Health under threat by imperialist globalization

By Bert De Belder, M.D.
Coordinator, Medical Aid for the Third World (Belgium)

Keynote Address for the Workshop on Health
Founding Assembly, International League of Peoples’ Struggle, Zutphen, the Netherlands, 25-27 May 2001

I. INTRODUCTION

More than 20 years ago at Alma-Ata, the World Health Organization defined health as “a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity”. The Alma-Ata Declaration went on to affirm that “health is a fundamental human right” and that “the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector”.

It is clear that progress towards Health for All, in the WHO’s sweet dreams to be attained by the year 2000, has been largely insufficient and uneven and is even increasingly compromised. Although the last 50 years have witnessed, on average, improvements in life expectancy and mortality rates, these achievements hide the real disparities between and within countries and between social classes.

Billions of people continue to suffer deepening poverty, hunger and ill health. Each year, over 12 million children die from preventable diseases. Undernutrition is a contributing factor in more than half of these deaths, as is the ‘disease’ listed almost at the end of the WHO’s International Classification of Diseases as number Z59.5: extreme poverty. ‘Diseases of poverty’, mostly infectious diseases, and ‘diseases of modernity’, mostly chronic degenerative diseases, are on the increase. We witness the resurgence of ‘old diseases’ such as tuberculosis, malaria and vaccine-preventable diseases, as well as the emergence of ‘new diseases’, foremost among them AIDS.

From illusions to reality

By the year 2000, it became clear that a sharper analysis and more radical action were needed than those proposed in Alma-Ata. The first People’s Health Assembly that met in Savar, Bangladesh, in December 2000, may be seen as a step in the right direction. The People’s Health Charter that was drafted there describes health as “a social, economic and political issue and above all a fundamental human right”. It declares: “Inequality, poverty, exploitation, violence and injustice are at the root of ill health and the deaths of poor and marginalized people. Health for all means that powerful interests have to be challenged, that globalization has to be opposed and that political and economic priorities have to be drastically changed.”

At the assembly, David Werner denounced that “the global economy, governed by profit-hungry corporations, grows at a cancerous rate, devouring non-renewable resources, concentrating wealth into fewer and fewer hands, and unbalancing the planet’s life-sustaining resources.”

So far, so good. But what the People’s Health Assembly failed to point out, is that old or new diseases, diseases of poverty or of modernity, they are all, in essence, diseases of capitalism, diseases of imperialism. Through the ever intensifying exploitation of the workers and marginalization and exclusion of other layers of the toiling masses, capitalism breeds ill health, disease and death. Through ever-expanding domination, submission, re-colonization and wars, imposed by transnational corporations, multilateral institutions such as the International Monetary Fund, the World Bank, the World Trade Organization and NATO and the bourgeois states that prop them up, imperialism breeds even more ill health, disease and death. The people in the Third World are the main victims, dying in their millions and suffering in their billions. But more and more, workers and other simple citizens in industrialized capitalist countries are also affected. Given this reality, it is illusory and wrong to hope for a “change in the political and economic priorities” – the only right thing to do is changing the political and economic system. It is superficial and wrong to “oppose globalization” without opposing capitalism and imperialism and without asking the question of who owns and controls the means of production and who decides on the distribution and the use of their fruits.

Imperialist globalization is the name of the game

From UN officials to political leaders, from corporate managers to NGO staffers, everybody is talking about ‘globalization’ nowadays. The ideologues of ‘globalization’ would like us to believe that we live all happily together in a global village. Well, yes, let’s imagine the world to be a village, with, say, one hundred inhabitants. The good news is: this village now produces ten times more than fifty years ago. Unfortunately, all the other news is bad. Of the hundred villagers, fifty go hungry, 25 don’t have potable water, 20 cannot read or write and 80 don’t have decent housing. Half of the inhabitants earn less than a dollar a day. The six richest villagers possess 59% of the village’s wealth. They are all US nationals.

This gap between rich and poor is being produced, maintained and widened by the big transnational corporations, banks and stock markets, that function according to the one and only principle of maximizing profit. They are assisted by the International Monetary Fund, prescribing free-market economics everywhere and imposing budgetary restraint in order to repay foreign debts. They are assisted by the World Bank, imposing everywhere a dependent capitalist model of ‘development’. They are assisted by the World Trade Organization, organizing world trade in a manner that benefits only the TNCs. Finally, they are assisted by NATO, intervening militarily where and whenever the other scenarios fail.

Let us call things by their name. The much talked about ‘globalization’ is nothing else than the further development of imperialism, a process that has been going on for more than a century now. It is the concentration of capital in ever larger monopolies; it is the quest for higher profits through more international trade, investments and production under monopoly control; it is the ever increasing exploitation of the people in the neocolonial and dependent countries and of the workers in the entire world. ‘Globalization’ is a capitalism in which the role of the financial markets is exploding, with fabulous speculative capital flows. It is the conquest of the entire world market by a few large transnational corporations who are distributing the spoils among themselves. The whole planet has been neatly divided into ‘spheres of influence’ which the great imperialist powers consider as their own backyard. The collapse of the Berlin Wall has added an immense economic hunting ground to that backyard. With the countervailing political and military power of the Soviet bloc gone, imperialism has become more greedy than ever.

II. IMPERIALISM, A SICK SYSTEM

The widening gap between rich and poor, both between countries and within them, is jeopardizing the health and reducing the quality of life of billions of people. Nevertheless, in today’s world the knowledge and resources exist to remedy the world’s health and other social problems. But the world’s high-powered politicians, their palms greased by giant corporations, put their hunger for profits before human and environmental needs.

Health scientists have found that high levels of transnational corporate penetration are associated with high infant mortality rates and high child death rates. Among the transnationals, the pharmaceutical industry excels – in crime, that is. Every year, the US magazines Multinational Monitor and Corporate Crime Reporter draw up a list of the ten most irresponsible companies. For the year 2000, the pharmaceutical company Glaxo Wellcome shared the honors, for its attempts to block the distribution and production of cheaper generic aids medicines in the Third World. Today the company has merged to become GlaxoSmithKline. Bigger and more powerful than ever, it was the prime mover behind the court case initiated by 39 pharmaceutical transnational corporations against South Africa, which was planning to use parallel import and compulsory licensing to circumvent TNC patents on aids medicines. A stark illustration of the misdeeds and crimes of TNCs under imperialist globalization.

The European biotechnology company Aventis also made it to the top10, for neglecting the fact that its genetically modified StarLink Bt-corn had contaminated corn meant for human consumption. Aventis, never heard of? Indeed a new player on the market. This is, the name is new. Aventis was born upon the merger of the German company Hoechst with the French Rhone-Poulenc. An example of the ever faster and bigger concentration and centralization of capital under imperialist globalization.

For the entire decade of the 90s, a top 100 of the most criminal corporations was also drawn up. Topping the list is the Swiss pharmaceutical company Hoffman-La Roche, which had been able to fix both the world price and the market share for vitamins among the biggest TNCs. Free market, anyone? Rather, monopoly capitalism, which is becoming further entrenched under imperialist globalization.

At first glance, it may seem strange that pharmaceutical companies appear to be marketing crime rather than health. But then, capitalists have never been bothered by any sense of social or ethical responsibility, notwithstanding their grand image-boosting campaigns of late. Listen to what the director general of the French pharmaceutical industry has to say on this issue: “Why do they require special efforts from the pharmaceutical industry? You don’t request Renault to give away its cars for free to those who haven’t got one, do you?” Which succinctly captures the essence of capitalism: anarchic production for private profit – and all the rest is bullshit.

Under imperialist globalization the holy principle of profit extends to the four corners of the globe – as does the bullshit. The gap between rich and poor keeps on widening. 40 years ago, the 20 richest inhabitants of our world village possessed thirty times more than the 20 poorest; today, they possess 74 times more. Consequently, also the health gap between rich and poor countries in the world has widened: the relative probability of dying for under-five-year-olds in developing countries compared to the developed countries (established market economies and formerly socialist countries combined) has more than doubled, from a ratio of 3.4 in 1950 to 8.8 in 1990.

This deadly divide is, once again, replicated by the pharmaceutical industry. In one year, the five biggest pharmaceutical companies produce double as much as the whole of sub-Saharan Africa. And in one year (1999), the ten biggest pharmaceutical companies made a profit (25.5 billion US dollar) which is almost double the amount of the debt reduction the so-called Highly Indebted Poor Countries received over the past five years (13.5 billion US dollar).

III. CAPITALISM MAKES SICK

The myth of the ‘social welfare state’

Many people are at a loss when they are confronted with the fact that most advanced capitalist countries have achieved a relatively high level of economic and human development. They stand in awe of the Western ‘social welfare state’, supposedly so successful in Scandinavian and Western European countries. But look again, and you will see through the hype and discover an ever harsher reality.

In the first place, how did the advanced capitalist countries ever get that far? First of all, compared to socialist or Third World countries, the capitalist system has had an enormous head start in accumulating capital and creating wealth, through the extreme exploitation of its colonies and of the working class. Second, most gains in social security or political rights were not conceded voluntarily by the capitalists, but were only obtained through fierce class struggle. Third, the ruling bourgeoisie gave these concessions in part because they wanted to preempt the growing influence among the workers of the positive example set by the then socialist countries. And fourth, social benefits under capitalism can easily be eroded or even reversed in times of crisis, or when one of the above-mentioned conditions (class struggle, the socialist example) are no longer present.

This is exactly what is happening today. While the poor world has to face ‘structural adjustment’, very similar policies are being implemented in the rich world, generally labeled as ‘neoliberalism’: liberalization, deregulation and privatization. By these measures, imperialism tries to defer a major economic crisis, a crisis of overproduction that stems from accelerating productivity combined with constrained demand – the growing army of jobless and poor don’t make for high-spending consumers. By doing so, world capitalism shifts the burden to the people in the Third World and to the working class in the industrialized capitalist countries.

The catastrophe of capitalist restoration

If you want to see what capitalism means to the people’s health, just take a look at the former Soviet Union and Eastern Europe, where capitalism has been restored for some ten years now. The former Soviet Union, which had been the second world power until 1989, has now reached the level of a Third World country. Russia’s GDP equals the turnover of two big automobile giants, GM and Ford! The countries of the East have experienced an average annual negative growth of 4% since 1990. In terms of GDP, Russia’s production is at a level of 57% compared to 1990, the Ukraine’s at 39% and Georgia’s at 30%.

The 2000 report of the International Labor Organization has to admit that in the countries of the East, “unemployment was almost non-existent before 1989. But rapidly, the rise in unemployment has started to exert pressure on the welfare systems in Bulgaria, Hungary, Poland and Slovakia, has deteriorated the conditions of benefits and reduced their level and duration.” In the whole region, less than half of the unemployed are receiving any unemployment benefit or social help. In many countries, the minimum wage has fallen below the poverty line, and often, wages are simply not paid.

As early as in 1995, when these countries had known capitalist paradise for just five years, Unicef came up with an astonishing report on growing poverty and ill health in the countries of Central and Eastern Europe and the former Soviet Union. Unicef observed: “The tendencies include a severe welfare crisis affecting especially children and adolescents, an upsurge in mortality, equally shocking falls in births and increases in poverty, and faltering social protection and child development programs.” In Russia, life expectancy had decreased to only 61 years, the level of an average developing country like India. In Eastern Europe and the former Soviet Union, the incidence of tuberculosis has increased threefold in ten years time.

Health gaps under capitalism

But also in the centers of monopoly capitalism, the health of the people is under fire as the exploitation of the workers increases and their salaries decrease in real terms. In the US, the income of the 40% poorest has diminished every year since 1977.

The best predictor of life expectancy, old-age disability or the frequency of heart attacks is… class. As a predictor of coronary disease, it is more accurate to measure class position than to measure cholesterol. Of course we all know that landlords live longer and healthier lives than peasants, and corporate managers than workers. But it is important to underpin this common knowledge with hard figures.

The Economist reports on the situation in the United Kingdom: “Among men of working age, those in the lowest social class are three times more likely to die prematurely than those in the highest. A baby boy born today of parents in the top two social classes can expect to live five years longer than a baby born to parents in the lowest classes. Thirty years ago the gap was less than four years.”

In Belgium, one of the richest countries in the world and a country with a relatively well organized social security and health care system, a study comparing infant mortality rates for different occupations of the mother found that in the period from 1990 to 1994, the infant mortality rate for children of employees was between 6 and 7 per 1000 live births, for children of workers between 7 and 8 and for children of jobless mothers between 8 and 12.

Disease and death on the factory floor

Work-related stress, disease and death as a consequence of landlord and capitalist exploitation are consciously hidden from the limelight and rarely appear in statistics. And yet, every year 1.1 million people die on their job and 125 to 250 million have a work-related accident. 160 million people suffer from an occupational disease. Since 1998, the number of work-related accidents in the world is again on the rise, thanks to ‘globalization’. Working conditions in Third World countries, in industrial as well as in agricultural industries, are more often than not horrible. Concrete testimonies aside, very few hard data exist on the health effects of the working conditions of “the wretched of the earth”. I will just cite a few cases and statistics from industrialized capitalist countries, and if you multiply them by ten or by one hundred, you’ll get an idea of the world situation.

Males in rural Australia have seen their life expectancy decrease because of long term unemployment and its consequences of depression and suicide. One worker in ten suffers from depression or stress. In Great Britain, three out of every ten workers suffer from psychological problems.

In Belgium, 93 out of every 100 workers have at least one work-related accident in the course of their 25-year career. Every day, a Belgian worker dies on his job. According to European studies, 40% of all pathology doctors come across are related to work. The industrial proletariat suffers the most. Employees have six times less work-related accidents and diseases than workers. Shift workers and especially night shift workers suffer more accidents. And the accident rate among interim workers is 3.5 times higher than average.

Stress at work may lead to suicide, as is well known in Japan. But not only there… In the Renault automobile factory in Douai, France, the pressure at work has increased a lot since the closure of the Renault plant in Vilvoorde, Belgium. The workers now have to work 16 Saturdays a year. Breaks used to be 10 minutes, now only 6; lunch break has shortened from 35 to 15 minutes, and the workers’ canteen is closed. The consequences are deadly: in 1996, there were 12 deaths among the workers of Renault-Douai, 3 of them suicides; in 1998, the workers counted 27 deaths with 7 suicides…

The reasons for stress, accidents, disease and death on the factory floor are to be found in the increased productivity, intensity and flexibility imposed on the workers by all means: shift work, night work, interim work, subcontracting, part-time work, team work, just-in-time production, extra working hours, quality circles, wages linked to production output or to sales, dismissals, etc.

What a criminal system is it in which half of the workers get sick because they have no job, and the other half get sick because they have to work too hard, with too much stress or in too dangerous conditions?

The environment under attack

Capitalism and imperialism are also destroying the environment at a pace never seen before. This has direct and indirect, immediate and delayed effects on people’s health. Direct threats include exposure to toxic substances in water, air or soil, and potentially unknown threats such as those from genetically modified organisms. Particularly despicable human toxicity derives from imperialist nuclear, chemical and biological warfare – the most recent example being the use of munitions with depleted uranium on the NATO battlefields in Iraq and the former Yugoslavia, leaving both local populations and soldiers contaminated, sick and dying. Indirect threats include environmental degradation, food shortages, climate changes and the like. And once more, for all forms of environmental degradation, the Third World is the main victim.

IV. HOW TO GET WELL IF THE HEALTH CARE SYSTEM IS SICK?

Health services are today more inaccessible, unaffordable, inequitably distributed and inappropriate as ever, the world over but particularly in the Third World and the formerly socialist countries. Severe cuts in national budgets for health – in the poorest 37 countries, public per capita spending on health was reduced by 50% in the 1980s – have resulted in the deterioration and often collapse of services at many levels. Inadequate resource allocation for capital and recurrent costs have resulted in deteriorating health facilities, shortages of equipment, drugs and means of transportation, reduction in the numbers of health personnel and deterioration of their performance as a result of worsening working conditions.

Health Sector Reform imposed by the IMF and the World Bank has promoted privatization which, together with the lack of human and other resources in the under-funded public sector, have led to the rapid growth of the private health sector. Through privatization, governments are reneging on their responsibility to provide health for the people.

Liberalization means the unbridled entry of hazardous goods, including drugs and food, as well as the entry of foreign capital groups and consultants to invest in hospitals and laboratory services or establish health maintenance organizations (or should we say: profit maintenance organizations?).

Health care has been commodified – converted from a basic right into a product that can be sold or exchanged for profit. The monopoly ownership, production and distribution of the commodity that is health care is consolidated by the establishment of professional associations, colleges and hospitals, by capitalist health corporations and by their minions in government.

As a Marxist scholar notes: “Health is part of the wage goods of society, part of the value of labor power, and therefore a regular object of class struggle. But health is also a consumer good, particularly for the affluent, who can buy improvements in health for themselves. Rather than improve water quality, they buy bottled water.”

A threat called GATS

Pervertedly calling it intellectual property rights, the WTO protects the plunder of the collective intellectual, natural and cultural property and heritage of humankind, while denying the Third World countries any rights on any property at all. Even the human genome is no longer collective property but prey to giant private corporations.

The WTO is also instrumental in forcing the opening up of the services sector to capitalist interests by imposing the GATS, the General Agreement on Trade in Services. New negotiations on the GATS are underway – of course in the secretive Green Room of the WTO, to which powerful corporations have access and countries from the South not – which intend to expand this process even further.

The GATS negotiations aim:

  1. to minimize domestic regulation on the services sector
  2. to impose the ‘national treatment’ regime on services, which means that foreign corporations would enjoy the same advantages as local companies
  3. to demand from governments unlimited market access for foreign service providers.

48 countries have already signaled their agreement to include health care in the WTO negotiations on privatization, with priority for hospitals, social services and health assurance. For the 29 OECD countries, the amount of capital involved would be around 2,000 billion dollar; worldwide some 3,500 billion dollar. The patient will become a client, at the mercy of the whims of the free market – or rather, of the corporate health monopolies.

Inequality in capitalist health care

Even in industrialized capitalist countries, more and more people are experiencing exclusion in the health care system. As the social security system is gradually being dismantled, Belgian patients now have to pay out or their pocket one fourth of the cost of a hospitalization, as against one tenth before. In Antwerp’s main public hospital, almost one third of the patients are not able to foot the bill. Being chronically ill in a Western capitalist society is so expensive, that forty percent of these patients end up being poor.

It has been shown that patients from the upper social classes are given more time by doctors in consultation, receive different treatment and get more explanation. A study undertaken by the jobless workers of the Belgian trade union CSC in the impoverished old industrial city of Charleroi found an important underconsumption of medical care among the jobless: more than one third report not having visited the doctor when needed during the past six months. Inability to pay appeared to be a major factor: almost 7 out of every 10 jobless people don’t pay their medical care bills on time, and 41% report to have already asked their doctor to postpone payment.

In the main public hospital of Brussels, the proud capital of Europe, the lack of prenatal care available to pregnant women not covered by medical insurance (these are practically all foreigners – migrant workers and refugees) led to a six-fold increase in perinatal mortality.

But what to say then about the often-discussed problem of so-called medical overconsumption? If we consider the capitalist nature of health care, the answer is clear: “Sometimes people get too much care, sometimes too little. But in both cases, our health is a side effect of the obsessions with making money.”

Corporate medical education

Not surprisingly, medical education has also become more commercialized and subservient to big capital groups. In the Faculty of Medicine of the Catholic University of Louvain, one of the most prestigious universities in the world, there are 31 academic chairs with names such as the Aventis chair in Thrombosis and Haemostasis, the Boeringher Ingelheim chair in Hypertension and the GlaxoSmithKline chair in Medical Microbiology.

Medical education, in Third World countries as anywhere, has become big business, geared towards hospital-based, doctor-dependent, urban-centered, drug-dependent and technologically inappropriate health care. The doctor factories that are inaptly called medical schools turn out graduates to join the reserve army of globally competitive cheap labor.

Is it so strange, then, that doctors almost never consider the fundamental causes of ill health? Any open recognition of the real causes would call into question the very system that allows them to own and market their commodity. Thus it is not in the interest of the medical profession to examine, let alone to confront the fundamental social roots of illness.

V. HEALTHY ALTERNATIVES

As the worldwide crisis deepens and more and more people begin to realize that the current global economic system of capitalism has lethal flaws, the groundswell for change is gaining momentum.

Philippine professor and health activist Romy Quijano coined an acronym to describe how he proposes to confront the dismal situation of pharmaceuticals, but it can likewise be used in the broader context of the struggle for health:

  • Awareness raising
  • Networking
  • Technical capability building
  • Information gathering and monitoring
  • Deepening of understanding
  • Organizing
  • Transformation
  • Empowerment

In order to act against transnational corporations, the World Bank, the IMF and the WTO, you first have to raise the people’s awareness. National and international networking strengthens your movement for health. Health workers and activists, however well-versed in politics, need to have the technical capabilities to confront ill health. Information is vital, especially the one that you can gather through community diagnosis, social investigation and class analysis. Integration with the basis masses will let you deepen your understanding of their problems and of their struggles. It is only by organizing the people that you can effectively work towards the transformation of society. And only a people empowered will be able to do so. These guidelines will equip you with a strong ANTIDOTE against imperialist globalization.

People’s struggles for health

And this antidote is already showing its effectiveness. Social movements, people’s organizations, trade unions, revolutionary movements and socialist forces from all over the world declare that the world is not for sale and that another world is possible. There are innumerable examples of peoples’ struggles for health and liberation over the last century. Years back, the International People’s Health Council already stated that “the struggle for health is the struggle for liberation from poverty, exploitation and unfair social-economic structures”. Medical Aid for the Third World’s central slogan is “Health is a matter of fighting injustice”.

And in this struggle, victories can be won. Just one recent example: under national and international pressure from health activists, the 39 TNCs have had to withdraw their court case against South Africa’s supposed breach of their holy patent rights.

But what we have to say loud and clear, is that the struggle for the people’s health can only bear fruit to the extent that it is imbedded in the people’s overall struggle against imperialism. In order to overcome ill health brought about by exploitation and oppression, we have to defeat imperialism, using various forms of struggle, including open mass movements and armed struggle. The struggle for health must be part and parcel of the workers’ and peasants’ struggle for food and freedom, land and liberty, jobs and justice, of the struggle of the global working class for socialism.

Against the globalization of poverty and ill health, the only alternative is the globalization of the people’s solidarity and struggles. There is a need to coordinate actions at the international level and to make health efforts integral to international movements of solidarity with the various but increasingly inter-related struggles for national and social liberation. We are confident that the launching of the International League of Peoples’ Struggle will greatly contribute to this goal.

Health under socialism

The overall level of health in a community or nation – or in the world as a whole – is a good indicator of its degree of equity and social justice. For this reason, health can be a good entry point in the struggle for fairer, more sustainable alternatives.

International health experts have long recognized the outstanding health developments in China and Cuba. As even bourgeois sources have to acknowledge, the people’s health is much better protected and promoted under socialism – although they take pains to decontextualize these achievements and disassociate them from the prevailing social-economic and political system, from socialism.

The World Bank wrote in 1981: “China’s most remarkable achievement during the past three decades (i.e. since its liberation and the construction of socialism) has been to make low-income groups far better-off in terms of basic needs than their counterparts in most other poor countries. (…) Life expectancy is at 64 outstandingly high for a country at China’s per capita GDP level.”

In 1985, the Rockefeller Foundation commissioned a study to investigate four countries or regions that experienced “good health at low cost”: China, Costa Rica, India’s Kerala State and Sri Lanka. It found out that China was the most exceptional in terms of equality, and that China’s results were largely due to fairer distribution of land use and food production.

A few more observations by UN agencies: “The growth of China’s wealth and of its agricultural economy throughout the 1980s is a known example of growth in favor of the poor. Vietnam’s experience in the 1990s is similar.” “If India would have the same health care services as China, each year 1.4 million children could be saved.” “In the 1987-1998 period, the number of poor in the developed capitalist countries increased with 340 million, while their number in China and Vietnam decreased with 153 million.”

Comparing the Physical Quality of Life Index (composed of the infant mortality, the life expectancy and the literacy rate) of almost all countries in the world, it was found that at the same level of economic development, socialist countries consistently showed more favorable outcomes than capitalist ones. The socialist countries had infant and under-five mortality rates two to three times lower than the capitalist countries, much higher numbers of health professionals per population and a higher daily per capita calorie supply. The adult literacy rate of the socialist countries by far surpassed that of the capitalist countries at each level of development.

Of course we have to add that since the introduction of pro-capitalist reforms in China, although the general standard of living has continued to increase, many of the gains of socialist medicine have slowly been eroded. As observed by the World Bank, “since the early eighties, infection rates in about half the country’s provinces have stagnated or increased. (…) Much of the trend is attributable to changed health-financing policies and, in particular, to the government’s decision that health facilities should be encouraged to charge patients for virtually all services.” This is, by introducing the typical World Bank reforms.

The negative effects of these are hesitantly recognized by China’s authorities. A recent issue of Beijing Information describes how, with the decentralization of hospital management, the sale of often over-priced pharmaceuticals is being pushed to subsidize hospital operations. As public dissatisfaction with such practices is mounting, the State is trying to counter them by lowering the prices for a number of drugs and by introducing new legislation to protect consumers.

A comparison of the relatively poor Asian republics of the former Soviet Union with the capitalist-oriented countries on their borders, such as Turkey, Afghanistan of Iran, show that health indicators developed much more favorably in the former than in the latter. E.g. by the late 60s, Azerbaijan had an infant mortality rate of 43 per 1000 as against 215 per 1000 for neighboring Afghanistan. At its top, the Soviet Union attained a life expectancy of 70.4, just eight months less than in the much richer United States.

Cuba is an even clearer example of the superiority of socialism. “Child mortality in Cuba is 17 times lower than the world average”, Unicef says. And even World Bank President Wolfensohn has recently admitted that “Cuba has done a great job in terms of health care and education”. He said this upon viewing the most recent World Development Indicators, which indicate that Cuba’s infant mortality rate has further decreased from 11 per 1000 in 1990 to 7 per 1000 in 1999, putting the country ahead of many rich industrialized nations. Throughout the 1990s, Cuba spent some 9.1% of its GDP on health, it has the highest proportion of doctors in the world (5.3 per 1000 inhabitants) and produces up to 80% of its pharmaceuticals itself. And yet, Cuba is something of a nightmare to the World Bank, for the simple reason that it has never been a member of the Bank and is the only developing country in the world, with North Korea, that has never received support nor advice from the Bank. But then, didn’t Fidel Castro say that Cuba’s social success story is “thanks to its privileged position as a non-member of the IMF”?

Che, doctor and freedom fighter

It is important to note that it is only in countries where the capitalist system has been overthrown and the economic system is oriented to social need rather than private profit, that the contribution of the health sector to the improvement of the people’s health has changed fundamentally. Changes in the health sector follow rather than precede fundamental societal change. Genuine and lasting changes for the better in the people’s health are only possible once imperialism has been crushed.

Which explains the choice Ernesto Che Guevara made on one of the first days of the war for the liberation of Cuba. Che wrote: “At my feet were a pack full of medicines and a cartridge box; together, they were too heavy to carry. This was perhaps the first time I was faced with the dilemma of choosing between my dedication to medicine and my duty as a revolutionary soldier. I chose the cartridge box, leaving behind the medicine pack.”

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