Neoliberalism has been the defining paradigm in global health since the latter part of the twentieth century. What started as an untested and unproven theory that the creation of unfettered markets would give rise to political democracy led to policies that promoted the belief that private markets were the optimal agents for the distribution of social goods, including health care. A vivid illustration of the infiltration of neoliberal ideology into the design and implementation of development programs, this case study, set in post-Soviet Tajikistan's remote eastern province of Badakhshan, draws on extensive ethnographic and historical material to examine a "revolving drug fund" program-used by numerous nongovernmental organizations globally to address shortages of high-quality pharmaceuticals in poor communities. Provocative, rigorous, and accessible, Blind Spot offers a cautionary tale about the forces driving decision making in health and development policy today, illustrating how the privatization of health care can have catastrophic outcomes for some of the world's most vulnerable populations.
About the Author
Salmaan Keshavjee is a physician and anthropologist with more than two decades of experience working in global health. He is the Director of the Program in
Infectious Disease and Social Change in the Department of Global Health at Harvard Medical School, where he is also Associate Professor of Global Health and Social Medicine and Associate Professor of Medicine. He also serves on the faculty of the Division of Global Health Equity (DGHE) at Boston's Brigham and Women's Hospital, and is a physician in the Department of Medicine.Paul Farmer is cofounder of Partners
In Health and Chair of the Department of Global Health and Social Medicine at Harvard Medical School. His most recent book is Reimagining Global Health. Other titles include To Repair the World; Pathologies of Power: Health, Human Rights, and the New War on the Poor;
Inequalities: The Modern Plagues; and AIDS and Accusation: Haiti and the Geography of Blame, all by UC Press.
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How Neoliberalism Infiltrated Global Health
By Salmaan Keshavjee
UNIVERSITY OF CALIFORNIA PRESSCopyright © 2014 The Regents of the University of California
All rights reserved.
A WORLD TRANSFORMED
Spring in Badakhshan can be hauntingly beautiful. Ahmed and I had been traversing Tajikistan's Pamir Mountains for a week in an old Russian jeep when we paused at a juncture in the road to look at our map. I gazed out at the desolation of an almost treeless mountainside—endless rock formations standing in stark contrast to a powder blue sky—whose heights concealed roaring rivers, fertile pastures, and in the lower areas, small orchards. The local people say that when God created the world, he gave everybody something they could use. But by the time Badakhshan's turn came, almost everything had already been distributed, so God gave the Pamiri people rocks and stones.
We'd been moving along at a hectic pace, and in that instant, I had the weary sensation of having driven over every boulder, rock, and pebble in those barren hills. Studying the map, Ahmed asked if I wanted to continue along the same road or turn off toward the village of Kuhdeh. It was the spring of 1996, and Ahmed and I had been visiting the medical clinics of Badakhshan's Roshtqala District to monitor the distribution of vitamins and polio vaccine. Known as the rooftop of the world, Badakhshan—which borders China to the east, Afghanistan to the southwest, and the Kyrgyz Republic to the northeast—has only 220,000 inhabitants scattered overmore than 64,000 square kilometers. Journeys between towns and villages—along some of the bumpiest thoroughfares I have ever encountered—can be formidable. Moreover, we had slept fitfully in our tent the night before, a night that in retrospect was too cold for us to have refused our host's insistence that we sleep indoors. To go to Kuhdeh now surely meant traveling up a valley for an hour only to find another closed health post. I looked off the main road and saw what appeared to be a pile of dirt and gravel leading into the river. "There doesn't seem to be a road here," I said. The driver, who had been working in the district for more than twenty-five years, assured me that this was in fact the road to Kuhdeh, adding that it had been washed away. To get there, he said, we would have to cross the river in our jeep. I glanced over at Ahmed, who looked doubtful. If we did not feel like going to Kuhdeh because of the road, I reasoned, perhaps the health workers had not either.
So we set out through the river and along ten kilometers of rocky, bone-rattling road. The route at times towered over a deep gorge, and at other points descended to the level of the river. We were later to discover that the people of Kuhdeh had built the road themselves with the help of a neighboring village. As we crossed the river, this time over a worn wooden bridge, we happened upon some farmers and asked if anyone from the medical clinic had come by recently. They laughed and told us that it had been months since any health officials had visited. "Check with Rais [village leader]," they said, "just to make certain." We continued up the road, which ran between small fields bordered on one side by a steep cliff and on the other by a mountain, until we reached the home of the village head.
We were met by a lanky, taciturn man who eyed us with skepticism. We introduced ourselves, and he called us into his home to drink shir choi, a local drink made with tea, milk, salt, and sometimes nuts, and to eat bread with sour cream. Light streamed from a central upper window into his single-room Pamiri-style house. I explained that we were there to monitor vaccination coverage and micronutrient distribution for the Aga Khan Foundation and asked about his contact with the health authorities. Like the farmers we had met, he laughed, telling us that our car was the first one that had come to Kuhdeh in almost a year; nobody else had made the effort, not even the nurse at the health post. "They've forgotten us," he said.
I later discovered that Kuhdeh had had little assistance since the collapse of the Soviet Union, and that the clothes the villagers wore were, in most cases, the same ones they had owned on the day Tajikistan was forced into independence five years earlier. Rais himself had faced particularly hard times after the Soviet Union collapsed. His brother, after weeks of drinking, had fallen to his death in a ravine not far from his house; Rais had taken his brother's wife and children into his home. I never learned whether he fell or jumped, but Rais always intimated that it had been related to the collapse. Now fourteen people were living under Rais's roof. Despite the difficulties, Rais himself was cautiously optimistic: "Now that the Aga Khan Foundation is here and we're getting food," he would say, "things will be better." As I looked around the village, I desperately wanted to believe him.
Our chance turn onto the Kuhdeh road would prove fortuitous for my understanding of Badakhshan. Over the months that followed, I returned to the village dozens of times, and Ahmed and I lived with Rais's family for a few weeks. From countless conversations with people in Kuhdeh and other villages in Badakhshan, I was able to piece together a clearer picture of the myriad ways the collapse of the Soviet Union in 1991 had altered their lives. Although our mission focused on nutrition and vaccination—and later on pharmaceutical drugs—our trips to Kuhdeh and many other villages and towns in Badakhshan allowed us to witness firsthand the transformation of health care in the region from a universal, socialized system to a privatized apparatus guided by the priorities of donors from abroad. From the moment Moscow ceded control over the Soviet Union's vast Central Asian domains, Western governments, development banks, and international NGOs launched a remarkable experiment in privatization and economic liberalization. Some of these interventions have been productive, while others have exacerbated an already precarious situation, primarily for more marginal populations. Various aspects of this evolution—particularly in the banking, petroleum, and consumer goods sectors—have been well documented elsewhere. Relatively little attention has been paid, however, to the delivery of medical care at the village level.
This gap in the scholarship was very much on my mind when I was invited to Tajikistan's easternmost province of Badakhshan in the summer of 1995 by Dr. Pierre Claquin, the health officer at the Aga Khan Foundation (AKF), an international NGO based in Geneva, Switzerland. I had been conducting research for my doctoral dissertation in Tajikistan's capital, Dushanbe, which at the time was under curfew. The country was in the midst of a civil war that had started in 1992 and would continue until mid-1997. The origin of the war was itself a point of debate. According to some, it was driven by ethnic rivalries; according to others, it was a political conflict between supporters of reform and a conservative old guard holding onto power. There were even those who attributed it to the rise of groups referred to as "Islamists" or "the mafia." It is likely that there were multiple contributing factors. Regardless, the violence resulted in an estimated 150,000 to 300,000 deaths across the political and ethnic spectrum. Roughly 700,000 refugees who traced their origin to Badakhshan and its neighboring province, Gharm, fled from Tajikistan into Afghanistan; an additional 150,000 people are said to have fled to the Russian Federation.
The war was a significant tipping point for Tajikistan. The country was one of the poorest republics in the Soviet Union, and although many gains in the population's health and education status had been registered during the Soviet period, Tajikistan emerged as an independent state in a precarious position. But even the most destitute citizens—many of whom were no strangers to deprivation even prior to the breakup—were not prepared for the sudden decline in living standards that began in 1991. The loss of subsidies from Moscow, exacerbated by the years of civil war, would ultimately plunge the newly independent nation into the ranks of the world's most impoverished states. Per capita GDP would fall from $2,870 in 1990 to $215 in 1998; by the end of the 1990s, almost 85 percent of the population was living below the poverty line. By 1996, real wages were only 5 percent of their 1991 level.
Although statistics offer only a hint of the suffering endured by the people of Tajikistan, they paint a dismal picture. Rapid inflation severely eroded purchasing power and food consumption, and health, nutrition, and educational services were on the brink of collapse. In the midst of this crisis, the central and regional governments no longer paid the cost of providing health services. The Health Ministry could no longer purchase medical supplies, including essential pharmaceutical drugs that, though subsidized during the Soviet period, had consumed from 13 to 16 percent of the state budget. As social sector spending dropped, the effects on the quality of life for most Tajiks were immediate and devastating. Life expectancy at birth for both men and women dropped during the early 1990s from 72.3 years for women and 67.1 years for men in 1991 to 68.5 for women and 63.2 for men in 1994. By 1998, the figures were 67.5 and 61.1, respectively. By 1995, infant mortality exceeded 30.7 per 1,000 live births (compared to an EU average of 5.8 and a former Soviet Union average of 21.7), mostly due to respiratory infections, diarrhea, and developmental disorders causing death in the first few weeks of life. Maternal mortality increased from 41.8 per 100,000 live births in 1991 to 93.7 in 1995, almost ten times the European Union average. The breakdown in clean water supply, proper sewerage, and the public health system led to an upsurge of communicable diseases, including waterborne diseases, tuberculosis, malaria, typhoid fever, measles, and diphtheria.
In Badakhshan, the situation was even more desperate due to its remoteness and sparse population. Winters there are long and extremely severe, making travel almost impossible and leaving the region isolated most of the year. The region had become even more inaccessible with essential supply lines cut because of war: fighting had severed the only road to the rest of Tajikistan. One could still fly to Khorog, Badakhshan's capital—a hair-raising trip on a Soviet-made Yak-40 aircraft, described to me by a seasoned pilot as one of the most harrowing landing approaches in the world—or drive in via Osh in the Kyrgyz Republic through eastern Badakhshan's desolate and sparsely populated Murghab region, a route along the Pamir Highway at more than 3,650 meters (11,975 feet) above sea level. Although many Badakhshanis had been killed during Tajikistan's civil war, the region itself, for the most part, did not suffer much active conflict because of its isolation. This, however, did not stop the influx of more than 60,000 ethnic Pamiri refugees who returned to the relative safety of their ancestral land from other parts of Tajikistan to wait out the war, bringing the population to more than 200,000 souls.
Meanwhile, the Soviet state and its complex bureaucracy had stopped functioning, and what local institutional remnants remained were too weak to fill the vacuum. Only after living in the country for an extended period did I come to better understand the degree of shock that had descended on the society after the collapse of the Soviet Union and the ensuing civil war. Their rudder had been destroyed; the surety and security to which they had grown accustomed under Soviet rule had givenway to an uncertain future. With the demise of communism, health care and education, once universally available throughout Tajikistan, became scarce. Where the government had once offered a code of ethics and a sense of stability, there was now only deprivation, civil war, and mass upheaval. The government itself had been so weakened by the collapse that in many areas it lacked the wherewithal to run even basic social services. Individuals raised in a world of adequate electricity and food were now forced to live hand to mouth.
In places like Badakhshan, which had survived on direct food and fuel shipments from Moscow during the Soviet period, the situation rapidly became dire. By 1993, the humanitarian crisis facing the region left almost the entire population at risk of death from starvation and exposure. It also led to the arrival of a number of international NGOs—including AKF—who, virtually overnight, had to provide the assistance to avert an even greater catastrophe.
NGOs stepped into Badakhshan's ravaged landscape with a remarkably expansive and varied mandate. Not only would they provide emergency assistance to citizens at risk of malnutrition and disease, but they were also, de facto, empowered to set up a system for providing Badakhshanis with the crucial social services once delivered by the Soviet state.
For me, an anthropology doctoral candidate having finished graduate work in public health, Dr. Claquin's invitation was a remarkable opportunity. AKF had received funding from the U.S. Agency for International Development (USAID) for their food assistance program, as well as an invitation to expand their health programs. USAID, he told me, had also provided funding for a social researcher to work with the foundation to better understand the effects of health care delivery interventions at the community level, specifically in providing pharmaceuticals. After spending two weeks together exploring the health situation in Badakhshan and discussing the pharmaceutical crisis, Dr. Claquin offered me the job.
At the time, I did not fully appreciate the extent to which the changes taking place in this small mountainous region at the far reaches of the recently dissolved Soviet empire would be a window onto global health policy. However, after spending time in Badakhshan, I realized that the rise of NGOs as major regional and global development actors, a socialapparatus hitherto unknown in the Soviet world, was no accident. Their rise was linked to profound changes in economic and political thinking—what political scientist Mark Robinson (1993) refers to as the "new policy agenda" in the United States and the United Kingdom, which combined neoliberal economics (which at that time was being referred to as late twentieth-century capitalism but is now captured in the termneoliberalism ) and, at least on paper, a commitment to liberal democratic theory and good governance. It was part of an ideological agenda that saw participation in markets as an economic form of political democracy. Its architects deliberately set out to reengineer the role of government and the idea of the welfare state by arguing that private enterprise was more efficient in providing social services. Under the new policy agenda, NGOs were conceived as instruments for fostering democracy and the creation of new markets, which, it was believed, would act as a bulwark against totalitarianism. Lester Salamon, founding director of Johns Hopkins University's Institute for Policy Studies, referred to this movement and the resulting social transformation as an "associational revolution" that "may constitute as significant a social and political development of the latter twentieth century as the rise of the nation state was for the nineteenth century."
THE AFTERMATH OF EMPIRE
It is very difficult to sugarcoat the collapse of an empire, no matter how bad things may have been before. During moments of reflection, people would describe the hardship they had endured during Soviet times, but it paled in comparison to their post-Soviet predicament. As one woman in Khorog put it, "After the collapse ... not many changes occurred. Everything is okay. The only problem is starvation."
The trauma of the people in Badakhshan, I would find, had implications that extended far beyond the borders of Tajikistan. Many of the changes brought on by the Soviet collapse were linked in subtle ways to broader processes associated with a sudden and relatively unbuffered immersion in the global economy. Using the lens of medical anthropology and combining ethnographic fieldwork, historical research, and social analysis, I hoped tocapture a snapshot of rapid political-economic change, set against a backdrop of the collapse of empire, civil war, and the previously unimaginable local presence of NGOs. In the end I focused on pharmaceuticals but could just as easily have studied the distribution of food, clothing, housing, fuel, or other necessities of life, all of which became increasingly subject to larger global processes. For all its poverty and isolation, Badakhshan would yield a rich treasury of ethnographic material on the consequences of abrupt, radical privatization, supported by bilateral and multilateral institutions with mandates largely framed by the discourse of neoliberalism and implemented amid profound social upheaval and transformation.
Excerpted from Blind Spot by Salmaan Keshavjee. Copyright © 2014 The Regents of the University of California. Excerpted by permission of UNIVERSITY OF CALIFORNIA PRESS.
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Table of Contents
List of IllustrationsForewordPaul FarmerPrefaceAcknowledgments1.
Introduction: A World TransformedPart I. The Beginning of the Encounter: The Soviet World Meets Its Global Counterparts2. Health in the Time of the USSR: A Window into the Communist Moral World3. Seeking Help at the End of Empire: A Transnational Lifeline for BadakhshanPart II. Life at the End of Empire: The Crisis and the Response4. The Health Crisis in Badakhshan: Sickness and Misery at the End of Empire5. Minding the Gap? The Revolving Drug FundPart III. Transplanting Ideology: Village Health Meets the Global Economy6. Bretton Woods to Bamako: How Free-Market Orthodoxy
Infiltrated the International Aid Movement7. From Bamako to Badakhshan: Neoliberalism’s Transplanting MechanismPart IV. The Aftermath: Neoliberal Success, Global Health Failure8. Privatizing Health Services: Reforming the Old World9. Revealing the Blind Spot: Outcomes That Matter10. Epilogue: Reframing the Moral Dimensions of EngagementNotesBibliography