and are referred to as the peasantry. The second group are the waged labourers, in the capitalist sector of agriculture, who constitute the rural proletariat. The peasantry make up the majority of the agricultural workers in the Third World. Their mode of production is labour intensive; they cultivate small plots of land with simple tools. Laurell(16) has described the twofold relations that the peasants establish with the capitalist agricultural sector. Firstly, the historical relation linked to the overall development of capitalism in the countryside and which was associated with the sometimes violent displacement of the peasantry to the least fertile land; secondly, the everyday relations of exploitation which occur in the unequal interchange between the peasants’ products and those of industry.

The poverty of the peasant obliges him to perform wage labour for some months of the year, possibly by having to migrate. Whilst this may be part of the process towards a complete incorporation of the peasant sector into the capitalist sector of agriculture, its immediate benefit to the capitalist sector is that it provides it with workers who only need to be paid during the few months of intensive labour. The peasant sector has a very low level of control over nature, a problem that is exacerbated because of its close relation to the capitalist sector. This was shown to be the case in the Sahelian drought of 1968-1973 when the natural phenomenon of drought was potentiated by the ecological degradation due to the process of overcultivation and overgrazing that had occurred in the area (17).

The labour intensive concrete work process of the peasant agricultural worker is characterized by periods of long and intensive labour, alternating with periods of inactivity, amongst a precarious nutritional situation and hard life conditions. Even in a capitalist developed country, such as the United States, the life expectancy of agricultural workers is less than that of the average person (18). This is even more true of underdeveloped capitalist countries such as India(19) though not of socialist Cuba(20) which has about the same level of technological and industrial development as many economically dependent Third World countries. A close relationship has also been demonstrated between mortality rates and rainfall, population density, extension of farmland per person, and the type of crops, as well as malnutrition (21).

The epidemiological profile of the peasant is dominated by infectious and nutritional diseases. It was shown in different studies of tropical Africa that there are, on an average, two infections per person, the common diseases being bilharzia, filariasis, yaws, leprosy and malaria (22). Agricultural workers are also vulnerable, increasingly so, as a result of the ecological effects of newer agricultural developments, to natural disasters such as earthquakes, cyclones and floods.

Agricultural workers in many parts of the world are living in a state of transition from subsistence agriculture through cash cropping, to waged labour. A study of the situation in Mexico(23) revealed a morbidity differential between peasants, cash croppers and waged labourers with peasants having the lowest morbidity, wage labourers the highest and cash croppers lying somewhere in between. An analysis of figures taken from nineteenth century Phi1ippines(24) demonstrated an increase in mortality related to the change from subsistence to commercial agriculture.

Sisal was introduced as the dominant cash crop in areas of subsistence agriculture in northeastern Brazil, a couple of decades ago. It was shown(25) that, although this was a technological advance, it left the population much worse off. The price of the product was now decided in the international market. Peasants became extremely poorly paid waged labourers, and had to purchase all subsistence articles themselves. It was calculated that the wage received by each labourer was insufficient even to cover the cost of food to replace the calories spent, and was totally insufficient for the nutritional requirements of his family; 45 per cent of the children of sisal workers were under-nourished. The health of the population was also affected by changes in the environment, wrought by so-called ‘development’, as regards water supplies, the habitat, vegetation cover and the micro-enviroment.

A horrendous life is the lot of the rural wage labourer (the rural proletariat) in the capitalist sector of agriculture. It is not uncommon for him/her to find work for only 3 to 6 months in the year(26). The large rural pool and the temporary and migratory nature of labour makes attempts to unionise difficult. There are new risks associated with the operation of machinery and the use of a wide range of agricultural and industrial chemicals and pesticides. Some of the products could be hazardous through inhalation, e.g. cotton. When working, an agricultural labourer could be subject to 10 to 13 hours of hard labour. Rural workers are young and their active working life is about 12 years; they tend to be undernourished and to suffer from high rates of disability (27). In the case of waged labourers, their nutritional problems are less dependent on the lack of control over nature than on the low wage levels and the enforced new patterns of food consumption in the capitalist sector of agriculture. The problems of migration have more to do with the rupture of subsistence agriculture than with life in an urban enclave. Migration is related to an increase in infectious disease, accidents, alcoholism, stress-related illness and venereal disease (28), and, in Africa, tuberculosis and trypanosomiasis.

Workers in the capitalist agricultural sector suffer a very high accident rate. The accidents relate to the handling of machinery and, more importantly, the use of pesticides. Not only are these substances dangerous because of their immediate toxic effects, some are also suspected carcinogens and genetic mutagens. Some of these chemicals are freely used without even minimum precautions in Third World countries, when they have been banned in the metropolitan countries (29). A report from Ceylon (Sri Lanka) stated that 30 per cent of the accidental poisoning was caused by agricultural chemicals and that the majority of the victims were between 15 and 50 years of age (30).

 

BIRTH CONTROL PROGRAMMES

FAMILY PLANNING IN CHINA

After the bitter civil war, the Government of the People’s Republic of China came out in 1949 in favour of rapid population growth, but changed its mind in 1957. There was resistance, however, to the first family planning campaign on the part of the peasants in the countryside who considered ideas about birth control to be foreign. This first campaign was a failure. A second campaign was launched in 1962. This promoted the idea of late marriages and limiting the number of children to 2 per family. Chinese-manufactured contraceptive pills were prescribed and intrauterine devices and condoms were freely available. Abortion and sterilization played a limited role in the campaign (34).

The Chinese government believed that rapid population growth is not wrong as it felt that it is possible to achieve economic growth much more rapidly than population growth, contrary to neo-Malthusian arguments. The Chinese government initially favoured population growth in the sparsely populated areas of China and encouraged the national minority races to give birth to more children. It felt, however, that, in the main areas of the country, population density was so great that further growth would be unacceptable. In 1979, the Fifth National People’s Congress estimated that, because of the structure of China’s population (39 per cent of the population in 1978 being under 15 years of age), even if the number of children born were reduced dramatically to, and maintained at, one child per couple, the population would still continue to grow and reach 1 billion in 2004. That figure has now been reached. The Congress then launched a campaign to promote the one-child family, backed by an ideological approach and supported with appropriate inducements and discouragements (35).

THE IDEOLOGIES IN POPULATION GROWTH

In the years following the Second World War and up to the present time, four different ideologies in the area of population growth have become discernible: the moral, the nationalist, the neo-Malthusian and the anti-imperialist (36). In the moral ideology, as demonstrated by the attitude of the Vatican, the use of contraceptives is considered immoral, as is, of course, sterilization and abortion, though the use of “natural” methods, such as the “safe periods” , to limit fertility is permitted. The nationalist ideology, as maintained by some Latin American and African nations, favours large populations and rapid population growth. This attitude has been criticised by the Left who claim that increases in population will naturally follow the present reduced mortality and that special action to increase the population will only result in such a large increase that governments concerned will simply not be able to cope.

The supporters of the neo-Malthusian school argue that the underdeveloped countries are overpopulated and this makes it impossible for them to achieve social and economic progress. They further suggest that, on a planet where the population is already becoming too large and where resources are limited, the underdeveloped countries should attempt zero population growth. Family planning programmes must have top priority, they say, and there must be a place for sterilization and abortion.

The anti-imperialist ideology is critical of the neo-Malthusian stance, its use of emotive language such as ‘population explosion’ and ‘population bomb’ and the implication that the population increases in underdeveloped countries are responsible for the poverty, unemployment, slum areas in rapidly expanding cities and slow economic development, and the tendency to blame the population for the diseases of society. Anti-imperialists believe that population stability will not occur through family planning measures alone, but only when this is part of a strategy for genuine social and economic development for all. They concede the right of access to contraceptive services, abortion or sterilization to those who want to limit the number of their children.

THE CONNECTION BETWEEN THE POPULATION AND EUGENICS MOVEMENTS

In 1816, the Reverend Thomas Robert Malthus wrote that the poor laws of England permitted the poor to multiply without increasing the food supply for their support. Their consumption of the supply of provisions, he said, not only reduced the share that would fall to more industrious members of the community but also caused even more members of the community to become destitute (37). Malthus’ theories of population increase in geometric progression but of food supply increase only in arithmetic progression were refuted by Karl Marx and Frederich Engels and undermined by Charles Darwin’s ‘Origin of Species’.

In recent years, the theories that Malthus postulated have come back into their own again, and the population movement and the eugenics movement appear to have found common cause. The eugenicists followed closely on the heels of the Social Darwinists in the early part of this century, and preached ‘selective breeding’ whereby the wealthy and the privileged were to be encouraged to breed and the poor and ‘unfit’ were to be encouraged to practise abstinence, or worse. At this time, the birth rates among white Anglo-Saxon Protestant (WASP) families began to fall. In his State of the Union Message in 1906, President of the U.S., Theodore Rooseveldt, spoke of “wilful sterility.........the one sin for which the penalty is national death, race death” (38).

After World War I, and during the next few decades, the ‘race suicide theory’ was popularized by the writings and utterances of prominent men and women. Many of the recent immigrants to the U.S. had been influenced by the strong socialist movements in Europe and now became active in the radical sections of the American labour movement, and this, combined with the post World War I instability in Eastern Europe, added fuel to the eugenicists’ fire. Racial discrimination against blacks was intensified. The increased collaboration between the eugenics movement and the birth control movement permitted the latter to become a platform for the propagation of ‘race suicide theories’. The eugenicists proclaimed their aim of preventing the American people from being replaced by alien or negro peoples, whether by immigration or high birth rates.

In the late 1920s, members of both movements began to speak out about the population increases in Asia and warned of the dangers to the U.S. of domination of the world by the people of Russia, India or China. Even at this time, they suggested that the low birth rate nations of the world form a league to retain control of the raw materials without which, they believed, industrial and military strength was impossible.

The Population Establishment seized upon an opportunity to prove the usefulness of population control in strategies of economic and political oppression. Following the suppression of the Nationalist Party in Puerto Rico (which had been demanding independence from the U.S.) in 1936, extensive programmes of sterilization and of the distribution of contraceptives were carried through. Sterilizations were being performed on every 1 in 5 or 6 of all hospital deliveries in Puerto Rico by the late 1940s, and more than 1 in 5 women interviewed on the island had undergone sterilization (39).

The birth control and eugenics movements merged, with the formation, in 1942, of the Planned Parenthood Federation (PPF), and with the aim of preventing the impoverished from multiplying. In England, in 1948, the International Planned Parenthood Federation (IPPF) was established, with its headquarters in London, declaring that “control of population increase is one of the essential measures whereby real progress towards peace and prosperity can be made” (40).

Despite the publicly expressed hopes for a future with peace, the U.S. ruling class, at the end of World War II, was already planning the penetration of the economies of Europe, Africa and Asia. It saw, however, that socialism in Europe and nationalism in Asia and Africa would present obstacles to the establishment of U.S. hegemony. Attempts were made to convince the American public that communism, overpopulation and the mounting populations in the Soviet Union were creating unrest in the world. In the 1950s, Western leaders became increasingly aware that the prosperity of their countries depended on the uninterrupted supply of raw materials from the countries of the Third World, and concluded that the loss of this would be the equivalent of a major military reversal. Especially after the Korean War, they began to conclude that ‘excess populations’ in the Third World were a serious threat to their own security, which they equated with global security.

In 1952, the major philanthropic foundations in the U.S. came together and founded the Population Council (41). With the Rockefeller Foundation supplying most of the funds, the Council set about donating funds on every continent, to mould public opinion and win popular support for their family planning programmes; the Council also directly funded birth control programmes. In 1954, a private foundation, the Hugh Moore Fund, sponsored a pamphlet entitled ‘The Population Bomb’. Likening the dangerous and disruptive effects of the ‘population explosion’ to that caused by the atom bomb, the pamphlet proved to be very popular.

A national population programme had existed in India since 1951, but in 1955 the Population Council (of the U.S. philanthropic foundations) donated funds to India’s Institute of Public Health. In 1958, the Ford Foundation donated US$ 9 million to the Indian government for the supply and distribution of contraceptives and for research in population control (42). Also, in 1958, President Eisenhower created the Committee to Study the U.S. Mi1itary Assistance Programme (43). This Committee, headed by General Draper, also came to be known as ‘the Draper Committee’ and was the first official agency of the U.S. government to publicly support birth control programmes. The Draper Committee supported assistance to Third World countries for the development of population control programmes and for the establishment of maternity and child health programmes. The Draper Committee also supported assistance to international and U.N. research programmes in population control (44).

In 1960, the World Population Emergency Campaign (WPEC) was founded, strongly supported by wealthy business leaders, with the remit to expand the public role of the International Planned Parenthood Federation (45). It merged with the IPPF a year later and much of its funds was utilized to further IPPF’s overseas work. Furthermore, the newly founded Alliance for Progress and the Agency for International Development (AID) incorporated population control goals in their programmes.

Between 1959 and 1970, the Ford Foundation had expended $50 million in grants to finance research in reproductive biology viz., the ‘pill’ and intrauterine devices, with the research being carried out mainly in the underdeveloped countries. In 1964, the U.S. government officially endorsed population planning programmes and AID admitted that private resources alone could not cope with the demands for technical assistance (46). In the Kennedy-Johnson years, U.S. government officials began to question the worth and efficacy of foreign assistance programmes in many Third World countries, where, they believed, the effects of U.S. foreign aid were negated by increases in population. These beliefs found expression in President Johnson’s famous statement at the United Nations’ twentieth anniversary celebrations, in which he said that “...........less than five dollars invested in population control is worth a hundred dollars invested in economic growth”. At this time in the U.S. itself, the newly created Office of Economic Opportunity, together with the Planned Parenthood Federation, was supplying contraceptives and establishing birth control clinics as part of the Johnson ‘ Great Society’ programmes in the United States.

Fears regarding famine and insurrections in Southern Asia led to the formation in Washington of the Population Crisis Committee, under the chairmanship of General Draper with the remit to brief Congressmen on the latest in the field of population control technology. Public Law 480 which was known as the ‘Food for Peace’Act was modified to include a provision for voluntary programmes towards population control, in order that countries that had family planning programmes would receive additional foreign assistance to fund these programmes. The Agency for International Development (AID) then inaugurated its own Office of Population; as AID funds for population control increased, grants toward other forms of foreign assistance were reduced.

By the end of 1966, official population programmes had been established in more than 25 countries, and the U.N. General Assembly passed a resolution calling on all agencies to assist when requested in further developing and strengthening national and regional facilities for training, research, information, and advisory services in the field of population. In 1967, Secretary-General of the U.N., U Thant, established a U.N. trust fund for population activities, which would serve as an international mechanism for promoting action by member governments, U.N. agencies and the Population Establishment. The fund was open to donations from member governments and private sources. However, as contributions to the trust fund were not forthcoming, it was transferred to the United Nations Development Programme (UNDP) which was then renamed the United Nations Fund for Population Activities (UNFPA).

The President of the World Bank, George Woods, called for a closer inspection of the credentials of prospective borrowers with regard to their record on implementing strategies in population control. Population control was, at that time, not just the concern of American private philanthropic foundations and the U.S. government, but of the World Bank and even the World Health Organisation. In 1969, President Nixon declared that population growth was a major problem both in the U.S. as well as abroad, and called for the United Nations, its specialized agencies, and other international bodies to respond, along with the U.S., to world population growth. The Agency for International Development was re-organized; its ‘War on Hunger’ office was renamed the Bureau for Technical Assistance and its Population Office was expanded.

Intense lobbying by the Population Establishment in the U.S. led, in 1970, to the passage of the Family Planning Services and Population Research Bill, when Congress authorized expenditures of £382 million for the next three years and provided for separate funding for population planning inside the U.S. itself. In 1970, the General Assembly of the United Nations voted for a more dynamic population policy and to designate 1974 as World Population Year. The United Nations Fund for Population Activities was to implement this policy. In 1973, the UNFPA budget was more than $40 million and it had funded many projects in the Third World.

Although the initiative for population planning on a world scale had passed from the U.S. to the U.N agencies, the actual sums of money spent by the U.S. Federal as well as private sources in this regard continued to increase. As a result of the increase in the population planning efforts in the U.S., expenditure on health, both in the U.S. and abroad, fell. AID’s health assistance was reduced from $164 million in 1968 to $60 million in 1972. The International Planned Parenthood Federation had, by this time, chapters in 79 nations and boosted its expenditures to $26 million, while the Population Council was spending more than $17 million annually. Between 1969 and 1972, AID’s programmes in Latin America grew from $10.3 million to $11.1 million, whilst their programmes in Africa and Asia expanded from $9.4 million to $25.7 million. AID programmes were activated in more than 70 countries, including South Vietnam (47). In anticipation of World Population Year, UNFPA initiated information and education activities, in several countries, aimed at policy-makers, community leaders, teachers and the population at large and with the intention of overcoming resistance to the idea of population planning.

WORLD POPULATION CONFERENCE

The Secretary-General of the United Nations, Kurt Waldheim, opened the World Population Conference in Bucharest on August 18th, 1974, by evoking the theme of a “demographic explosion”, and went on to declare that the world was in danger from the rapid rise in population. He proposed that strategies be developed for cutting the world’s population growth from 2.0 to 1.7 per cent annually, in order to prevent the world’s population from doubling during the next generation (48).

Caspar Weinberger, the U.S. Secretary of Health, Education and Welfare, suggested that satellite technology could be utilised to develop mass educational programmes worldwide on the subject of population planning. Latin American nations submitted amendments that emphasized the importance of social and economic factors, whose absence could well negate the most well planned population programmes, whilst the delegate from the People’s Republic of China called upon the Conference to “thoroughly liquidate the absurd theory of population explosion” (49). Dr Yusuf Eraj, a Kenyan gynaecologist, denounced the Conference as a diversion from the real problems of disease, illiteracy and the unjust distribution of resources. Algeria’s delegate argued in the same vein.

The final text of the Conference’s World Population Plan of Action included the following statement:
“In the light of the principles of this Plan of Action, countries which consider their birth rates detrimental to their national purposes are invited to consider setting quantitative goals and implementing policies that may lead to the attainment of such goals by 1985. Nothing herein should interfere with the sovereignity of any government to adopt or not to adopt such quantitative goals” (50).

Although the lesson had been driven home that the problem of rapidly rising populations could not be tested in isolation from the complex factors that determine population levels, the Population Establishment and their American and multilateral agencies continued to further their neo-Malthusian goals.

Weissman wrote in 1970 that: “The same elites and institutions which made America the world’s policeman have long been eager to serve as the world’s prophylactic and agricultural provisioners, and they are damned grateful to the academics for creating a new humanitarian justification for the age-old game of empire” (51). Malthus’s original “Essay on Population", the first edition of which came out in 1798, was an attempt to provide an ‘intellectual’ and ‘scientific’ justification for the social order in Britain in the dawn of industrial capitalism. It was an antidote to the revolutionary fervour that was sweeping across the Western World and which had manifested itself in the French and American revolutions.

Racism and imperialism lie at the core of the population control strategies advocated by Western institutions and governments; this may be obvious and blatant or subtle and wrapped up in a humanitarian carapace. Racism is overt when propagandists suggest a division of the world into categories such as ‘hopeless’ (not deserving of American aid), ‘worth aiding’, and ‘self-sufficient’ (52). Others speak of a white superstate dominating the planet for the good of the white race (53). The rest, of course, simply tag financial aid on to the end of their supplies of contraceptive pills, prophylactics and IUDs, with free education, thrown in to the locals, to motivate them to reduce the size of their families.

The Population Establishment in the Western World have utilized the ideology of population and fertility to counter the mounting opposition to Western imperialism in the Third World and to conceal the true causes of poverty, malnutrition, famine and early death. Amongst the supporters of the Population Establishment’s population control strategies were Robert McNamara, who directed the fierce war against the Vietnamese peasants, and John Hannah (director of AID from 1970 to 1971, and former president of Michigan State University) whose staff trained the special police of former South Vietnam President Ngo Dinh Diem.

A Rockefeller Foundation study reported that “restlessness produced in a rapidly growing population is magnified by the preponderance of youth. In a completely youthful population, impatience to realise rising expectations is likely to be pronounced. Extreme nationalism has often been the result”. Underdeveloped countries which accepted population control strategies would receive financial aid and aid to develop industry in order that they might accede to a community of interest with us” (54). Western multinationals would then continue to be free to exploit their human and natural resources and to dump their manufactured goods on them.

INTRODUCTION

Under capitalism, health care is transferred into a commodity and the production of surplus value is a central feature of contemporary health care delivery in a capitalist society. The health care industry performs four interrelated economic functions: capital accumulation, provision of investment opportunities, absorption of surplus labour, and maintenance of the labour force. Its ideological functions are those of systemic legitimation, social control, and the reproduction of the capitalist class structure. “Like many other services, health care has become a commodity, offered for a price in the market-place. It is purchased by the working class (and members of the capitalist class as well) very much as are food, clothing, automobiles, and hair-cuts, and for the same purposes, e.g. to satisfy needs some of which are created artificially via the mass media and other means of propaganda” (55).

Marx described the four characteristics of a commodity as being, firstly, that a commodity has use value (which need not be a genuine need); secondly, a commodity is produced to be used by someone else; thirdly, it is produced to be exchanged for an object of equivalent value; fourthly, those engaged in commodity exchange meet in the market-place where they exchange their products. In this respect, services can be regarded as commodities, as in the case of a schoolmaster who sells his teaching services in a school (a teaching ‘factory’) with the proprietors of the school then earning a profit on the whole enterprise (56). As a result of the urbanization that occurred under capitalism, services that individuals or groups previously produced for themselves, such as transport, had then to be bought from the producers of these services, viz., the privately owned bus or train transportation services. Many such services have now become the responsibility of government.

The capitalist’s sole concern is with the realisation of profit. “The capitalist is indifferent to the particular form of labour; he does not care, in the last analysis, whether he hires workers to produce automobiles, wash them, repair them, repaint them, fill them with gasoline and oil, rent them by day, drive them for hire, park them, or convert them into scrap metal” (57). The wants of society could well be induced by advertising or ideological conditioning, and a particular commodity could well have no benefit and even be detrimental to the user.

As the provision of many services does not need much capital, individuals can set themselves up as providers of services in a petty commodity mode, as in the case of small businessmen and shopkeepers. The direct interaction between the provider of the service and the receipient excludes the intervention of the capitalist. In situations where there is a need for expensive equipment or special marketing, such as in car rental or health care, capital intervenes in the interaction between the provider of services and the receipient, and, furthermore, defines the role of the service worker.

MODES OF PRODUCTION IN HEALTH CARE

In early times, health care was an integral part of communal society. The traditional healers conducted religious and social ceremonies and they were presented with gifts. Under feudalism and, later, under capitalism, health care was placed in the hands of doctors (and midwives) and became commodified. Petty commodity production was the first stage, with the physician, an independent producer, selling the product of his own labour. As the delivery of health care moved from the doctor’s office to the hospital where junior doctors, nurses and supporting staff were employed full time, the capitalist stage of health care production by alienated wage labour was reached. This has been reinforced by the development of technology-based, capital-intensive medicine. In capitalist societies, many physicians, however, are still engaged in a petty commodity mode of production as solo practitioners.

The medical profession has a monopoly, granted by the state, which permits it to control entrance into the profession and to control the registration of all workers permitted to deliver medical care. As a result of this, doctors are able to extract a form of ‘economic rent’ from the consumer of their services. Doctors’ fees in the private sector of medical care exceed the cost of producing and reproducing that form of labour power. Just as owners of land, through the monopoly of the land they own, extract rent for its use, so doctors, possessors of a monopoly on the right to deliver medical care, can charge a rent for this service (58). Fees are set by doctors and hospitals with little price competition within a range of supposed ‘customary and reasonable’ charges. Hospitals compete for doctors who bring in the most patients, by providing the latest (and most expensive) medical technology, thus leading to an increase in costs.

SURPLUS VALUE AND CAPITALACCUMULATION

Surplus value is the difference between the value produced by a worker and the wages he/she receives. It represents the profit that accrues to the employer. The wages a worker receives reflects the value of the subsistence goods and services needed to reproduce the worker’s labour power. The surplus value has to be realised in the market place and appropriated.

In capitalism, the process of capital accumulation is the core engine of capitalist development. Accumulated wealth is not just associated with status and power; the survival of the capitalist depends on it. To realize a profit, a capitalist has to engage in continuing cost-trimming, technological innovation, expansion of his share of the market and massive sales efforts through advertising campaigns and the creation of a consumer culture (59).

The private health care industry is big business. Chains of clinics, hospitals and nursing homes bring profit to pharmaceutical companies, medical supply companies and firms engaged in building construction, financial and management services, insurance and management consultation. The non-profit voluntary hospitals and nursing homes, and the public hospitals, like their private profit-making counterparts, also exhibit an expansionist drive and compete for physicians, patients and prestige. They invest their surplus revenues, where applicable, in additional equipment and buildings. Preventive services and ambulatory care are less easily centralized, are treated as commodities and are, therefore, not satisfactorily catered for, if at all, by the private profit-making health sector. Consumers of health services, themselves, have little voice in the selection of health care delivery choices in their own areas and their priorities would appear to differ from those of the professionals and the bureaucrats.

INVESTMENT OPPORTUNITIES IN THE HEALTH CARE INDUSTRY

The investment, and expansion, of surplus is central to the survival of capitalism. In the absence of the aforesaid, the system will contract, sales will fall and the accumulation of capital will not occur. With the growth of the health care industry, there has been investment in new construction and costly medical equipment, irrespective of the actual relevance of the equipment. However, the investment of surplus keeps up the levels of employment and of profit (60). The growth of the health care industry has opened up new markets for new goods and services as well as new markets for old goods and services. Selling pharmaceutical products in the Third World is an example of new markets for old goods. Examples of new markets for new goods and services are nursing homes, new drugs, ambulatory services, and cosmetic surgery.

ABSORPTION OF SURPLUS LABOUR

Driven by the need to continually expand and produce surplus, capitalism displaces large numbers of workers from their jobs. Furthermore, the self-employed petty bourgeoisie, e.g. the small business men, shopkeepers and craftsmen lose out in the struggle against big business and become bankrupt. They then become waged labour (a process known as proletarianization). Other workers become redundant as men are replaced by machines (technological unemployment). Declining rural economies oblige workers on the land to migrate to the urban enclaves and compete for the declining number of available jobs there. These three groups, viz., the newly proletarianized petty bourgeoisie, the technologically unemployed and the new entrants to the labour force comprise ‘the reserve army of the unemployed’, the existence and the fate of which has been utilized by capital to threaten and discipline workers in employment. The army of the unemployed, however, poses a threat to the security and stability of the status quo, hence the attempts in recent times in capitalist societies to accommodate the surplus population whose labour is not required in the core capitalist employment sector.

One attempt at this accommodation is the provision of a minimum level of benefits in goods and services through unemployment compensation and the welfare system. Another approach has been to keep the number of unemployed to as low a level as possible with spurious job training schemes and early retirement. A third approach is the absorption of as many of the unemployed as is possible into peripheral (as opposed to core) low-wage employment in the service industries, especially the health care industry. The National Health Service in Britain is the largest single employer in the European Economic Community (EEC).

In the health care industry, at least, the introduction of new technology has generated more employment through the need for more laboratory and other tests to be performed and for new equipment to be operated and maintained. The industrialization of the labour force in the health care industry has enabled the industry to absorb workers. This labour force is mainly low skilled (clerical, maintenance, and ancillary workers), or moderately-skilled (nurses and nursing aides). A large number of the new entrants into the labour force are from the disadvantaged national minorities in capitalist societies. Only a small proportion of the total labour force are doctors.

THE MAINTENANCE OF HUMAN CAPITAL

One function of the health care industry under capitalism is to maintain the workers in good working order, not that they should feel well and be satisfied with their health status. Capital views workers as machines contributing to the process of capital accumulation. In the introduction to his textbook of occupational medicine in 1925, Dr. J.D. Hackett had this to say: “Chickens, race-horses, and circus monkeys are fed, housed, trained, and kept up to the highest physical pitch in order to secure a full return from them as producers in their respective functions. The same principle applies to human beings: increased production cannot be expected from workers unless some attention is paid to their physical enviroment and needs. The object of this book is to show those who manage (industrial) plants and are, therefore, responsible for the management of medical departments, how the workers’ health may be maintained and improved as a means of increasing production...... (they) must be able to guide and direct the medical staff just as (they guide) other technical branches of plant operation” (61).

Similarly, in reporting to President Truman in 1949 concerning conditions in the strikebound steel industry, the Steel Industry Board stated in part that: “Social insurance and pensions should be considered a part of normal business costs to take care of temporary and permanent depreciation in the human ‘machine’ in much the same way as provision is made for depreciation and insurance of plant and machinery. This obligation should be amongst the first charges on revenues” (62). Human resources, then, are analysed in the same manner as material and physical resources. Workers are treated as property and this ideology is manifest in practice in several ways. Those workers who contribute most to the process of capital accumulation are regarded as the most valuable and receive, correspondingly, a wider and more comprehensive range of health and medical benefits. The poor and the elderly will receive less care as they contribute less to capital accumulation. The factory will employ doctors to keep the workforce in satisfactory physical condition and to weed out ‘malingerers’. Health is defined purely in terms of the ability to work, and disease is defined according to its impact on the worker’s performance as a worker. Conditions that affect the worker’s health and which arise as a direct result of the nature of the work process will not be defined as diseases and will, therefore, receive neither recognition nor treatment.

The health care industry also plays an ideological and political role by legitimating the socio-economic system, exercising social control, and contributing to the reproduction of the capitalist mode of productin and class structure.

LEGITIMATION

By appearing to meet some of the basic needs of society, such as the provision of effective and humane health care, the health care system can put a human face on the operations of capital and cause it to appear less unacceptable to the disadvantaged and the alienated.

SOCIAL CONTROL

Modern medicine operates according to an individualistic model with the sick receiving treatment outside of their normal enviromental context. McKeown described it in the following terms:
“The approach to biology and medicine established during the seventeenth century was an engineering one, based on a physical model. Nature was conceived in mechanistic terms, which led in biology to the idea that a living organism could be regarded as a machine which might be taken apart and re-assembled, if its structure and function were fully understood. In medicine, the same concept led further to the belief that an understanding of disease processes and of the body’s response to them would make it possible to intervene therapeutically, mainly by physical (surgery), chemical or electrical methods” (63).

Health problems and their solutions are seen as individual and not social, even though many prevalent diseases such as heart disease, cancer and hypertension have strong social and enviromental bases. Everything is to be cured through increased individual consumption. An infant with pneumonia, for example, is taken to the hospital, ‘cured’ with penicillin, then sent home to an apartment with no heat (64). In the alternative view of medicine that socialists propose, the emphasis would be on enviromental factors and on the material basis of health, with preventive health care leading to improved living conditions and lifestyles.

THE CAPITALIST CLASS STRUCTURE

The health care industry is organised in a hierarchical manner with a detailed division of labour and with hospitals controlled by physicians and administrators. The physicians come from high income families (65). Nurses and ancillary staff are stratified according to their class origins and racial backgrounds (66). Patients are given differential treatment based on their class, race and gender and the inferior social positions of working class people and of the disadvantaged are thereby reinforced (67).

MEDICAL SUPPLY INDUSTRIES THE PHARMACEUTICAL INDUSTRY

The medical supply industries are dominated by the multinational companies that produce chemicals, pharmaceuticals, specialised foods, computers, cosmetics and electronic equipment. The total market for medical technology exceeded $450 million in 1969 (68). Prescription drugs are the most profitable of all the products mentioned and account for over 80 per cent of total production. Account must also be taken of the sales of illegal drugs. Not only are drug companies guilty of illegal overproduction (69), but dealing in illegal drugs (e.g. the illicit traffic in heroin) is part of the business of the industry (70). The characteristics of the multinational pharmaceutical industry are diversification, an increasingly profitable market and, finally, concentration, with a small number of large companies accounting for most of the market (71). The situation in the underdeveloped countries is that the small national companies are unable to compete with the large multinational companies.

In Britain in the mid-sixties, the Report of the Committee of Enquiry into the Relationship of the Pharmaceutical Industry with the National Health Service (NHS) in 1965-1967, commonly known as the Sainsbury Report(72) alluded to the international and wide-ranging (non-pharmaceutical) operations of the drug industry, with about 60 firms accounting for over 90 per cent of the total value of sales of prescription medicines. In Britain itself, British pharmaceutical firms supplied 27 per cent of NHS prescriptions in 1966, U.S. firms 49 per cent, Swiss firms 14 per cent and other European firms 10 per cent.

The total output of the pharmaceutical industry in Britain in 1965 was £250 million. Exports constituted 30.9 per cent of sales, with British firms exporting 40.6 per cent, U.S. firms 23.8 per cent, Swiss firms 15.4 per cent, and other European firms 34.5 per cent. In 1967, almost the whole bill for prescription medicines in the U.K. was footed by the NHS. The Department of Health supervises contracts to ensure that hospitals do not pay unreasonable prices for drugs and joint pricing committees price prescriptions dispensed by retail pharmaceutical chemists under the pharmaceutical services of the NHS.

The Sainsbury Report concluded that the voluntary price regulation scheme (VPRS) between the Department of Health, individual manufacturers and the drug industry, to regulate the prices of proprietary medicines was not uniformly successful and that certain prices remained outside the limits of reasonableness despite the workings of the VPRS. Earlier, in 1961, the Public Accounts Committee reported that eight local subsidiaries of U.S. firms were making profits averaging 73 per cent (73).

Reporting on the profit margins of drug companies operating in Britain, the Sainsbury Report declared that the figures suggest that the cost to the NHS had been inflated by excessive prices to the extent of several millions of pounds over the (1963-1965) period. Itself rejecting the nationalization of the pharmaceutical industry as a solution, the Report went on to recommend that there should be no brand names for newly licensed pharmaceutical products. This recommendation, however, was rejected by the British government on the grounds that it would adversely affect the overseas profits of the pharmaceutical industry.

The underdevelopment of preventive health services and general social measures in the Third World results in a greater reliance being placed on drugs to effect the relief of illness. The high cost of imported drugs is a drain on health budgets and limits the extent of medical care that can be made available. On top of this, the pricing practices of pharmaceutical companies in the Third World, where regulation is minimal, results in gross over-pricing. A survey carried out in Africa on the cost of drugs utilised in the treatment of tuberculosis revealed a wide variation in the cost of drugs from one country to another and even between each of two neighbouring countries, differences that could not be explained by the cost of transporting the drugs and by the distance of the country supplied from the source of the drugs (74). It has been shown that overpricing in Colombia in 1968 of 48 intermediate pharmaceutical products ranged from 17 per cent to 6584 per cent (75).

DRUG PRICING

One of the reasons for the high cost of prescription drugs is that doctors in training are not taught to be cost-conscious when prescribing. Busy medical practitioners, attempting to see as many patients as possible, precribe according to symptoms rather than according to the diagnosis, and thus more drugs are consumed. These doctors are subject to an intensive advertising campaign by the drug companies (76).

With the prescription-only drugs, the advertising is aimed at the doctors. The Sainsbury Report claimed that the percentage of prescription drug sales spent on promotion by 27 pharmaceutical companies in the United Kingdom in 1965 ranged from 6.8 to 26.2 with an average of 12 per cent, revealing the enormous sums spent on advertising. The pharmaceutical industry vigorously opposes attempts to encourage doctors to prescribe drugs using the generic name (generally not subject to patent) rather than the brand name (often subject to patent). The industry claims that only the brand names guarantee quality, although this cannot be substantiated by the evidence.

A review undertaken between 1966 and 1969 by the National Academy of Sciences National Research Council on behalf of the U.S. Food and Drug Administration found that 8.8 per cent of 2000 brand names in the same period were ineffective, whilst the comparable figure for generic drugs was 7.7 per cent (77).

The pharmaceutical industry offers several reasons to justify the high prices of their products. Whilst the industry claims that it must invest in expensive research in order to survive competition, the Sainsbury Committee found that the amount of money invested in research is related mainly to the size of the company, and, in 1965, varied from 0.5 to 21.6 per cent of sales. In the U.K. and the U.S., government subsidization of research in the pharmaceutical industry is much more than what the industry itself spends, and lightens the burden on the industry’s resources. In 1965 in the U.K., the government investment in research was £20 million, whereas the industry invested £12 million; for the U.S. the comparable figures were £440 million and £160 million respectively (78). Less than 20 per cent of what the industry invests in research is for new products and more than half of its output consists of reformulations (79).

The pharmaceutical areas chosen, by the drug companies, for research are determined by the potential profit to be made rather than by any considerations of medical need, altruism or humanitarianism. This can be clearly seen in the area of infant food formulations. The promotion of these products, motivated by the greed of the pharmaceutical companies, in Third World countries,where mothers had been successfully breast-feeding their infants, caused many deaths, and earned the companies concerned the title of ‘Baby-killers’ (80). Contrary to what the industry claimed, the baby food products were bought, not by the affluent, but by the poor who, because of the cost of the product, over-diluted it with impure water, in contaminated vessels. The infants fed this were subject to multiple nutritional and bacteriological assaults.

Again, contrary to what the industry claims, its investments in research can hardly be said to constitute a financial risk for the companies, since their diversification (into drugs, food formulas and medical supplies) and their international character confer protection on their investments. Many products, in fact, maintain steady profits over a long period of time. Furthermore, many of the experiments which comprise pharmaceutical research are performed in university departments which, in the U.K., are state supported. But, as the Sainsbury Committee noted, the competitive nature of the industry leads to the duplication of research efforts and a waste of resources. The Committee suggested that developmental research activities should be nationalized to eliminate duplication. The Committee also found that weak price competition is a characteristic of the pharmaceutical industry and that the high profits are the result of low elasticity of demand and of patent protection.

PATENTS

In the U.K., patent life for a pharmaceutical product, at the time of the Sainsbury Report, was 16 years; this period included the time spent in technological development, clinical trials and product registration. The Sainsbury Committee felt that this period of 16 years was too long, although, under the European Economic Conventions, patent life, then, was 20 years. The Sainsbury report had this to say of patents in the pharmaceutical industry:

“Generally speaking, patent protection will enable a company to maintain higher prices than otherwise, and if, instead of retaining its monopoly, the company chooses to license the invention to others, or, if a competitor obtains a compulsory licence, then the royalty payments would also tend to raise prices”. In other words, patents are monopolies that maintain high prices and restrict competition.

The Sainsbury Committee realised that patents also duplicate research. “The imitation of existing products by the minimum of molecular manipulation required to circumvent patents has clearly proved profitable, and the number of ‘me -too’ products that follow a new therapeutic fashion shows that it is widely used”. Patents allow producers to market many versions of the same preparation. High profits can be earned just from re-packaging, as described by Mintz. “A French firm, Roussell, sold the oestradiol, Progynon, a drug used in menopausal disorders, to Schering in bulk form. Schering did no research on the drug merely, put it up in tablets and marketed the pills under its own label. In a bottle of 60 tablets, there was 11.7 cents worth of the drug. Schering sold the bottle for $8.40. That was a mark-up of 7,079 per cent” (81).

In the U.S. and the U.K., patents cover the substance, pharmaceutical formulations containing the substance, processes for making the substance and new methods of medical treatment centered around the substance. It was because the drug thalidomide was incorporated in several preparations, in combination with aspirin, phenacetin, quinine, aminopyrine, bacitracin, dihydrostreptomycin, or secobarbital, used for the treatment of a wide variety of common conditions, that a long interval of time elapsed between the recognition of the drug’s dangerous side-effects and its complete withdrawal. 37 different preparations were sold on five continents and went on to deform tens of thousands of babies (82).

In underdeveloped countries, the system of international patent protection prevents the transfer of patent protected technology to underdeveloped countries. Although the most important industrial patents in underdeveloped countries are foreign-owned, most are never used. The system ensures the dominance of the multinational companies and blocks competition from local industry by giving foreign firms operating in underdeveloped countries oligopolistic or monopolistic positions in their particular product lines. These monopoly rights block local research to adapt or modify imported foreign technology to local needs, and permit a whole series of abuses through restrictive practices, such as price-fixing, discriminatory royalties, tie-in arrangements, compulsory packaging, and restrictions on resales. Patent cartels ensure international market control and high profit levels.

In underdeveloped countries, 40 per cent to 75 per cent of pharmaceuticals are dispensed in hospitals and public dispensaries. The poverty of the majority of the population and the small number of retailing agents limit the sale of over-the-counter (OTC) drugs. This small market in pharmaceutical drugs in underdeveloped countries is augmented through the diversified and multinational nature of the pharmaceutical companies and their operations in the market for chemical products.

The same chemical substances that are used to produce drugs can also be used to produce a great number of other chemical products. Indeed, many multinational corporations already produce a wide range of chemical products that are sold in the Third World. The chemical industry comprises inorganic chemicals, dyes, explosives, organic chemicals, fertilizers, plastics, rubbers, nuclear materials, vegetable and animal oils and fats, synthetic fibres and resins, pharmaceuticals and cosmetics, soaps, polishes, inks, matches, candles, insecticides, paints, varnishes and lacquers. “The industry is characterized by processing chains that involve many intermediate steps in the transformation of chemicals and by inter-industry linkages that increase with industrial development. Thus, the chemical industry is both its own most important supplier and its own most important customer”(83).

DRUG PROMOTION

Silverman(84) describes a survey that was conducted on the promotion of 28 prescription drugs in the form of 40 different products sold by 23 multinational pharmaceutical companies in the United States and Latin America. The differences in the promotional and labelling material between the different countries were marked. In the U.S., the indications for the use of each product were few in number, while the contradications, warnings and possible adverse reactions were given in detail. In Latin America, the indications were much more numerous, while the hazards were minimized or ignored. A few examples will be quoted.

THE DUMPING OF DRUGS

A great number of pharmaceutical products and food additives banned by the U.S. Food and Drug Administration from use within the U.S. are dumped onto Third World countries because of the absence of rigorous control procedures in many of these countries. If it were not for this, the pharmaceutical companies would incur not inconsiderable financial losses. Cyclamates not passed for home consumption were exported to Third World countries. 10 million capsules of chloramphenicol manufactured in the U.S. by Parke-Davis, but banned from use there were dumped on to civilian medical clinics in South Vietnam, by the U.S. Defence Department, prior to that country’s liberation (92).

ILLEGAL COMMERCIAL ACTIVITIES OF THE MULTINATIONAL CORPORATIONS

In Chile, the pharmaceutical company Pfizer’s local subsidiary was accused by the government of President Allende of smuggling drugs illegally from Chile into Bolivia and Peru. Before the local subsidiary could be nationalised, the government was overthrown by a CIA-backed coup. Another European multinational pharmaceutical company was importing less than 30 per cent of declared contents in sealed cases into a Latin American country. However, it continued to pay 100 per cent of the reported cost to the parent company through a tax refuge, and thus transferred 300 per cent of increased profits to the parent company (93). It is also well known that the hard-sell practices of the drug companies include the bribing of local politicians and bureaucrats.

The present structuring of the pharmaceutical industry with its subsidiaries in the Third World leads to a sizeable drain of financial resources from poor countries. In an industry with scant regard for social ends, there is little technological transfer from the multinational to the local national companies. In the face of exploitation by a giant multinational with support from a metropolitan government, the response of most Third World countries has been piecemeal and fragmented.

The United Nations Committee on Trade and Development (UNCTAD) and the United Nations Department of Economic and Social Affairs have recommended the establishment of both national and international bodies to explore alternative means of acquiring technology for the underdeveloped countries. The Sri Lanka experience is discussed later in this chapter. The Indian government set up a committee to scrutinise technology reports(94); the Colombian government insisted that it should have a say in the negotiation of royalty payments and this resulted in a 100 per cent saving on these payments. The Mexican government passed an Act which provided for financial surveillance and for appropriate technology to be made available to the country.

Drugs are available under their generic names at a fraction of the cost at which they are sold under their brand names. Pakistan was the first country to insist on the marketing of drugs by their generic names (95). Following this, CIBA-GEIGY pulled out of all operations in Pakistan and pressure from other multinational pharmaceutical companies led to permission for the use of over 200 brand-named products for 18 months after the implementation of the measure. In India, the Haithi Committee was opposed by the pharmaceutical industry when it suggested a switch to generic names for 16 brand name essential drugs as well as measures to improve standards in quality control.

The purchasing of the cheapest quality drugs on the open market with distribution under state control would provide an effective and rational supply of drugs to a Third World population, whilst a local pharmaceutical industry was being established. Quality control is assured through routine assessment by either a local or regional committee of experts. In an attempt to exert more control over the drug industry, the Indian government in the seventies promulgated a Drugs (Price Control) Order which set a formula for the amount of profit that could be made on 18 basic drugs and their 69 f