International Health: Problems and Programs in Anthropological Perspective

The authors present an excellent summary of many of the contributions and priorities of international health, with excellent summaries of key literature and a broad overview of the field. It is more useful as a bibliographic resource and general introduction than as an article with a distinct theoretical contribution of its own. Due to the broad content of the article, this annotation restricts comments to a few of the points of greatest interest to me upon my initial reading. The article begins with an important discussion of the ways in which international health -- as a part of the larger "discourse of development" that has become so pervasive -- includes particular assumptions and premises which often go unanalyzed. Some of these are related to the historical roots of international health in missionizing efforts. Others are related to the fact that international health grew out of self-interested attempts by colonizing governments (1) to improve the productivity of the indigenous work force (see Leng's 1982: 411 argument about British colonists in Malaya), and (2) to protect their own citizens from "exotic diseases" (see El-Mehairy 1984: 11). In this context, they mention Escobar's (1985) Foucauldian argument that international health required the creation of the idea of "underdevelopment," which has resulted in the growth of assumptions that underdevelopment is a "problem" in need of technical solutions from the "developed" nations (p. 398). The coalescence of these assumptions has led to the rapid professionalization of international health (see annotation for Escobar 1985). The authors turn next to a description of the assumptions of international health work, as described by George Foster (1987). According to the authors, Foster's argument is that IH historically included the following assumptions: "(1) wealthier countries have the capital, the talent, and the know-how to solve the health problems of the poorer countries; (2) the wealthier countries should therefore plan and direct such efforts; and (3) Western health care institutions and approaches will work in solving health problems in LDCs" (p. 399). (Note: "LDCs" refers to less developed countries.) The irony of these assumptions, according to L & R, is that they entirely ignore the fact that sometimes IH projects can actually cause health problems rather than "cure" them, as illustrated by the work of scholars such as Thomas McKeown (1976). See p. 400 for a lengthy itemization of the four distinct types of international health organizations, as paraphrased from Foster (1987). Pp. 401-415 is a detailed discussion of many of the health problems of greatest concern for developing countries. The opening pages of this section (pp. 401-406) quickly details several of the most pressing problems, including: (1) high incidence of infectious diseases which lead to high infant and childhood death (e.g., diarrhea, respiratory illnesses, malaria, measles, and neonatal tetanus); (2) HIV/AIDS; (3) parasitic diseases (e.g., malaria, schistosomiasis, onchocerciasis, trypanasomiasis, leischmaniasis, filiriasis, dracunculiasis, and the intestinal parasites); (4) inappropriate use of antibiotics leading to resistant strains (e.g., MDR-TB); (5) occupational hazards; (6) high rates of illiteracy; (7) a "brain drain" leading to the emigration of health care professionals from developing countries; and (8) the growing external debt which constrains health care budgets. The subsequent sub-section ("Poor Access to Food") discusses the many factors which have led to the problems with malnutrition and undernutrition in the developing world. The authors note the irony of the poorest countries in the world supplying meat to the First World while most of their local populations are functionally denied access to high quality protein (p. 406). Following Susan George (1977), they argue that the transition to cash crops lowered nutritional status for most people in the developing world, in part because these crops are often non-food items such as cotton (p. 406). In addition, the "green revolution," which emphasized the scientific development of technologies to increase crop yields, actually decreased the quality of most peasant diets by replacing the dietary diversity of traditional agriculture with monocrops of cereals (p. 407). Worse, it reduced the crop's genetic diversity and required the purchase of high-priced fertilizers and pesticides from the First World. Because of these increased costs of farming, many Third World farmers have been pushed off their land, and many have been forced into land tenancy situations such as that described by P. J. Brown for Sardinia (see annotation for Brown 1987). The following sub-section discusses health consequences resulting from refugee flight, forced relocation, and rural-to-urban migration (pp. 408-9). The most interesting observations here are: (1) the fact that internally displaced persons (those who are forced from their homes but remain within the borders of their home country) often suffer the worst health effects since they "are harder to reach with emergency services and are frequently more vulnerable than officially recognized refugees" (p. 408) (see Frelick 1994 on this topic); (2) the authors' summary of Scudder & Colson's (1982) typology of three types of stress resulting in health effects: physiological, psychological, and sociocultural (p. 409). In the sub-section on "Political Repression, Violence, and War" (pp. 409-412), L & R note several consequences of war and political unrest for health and health care which are less obvious than the direct effects of violence and death. Two of these are of greatest interest: (1) the disruption of food distribution and health care services which tend to accompany political violence, and (2) the effects of war on the costs of staple commodities, which can dramatically raise the price of foods and lead to nutritional problems (see the example from Guatemala by Ehlers 1987). The followiing sub-section on "Multinational Business Interests" (pp. 412-413) provides two poignant examples of the ways in which multinational corporate interests often conflict with the delivery of health services: (1) the promotion of infant formula and the denigration of breastfeeding following WWII has caused enormous health consequences for developing countries (see annotation for George 1977); (2) the promotion of power antibiotics, such as chloramphenocol, in Third World countries has caused the overuse of antibiotics and encouraged the development of many resistant strains of various infections. The sub-section on "Large-Scale Development Projects" (pp. 413-414) gives several examples (see annotations for Livingstone 1958, Audy 1958, and Adams 1986) of the ways in which development efforts can actually result in "man-made maladies" (Audy's term). The following sub-section on the control of tropical diseases, which focuses on the Rockefeller Foundation's development scandals in the early twentieth century, similarly warns of the potentially detrimental effects and sinister motivations behind some development projects (see Brown 1976 and Molina-Guzman 1979). The following sub-section ("Medical Education and Population Programs") begins with a description of two important trends in international health following WWII: (1) the emergence in the developing world of medical schools and hospitals based on Western systems, and (2) the emergence of population control programs (p. 415). Most of the sub-section focuses on the latter trend. L & R note that early population control programs were based on the (faulty?) logic that poverty in the developing world was due to high fertility. However, analysts such as Ratcliffe (1978, 1985 -- see annotations) have "suggested that rather than being poor because they have many children, people may have many children because they are poor" (L & R's words, p. 416). However, while this rhetorical reversal of the common logic is interesting, L & R do not propose any mechanism whereby poverty would lead people to increase their fertility (p. 416). A fascinating point which the authors make is the fact that population control programs were used by the U.S. during the cold war as a strategic means to combat the expansion of communism. This was because of the U.S. government's tendency to associate large, dissatisfied peasant populations with the development of communist revolutionary attitudes (p. 416) (see annotation for Collins 1992). Despite these somewhat ominous roots of population control, L & R emphasize that family planning programs have been successful in reducing fertility in some developing countries (see Bongaarts et al. 1990). These successes, however, are tempered by the unethical aspects of family planning programs that have been criticized by many in the Third World as serving the goal of "genocide" (p. 417). Examples of the unethical use of fertility control devices, such as Depo-Provera, the Dalkon Shield, and Norplant, have been described by Elling (1981), Mintzes et al. (1993) and Morsy (1993) (see these annotations). Importantly, L & R observe that the problem is not with these technologies themselves, "but with formal and informal policies that give the decision-making power to someone other than the individual in whom they are used" (p. 417). The sub-section on Primary Health Care (PHC) notes that the emergence of this approach in the 1970s occurred because of "a growing realization that the supposed benefits of all the money spent on sophisticated curative medicine was not reaching the poor, mostly rural, populations who had the most disease (Golladay & Liese 1980)" (p. 418). L & R describe the basic components of PHC as follows: "The basic components of PHC are community involvement, appropriate health technology, and reorientation of health services away from ur