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Imperialism’s Health Component

Howard Waitzkin is distinguished professor emeritus of sociology at the University of New Mexico and adjunct professor of Internal Medicine at the University of Illinois. Rebeca Jasso-Aguilar is instructor of sociology at the University of New Mexico. This article grew from an ongoing collaboration that has included a recent book (Waitzkin, Medicine and Public Health at the End of Empire, Paradigm, 2011) and a doctoral dissertation (Jasso-Aguilar, How Common Citizens Transform Politics: The Cases of Mexico and Bolivia, Department of Sociology, University of New Mexico, 2012).

Medicine and public health have played important roles in imperialism. With the emergence of the United States as an imperial power in the early twentieth century, interlinkages between imperialism, public health, and health institutions were forged through several key mediating institutions. Philanthropic organizations sought to use public health initiatives to address several challenges faced by expanding capitalist enterprises: labor productivity, safety for investors and managers, and the costs of care. From modest origins, international financial institutions and trade agreements eventually morphed into a massive structure of trade rules that have exerted profound effects on public health and health services worldwide. International health organizations have collaborated with corporate interests to protect commerce and trade. In this article we clarify the connections among these mediating institutions and imperialism.

Imperialism and Health

Although it is a complex, multifaceted phenomenon, imperialism in simple terms refers to an expansion of economic activities—especially investment, sales, extraction of raw materials, and use of labor to produce commodities and services—beyond national boundaries, as well as the social, political, and economic effects of this expansion. Empire yields many advantages for economically dominant nations. For centuries, imperialism included military conquest and the maintenance of colonies under direct political control. The decline of colonialism in the twentieth century, however, led to the emergence of political and economic “neocolonialism,” by which poor countries provided similar advantages to richer countries as they had done under the earlier, more formal versions of colonialism.

One fundamental characteristic of capitalist imperialism involves the extraction of raw materials and human capital, which move from the global South to economically dominant countries in the North. In the global South, “underdevelopment of health” follows inevitably from this depletion of natural and human resources.1 Under imperialist relationships, such extraction of wealth limits poorer countries’ abilities to construct effective health systems. These countries also face a net loss of health workers who migrate to economically dominant nations after expensive training at home.

A cheap labor force also becomes an advantage for multinational corporations. The efficiency of labor became an important goal of public health programs sponsored abroad by philanthropies closely tied to expanding industries in the United States. The Rockefeller Foundation’s activities in public health, for instance, sought improved health conditions, especially control of infectious diseases, as a way to enhance the productivity of labor.2 Population-control programs initiated by the United States and other dominant countries also fostered more reliable participation by women in the labor force. Through public health initiatives, a healthier, more predictable, and more productive labor force could enhance the fortunes of corporations seeking to expand in the global South.

Another thrust of imperialism has involved the creation of new markets for products, including medical products, manufactured in dominant nations and sold throughout the rest of the world. This process, enhancing the accumulation of capital by multinational corporations, has appeared nowhere more clearly than in pharmaceutical and medical equipment industries.3 The monopolistic character of these industries, as well as the stultifying impact that imported technology has exerted on local research and development, has led to advocacy for nationalized drug and equipment formularies in the global South, with varying success. Such advocacy also has provided a framework for resistance to trade rules that protect patents and therefore enhance the financial interests of pharmaceutical and equipment corporations that operate in such countries.

Imperialism has reinforced international class relations, and medicine has contributed to this phenomenon. As in the United States, medical professionals in the global South most often come from higher-income families; even when they do not, they frequently view medicine as a route of upward mobility. As a result, medical professionals tend to ally themselves with the capitalist class—the “national bourgeoisie”—within these countries. They also frequently support cooperative links between the local capitalist class and business interests in economically dominant countries.4 The class position of health professionals has led them to resist social change that would threaten the current class structure, either nationally or internationally.5

Even after the decline of formal colonialism, imperialism frequently has involved military conquest in addition to economic domination. Despite its benign profile, medicine has contributed to the military efforts of European countries and the United States. For instance, health workers have assumed armed or paramilitary roles in Indochina, North Africa, Iraq, and Afghanistan. Health institutions also have taken part as bases for counterinsurgency and intelligence operations in Latin America and Asia.6

The connections among imperialism, public health, and health services have operated particularly through several institutions that have mediated these connections: philanthropic foundations, international financial institutions, organizations that enforce trade agreements, and international health organizations.

Philanthropic Foundations

Notions about charitable contributions by wealthy people to the needy date back at least to the Greek practice of “philanthropy,” but modern practices involving foundations with their own legal status began in the early twentieth century. Andrew Carnegie, who accumulated his fortune mainly through the steel industry, took a leadership role in the creation of philanthropic foundations. His philanthropic ventures began with the establishment of Carnegie libraries in small U.S. towns and cities. In writings such as The Gospel of Wealth, published in 1901, Carnegie presented his opinions about the social responsibilities of wealth.7

In this book, speeches, and other efforts to influence his fellow barons of capitalism, Carnegie argued that contributing to the needs of society was consistent with good business practices. According to Carnegie, philanthropy provided several advantages for capitalists, including the achievement of favorable popular opinion about capitalist enterprises and individual entrepreneurs. More importantly in Carnegie’s view, by contributing intelligently to address social needs rather than squandering one’s wealth, the business person also could assure personal entry into the heavenly realm—thus, the “gospel” of wealth. Among the book’s many notable features, Carnegie distinguished between “imperialism” and the more virtuous “Americanism”: “Imperialism implies naval and military force behind. Moral force, education, civilization are not the backbone of Imperialism. These are the moral forces which make for the higher civilization, for Americanism.”8 Through the Carnegie Endowment for International Peace and other interconnected foundations, Carnegie acted to achieve the fruits he preferred in the disposal of his earthly wealth and in his own heavenly future.

An important early extension of philanthropic foundations to health involved John D. Rockefeller and the Rockefeller Foundation. With a fortune based in oil, Rockefeller emulated Carnegie’s philanthropic activities, despite their conflicts in the realm of monopolistic business practices. Rockefeller and associates moved to support public health activities and health services that would benefit the economic interests of Rockefeller-controlled corporations throughout the world.

To foster this goal, the Rockefeller Foundation initiated international campaigns against infectious diseases such as hookworm, malaria, and yellow fever. Between 1913, the year of its founding, and 1920, the Foundation supported the development of research institutes and disease-eradication programs on every continent except Antarctica. For capitalist enterprises expanding internationally, infectious diseases proved troublesome for several reasons, which became clear from the writings of Rockefeller and the managers of the Rockefeller Foundation.9 First, these infections reduced workers’ energy and therefore their productivity; based on this perspective, hookworm became known as the “lazy man’s disease.” Second, endemic infections in areas of the world designated for such efforts as mining, oil extraction, agriculture, and the opening of new markets for the sale of commodities made those areas unattractive for investors and for managerial personnel. Third, when corporations assumed responsibility for the care of workers, these costs escalated when infectious diseases could not be prevented or easily treated.

Addressing these three problems, the Rockefeller Foundation’s massive campaigns took on certain characteristics that persist to this day, not only for Rockefeller but also for other foundations, international public health organizations, and nongovernmental organizations. The Rockefeller Foundation emphasized “vertical” programs, initiated by the donor and focusing on specific diseases such as hookworm or malaria. An alternative approach could encourage “horizontal” programs, to provide a broader spectrum of preventive and curative services through a well-organized public health infrastructure of clinics and hospitals. Rather than such broad public health initiatives targeting disadvantaged populations, the Rockefeller Foundation’s vertical orientation favored a so-called “magic bullet” approach targeting new vaccines and medications that could prevent and treat infectious diseases.

A vertical orientation has continued in recent, large-scale efforts by the Rockefeller Foundation, Gates Foundation, and other philanthropies to address public health problems like AIDS, tuberculosis, malaria, and most recently Ebola. The foundations often frame their participation as attempts to improve economic development by “investing in health,” a term first promoted by the World Bank.10 These initiatives usually encourage the participation of multinational pharmaceutical companies (which hold the patents for key medications and vaccines used in infectious-disease campaigns) and private insurance companies or managed care organizations (which assume responsibility and receive payment for delivering services in “public-private partnerships”).

Currently the Gates Foundation has emerged as the largest philanthropy worldwide focusing on public health. Its efforts continue to target specific infectious diseases, especially AIDS in Africa. Together with the World Health Organization (WHO), whose limited budget the Gates Foundation helps fund, and various nongovernmental organizations also supported by Gates and Rockefeller, philanthropies have invested heavily in the control of infectious diseases through vaccines and other pharmaceutical products. In general, these strategies have left the insufficient public health infrastructures in many countries of the global South relatively untouched, while lavish spending has occurred to support programs on AIDS, malaria, and tuberculosis.

As a result, access to medical and public health facilities remains inadequate for people who often face desperate circumstances. The contradictions of vertical programs, which persist as the legacy of the Rockefeller orientation in philanthropic support, lead to bizarre and tragic situations that become well known to public health workers in the global South. In countries devastated by AIDS, for instance, patients sick with other serious disorders like cancer feign or even intentionally get infected by HIV so they can receive medical care in well-funded AIDS programs. And when severe epidemics like Ebola strike, the vertically oriented investment policies of foundations leave countries in Africa without an urgently needed infrastructure of primary-care clinics and hospitals to care for critically ill patients.

International Financial Institutions and Trade Agreements

The framework for modern international financial institutions and trade agreements began after the Second World War with the Bretton Woods accords. These accords grew from meetings in Bretton Woods, New Hampshire, involving representatives of countries victorious in the war. The agreements initially focused on the economic reconstruction of Europe. Between 1944 and 1947, the Bretton Woods negotiations led to the creation of the International Monetary Fund (IMF) and the World Bank, as well as the establishment of the General Agreement on Tariffs and Trade (GATT).11

After Europe’s recovery, these institutions and agreements gradually expanded their focus to the rest of the world. For instance, the World Bank adopted as its vision statement, “Our dream—a world without poverty.”12 However, because the IMF and World Bank provided most of their assistance through loans rather than grants—and, in the case of the IMF, mainly established conditionalities that would open the door to private lending—the debt burden of the poorer countries increased rapidly. By 1980, many countries in the global South, including the poorest in the world, were spending on average about half their economic productivity, as measured by gross domestic product, on payment of their debts to international financial institutions—even though these institutions’ goals usually emphasized the reduction of poverty. During the early 1980s, the international financial institutions embraced a set of economic policies known as the Washington Consensus. These policies, mainly advocated by the United States and the United Kingdom, involved deregulation and privatization of public services, which added to the debt crisis by reducing even further the public health efforts and health services that poorer countries could afford.

Initially GATT aimed to reduce trade barriers among its twenty-three member countries by eliminating or cutting tariffs and other fees on exports and imports. The fairly simple principles of GATT included “most favored nation treatment” (according to which the same trade rules applied to all participating nations) and “national treatment” (which required no discrimination in taxes and regulations between domestic and foreign goods).13 GATT also established ongoing rounds of negotiations concerning trade agreements.

From their modest origins in GATT, international trade agreements eventually changed into a massive structure of rules that would exert profound effects on public health and health services worldwide. As the pace of international economic transactions intensified, facilitated by technological advances in communications and transportation, the World Trade Organization (WTO) in 1994 replaced the loose collection of agreements subsumed under GATT. The burgeoning array of international trade agreements encompassed under WTO—seen also in the current round of regional agreements such as the Trans-Pacific Partnership and the Trans-Atlantic Free Trade Agreement—expanded the purview of trade rules far beyond tariff barriers. Instead, the new trade agreements interpreted a variety of public health measures such as environmental protection, occupational safety and health regulations, quality assurance for foods and drugs, intellectual-property restrictions pertaining to patented medications and equipment, and even public-sector health services themselves as potential barriers to trade. This perspective in trade agreements transformed the sovereignty of governments to regulate public health and to provide health services. Together with regional trade agreements initiated by the United States, WTO has sought to remove both tariff and non-tariff barriers to trade. The removal of non-tariff barriers to trade has affected the ability of national, state, and local governments to protect public health and medical services.

While tariff barriers to trade involve financial methods of protecting national industries from competition by foreign corporations, including import taxes, “non-tariff barriers” refer to non-financial laws and regulations affecting trade, particularly those that governments use to assure accountability and quality. In over 900 pages of rules, the WTO set criteria for permissible or impermissible non-tariff barriers, such as domestic policies governing environmental protection, food safety, and health services. While aiming to achieve “free” trade across borders, the rules in trade agreements limit governments’ regulatory authority over trade while enhancing the authority of international financial institutions and trade organizations.14

WTO rules (under general exceptions of GATT, Article XX) permit national and subnational “measures necessary to protect human, animal or plant life or health,” but other provisions make this exception difficult to sustain in practice.15 For example, a country could be required to prove that its laws and regulations comprise the alternatives least restrictive to trade, and that they are not in fact disguised barriers to trade.16 These rules also restrict public subsidies, particularly those designated for domestic health programs and institutions, as potentially “trade distortive.” Requiring that such subsidies apply equally to domestic or foreign companies that provide services under public contracts preempts public policies that direct subsidies to domestic companies and to public programs.

With relevance to public health, a key WTO provision requires “harmonization,” which seeks to reduce variation in nations’ regulatory standards for goods and services.17 Proponents argue that harmonization can motivate some countries in the global South to initiate labor and environmental standards where none previously existed.18 However, harmonization also can lead to erosion of existing standards, since it requires uniform global standards at the level least restrictive to trade.19 WTO encourages national governments to harmonize standards on issues as diverse as truck safety, pesticides, worker safety, community right-to-know laws about toxic hazards, consumer rights regarding essential services, banking and accounting standards, informational labeling of products, and pharmaceutical testing standards.

WTO and regional agreements such as the North American Free Trade Agreement (NAFTA) supersede member countries’ internal laws and regulations, including those governing health. Under these agreements, governments at all levels faced a loss of sovereignty in policy making pertinent to public health and health services. Traditionally, government agencies at the federal, state, county, and municipal levels maintain responsibility for protecting public health by assuring safe water supplies, controlling environmental threats, and monitoring industries for occupational health conditions. Trade agreements can reduce or eliminate such governmental activities, because the agreements treat these activities as potential barriers to trade.

For disputes, an appointed tribunal, rather than a local or national government, determines whether a challenged policy conforms to the rules of WTO or a regional trade agreement. The tribunal includes experts in trade but not necessarily in the subject matter of the cases, such as health or safety, or in the laws of the contesting countries.20 Documents and hearings remain closed to the public, press, and state and local elected officials. Because trade agreements treat federal governments as the only pertinent level of participation, only representatives of contesting countries can participate in the hearings, in addition to “experts” whose participation the tribunal requests.

If a tribunal finds that a domestic law or regulation does not conform to the rules of WTO or a regional trade agreement, the tribunal orders that the disputed transaction proceed despite the wishes of government officials or public health experts. If a country fails to comply, WTO or the commission with authority over a regional agreement like NAFTA can impose financial penalties and can authorize the “winning” country to apply trade sanctions against the “losing” country in whatever sector the winner chooses until the other country complies. In challenges decided by WTO or NAFTA tribunals, for instance, corporations and even individual investors have caused governments to suffer financial consequences and trade sanctions because of their efforts to pursue traditional public health functions. As they grapple with imposed sanctions, losing countries usually succumb to pressures for eliminating or changing the laws or regulations in question and not enacting similar laws in the future.

Table 1 gives examples of decisions under trade agreements that have affected public health and health services. The table shows the immense scope of trade agreements’ health-related impacts. Trade agreements like the Trans-Pacific Partnership and the Trans-Atlantic Free Trade Agreement, still under negotiation as the Obama Administration’s two major trade initiatives, contain provisions that similarly remove or constrain governments’ ability to protect public health.

Table 1. Examples of Actions under International Trade Agreements that Affect Public Health

Occupational & Environmental HealthUnder Chapter 11 of the North American Free Trade Agreement (NAFTA), the Metalclad Corporation of the United States successfully sued the government of Mexico for damages after the state of San Luis Potosí prohibited Metalclad from re-opening a toxic waste dump. The Methanex Corporation of Canada sued the U.S. government in a challenge of environmental protections against a carcinogenic gasoline additive, methyl tertiary butyl ether (MTBE), banned by the state of California.
Access to MedicationsActing on behalf of pharmaceutical corporations, the U.S. government invoked the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) of WTO in working against attempts by South Africa, Thailand, Brazil, and India to produce low-cost, anti-retroviral medications effective against AIDS.
Safety and Quality of ProductsCanada challenged France’s ban on asbestos imports under WTO’s Agreement on Technical Barriers to Trade (TBT). Although a WTO tribunal initially approved Canada’s challenge, an appeal tribunal reversed the decision after international pressure.
Safety & Quality of FoodOn behalf of the beef and biotechnology industries, the United States and Canada successfully challenged the European Union’s ban of beef treated with artificial hormones under the WTO Agreement on the Application of Sanitary and Phyto-Sanitary Standards (SPS). The European Union still pays the United States and Canada more than $120 million annually in extra tariffs imposed due to the EU’s decision to limit importation of hormone-treated beef.
Medical & Public Health ServicesThe WTO General Agreement on Trade in Services (GATS) removes restrictions on corporate involvement in public hospitals, water, and sanitation systems. GATS affects state and national licensing requirements for professionals and can facilitate challenges to national health programs that limit participation by for-profit corporations.

International Health Organizations

The first approach to international public health organization arose in Europe during the Middle Ages. To block people from leaving or entering geographical areas affected by epidemics of infectious diseases, some governments established local, national, and international cordons sanitaires—guarded boundaries. Governments also imposed maritime quarantines that prevented ships from entering ports after visiting regions where epidemics were occurring. “Sanitary” authorities arose mostly on an ad hoc basis and remained active mainly when epidemics were present or anticipated.21

With the rise of export economies and the expansion of international trade during the late nineteenth and early twentieth centuries, conventional maritime public health went into decline. Instead, concerns about infectious diseases as detrimental to trade in the expanding reach of capitalist enterprise became a motivation for international cooperation in public health. An incentive for redesigning international public health emerged from a need to protect ports, investments, and land holdings such as plantations from infectious diseases.

The first formal international health organization arose in the Americas. Founded in 1902 in Washington, D.C., explicitly as a mechanism to protect trade and investments from the burden of disease, the International Sanitary Bureau focused on the prevention and control of epidemics.22 Mosquito-eradication campaigns and the implementation of a vaccine against yellow fever occupied public health professionals in this organization throughout the early twentieth century. During that period, plans proceeded for the construction of the Panama Canal, the development of agricultural enterprises in the “banana republics” of Central and northern South America, and the extraction of mineral resources as raw materials for industrial production from such areas as southern Mexico, Venezuela, Colombia, and Brazil. Work in the tropics demanded public health initiatives against mosquito-borne diseases like yellow fever and malaria, parasitic illnesses like hookworm, and the more common viral and bacterial illnesses like endemic diarrhea.

As the first modern international health organization, the International Sanitary Bureau devoted much of its early activities to infectious disease surveillance, prevention, and treatment, largely to protect trade and economic activities throughout the Americas. Later, during the 1950s, the International Sanitary Bureau became the Regional Office for the Americas of the WHO and in 1958 changed its name to the Pan American Health Organization (PAHO). Subsequently, PAHO’s public health mission broadened.23 However, PAHO has retained a focus on the protection of trade until the present day, and in general it supports the provisions of international trade agreements.

WHO emerged in 1948, as one of the component sub-organizations of the United Nations. Prevention and control of infectious disease epidemics remained a key objective throughout its history, but WHO did not frame its purpose in controlling infectious diseases as a way to protect trade and international economic transactions—as PAHO had done during its early history. Instead, during the 1970s, WHO prioritized the improved distribution of health services, especially primary health care. This orientation culminated in the famous WHO declaration on primary health care, issued at an international conference at Alma-Ata, USSR, in 1978.24 As the principle of universal entitlement to primary care services became one of WHO’s priorities, the organization advocated programs for improving access to care, especially in the poorest countries. This “horizontal” vision of public health policy gained substantial support worldwide, at least for a brief time.

However, during the 1980s, WHO entered a chronic financial crisis produced largely because of the fragile financing provided for by its parent organization, the United Nations. Because of ideological opposition to several programs operated by component organizations of the United Nations, especially those of the United Nations Educational, Scientific, and Cultural Organization (UNESCO), the Reagan administration withheld large portions of annual dues to the United Nations. As a result, the United Nations began to experience increasing budgetary shortfalls, which it needed to pass on to its component organizations, including WHO.

Into this financial vacuum entered the World Bank, which began to provide a large part of WHO’s budget. (Because WHO does not release its budget publicly, the precise degree of its dependency on the World Bank remains difficult to determine.) As WHO’s financial base shifted more toward the World Bank and away from the United Nations, its policies also transformed to an orientation that more closely resembled those of international financial institutions and trade agreements. The financial crisis that originated in the non-payment of dues by the United States eventually led within WHO to a policy perspective regarding international trade that proved similar to PAHO’s earlier orientation.

During the 1990s, the pendulum swung back from the horizontal orientation toward the preference for vertical interventions. This renewed stance emphasized “macroeconomic” policies that involved national and international economic relationships (rather than the “microeconomic” policies pertinent to markets for specific goods and services), as well as the roles of public health and health services in these broad economic relationships. The orientation emerged largely from the efforts of the World Bank and affiliated international financial institutions, as well as key private foundations. Again attention turned to vaccines and medications as technological solutions to the health problems of the global South. This orientation further facilitated the financial operations of multinational corporations in these countries.

The Report of the Commission on Macroeconomics and Health: Investing in Health for Economic Development (hereafter, Report), published by WHO in 2001, defined the relationships between health and the economy in the context of imperialism.23 This Report led to a series of WHO projects on economic issues in health policy, health services, and public health. Many of the Report‘s conceptual and methodological approaches mirrored the World Bank’s orientation to health and economic development. Partly for that reason, the Report gave a revealing picture of the dominant ideology that shaped imperial health policies.

Most of the commissioners responsible for the Report had extensive experience with the World Bank, IMF, or other international financial institutions. The commissioners showed little background in collaborating with other types of social organizations. Notably absent among the commissioners were representatives of political parties, unions, professional organizations in medicine and public health, organizations of indigenous or ethnic/racial minorities, activists in occupational and environmental health, or members of the worldwide movement targeting economic globalization.

The Report emphasized its central theme at the beginning: “Improving the health and longevity of the poor is, in one sense, an end in itself, a fundamental goal of economic development. But it is also a means to achieving the other development goals relating to poverty reduction.”26 Therefore the goal of improving health conditions of the poor became a key element of economic development strategies. From this viewpoint, reducing the burden of the endemic infections that plagued the poorest countries—AIDS, tuberculosis, and malaria—would increase workforce productivity and facilitate investment.

A policy emphasis on “investing in health” (the Report‘s subtitle) echoed the influential and controversial World Development Report, Investing in Health, published in 1993 by the World Bank.27 The terminology of the title conveyed a double meaning—investing in health to improve health and productivity; and investing capital as a route to private profit in the health sector. These two meanings of investment, complementary but distinct, pervaded the macroeconomic Report. As Jeffrey Sachs, the Commission’s chair (an economist previously known for “shock therapy” in the implementation of neoliberal policies of public-sector cutbacks in Bolivia and Poland), stated in an address about the Report‘s public health implications at the American Public Health Association’s annual meeting in 2001, “What investor would invest his capital in a malarial country?”28

In asserting that disease was a major determinant of poverty, the Report argued that investments to improve health comprised a key strategy toward economic development, distancing itself from prior interpretations of poverty as a cause of disease. Instead, the Report emphasized various data on the “channels of influence from disease to economic development.”29 The Report deemphasized social determinants of disease, such as class hierarchies, inequalities of income and wealth, and racial discrimination. Although the Report referred to health as “an end in itself,” the focus on economic productivity diminished the importance of health itself as a fundamental human right.

More recently, WHO has vacillated between two markedly different visions of global health. On the one hand, it has continued to pursue the vertically oriented emphasis on vaccines and medications rather than the horizontally oriented advocacy of comprehensive public health systems and access to services. With this orientation, WHO has collaborated with WTO (with headquarters close to WHO’s in Geneva), in trade agreements that limit governments’ ability to protect public health and medical services.30 On the other hand, WHO has responded intermittently to a worldwide constituency calling for greater attention to the social determinants of health. The latter orientation led to an influential report on social determinants and some suggestions about policy changes that would improve social conditions leading to ill health and early death.31 In research and policy analysis, economic inequality consistently has emerged as the most important social determinant crying out for dramatic changes in policy. Meanwhile, existing policies continue to worsen inequality in the United States and many other countries.

The Ebola epidemic epitomizes the failures of WHO’s leadership and the vertically oriented policies of the past. From its underfunded circumstances and dependency on the World Bank and Gates Foundation, WHO mounted a delayed and hopelessly inadequate response to the epidemic. As usual, a race for the magic bullet emerged, with predictable financial bonanzas for the pharmaceutical industry. But because no effective vaccine or treatment of Ebola yet exists, an infrastructure of clinics and hospitals must provide supportive services like hydration and blood products, as well as educational efforts and simple supplies such as adequate gloves and materials to block transmission of the virus. Such an infrastructure, nonexistent in West Africa largely due to failure of past public health policies, would prove feasible if the powers that be would recognize the practical benefits of a horizontal approach to the development of public health infrastructure. But that approach contradicts a long tradition of top-down vertical policies that have nurtured the political and economic foundations of empire.

Conclusion: Recycling Public Health Interventions
and an Emerging Challenge

Throughout most of the twentieth century, the Rockefeller Foundation sponsored “vertical” campaigns against endemic infections: hookworm, yellow fever, tuberculosis, and malaria, among others. Rockefeller campaigns interpreted these infections as impediments to labor productivity, investment, and economic development. Rockefeller-funded programs also recognized that endemic infections blocked efforts to extract raw materials and to transport products and workers throughout the world. Such campaigns did not foster a broader, “horizontal” infrastructure that could provide integrated public health and primary care services. Instead, these interventions aimed to improve the economic circumstances of enterprises in the imperial countries by improving the health of the imperialized.

WHO’s Report on Macroeconomics and Health updated this earlier Rockefellerism. Like its unacknowledged predecessor in macroeconomic thought, the Report called for investment to reduce poverty in poor countries—while enhancing the economic prospects of the rich in both rich and poor countries alike. This approach also revived a vertical attack on specific diseases, rather than encouraging the development of integrated health care systems. Health as a fundamental human value, worthy of investment for its own sake, slipped from consciousness, as did the vision of redistributing wealth as a worthy goal in macroeconomic policy.

More recent efforts by WHO, the Gates Foundation, the International Fund for AIDS, the World Bank, and other agencies focusing on global health have replicated the failed policies of earlier eras.32 Such influential programs that link public health, health services, and economic development generally emphasize vertical interventions based on technological fixes for specific diseases, rather than the horizontal enhancement of public health infrastructure. This old ideological wine continues to produce a familiar euphoria as it appears in new bottles.

But that age is ending. Conditions during the twenty-first century have changed to such an extent that a vision of a world without imperialism has become part of an imaginable future. In struggles throughout the world, especially in Latin America, a new consciousness rejects the inevitability of imperial power. This new consciousness also fosters a vision of medicine and public health constructed around principles of justice, not capital accumulation. Such scenarios convey a picture very different from that of the historical relation between imperialism and health—a picture that shows a diminishing tolerance among the world’s peoples for the public health policies of imperialism and a growing demand for public health systems grounded in solidarity rather than profitability and commodification.33


  1. Vicente Navarro argued this perspective in an important early work, “The Underdevelopment of Health or the Health of Underdevelopment: An Analysis of the Distribution of Human Health Resources in Latin America,”Politics & Society 4 (1974): 267–93.
  2. E. Richard Brown,Rockefeller Medicine Men: Medicine and Capitalism in the Progressive Era (Berkeley: University of California Press, 1979).
  3. Howard Waitzkin,The Second Sickness: Contradictions of Capitalist Health Care, second edition (Lanham, MD: Rowman & Littlefield, 2000), chapter 4; Milton Silverman, Mia Lydecker, Philip R. Lee,Bad Medicine: The Prescription Drug Industry in the Third World(Stanford: Stanford University Press, 1992); Peter Davis, ed.,Contested Ground: Public Purpose and Private Interest in the Regulation of Prescription Drugs(Oxford: Oxford University Press, 1996).
  4. William I. Robinson,A Theory of Global Capitalism: Production, Class, and State in a Transnational World (Baltimore: Johns Hopkins University Press, 2004);Latin America and Global Capitalism: A Critical Globalization Perspective (Baltimore: Johns Hopkins University Press, 2008).
  5. Waitzkin,The Second Sickness, chapter 2.
  6. Barry S. Levy and Victor W. Sidel, eds.,War and Public Health(New York: Oxford University Press, 2008).
  7. Andrew Carnegie,The Gospel of Wealth & Other Timely Essays (New York: The Century Company, 1901).
  8. Ibid, 176.
  9. Brown,Rockefeller Medicine Men; Anne-Emanuelle Birn,Marriage of Convenience: Rockefeller International Health and Revolutionary Mexico(Rochester, NY: Rochester University Press, 2006); Anne-Emanuelle Birn, Yogan Pillay, Timothy H. Holtz, eds.,Textbook of International Health: Global Health in a Dynamic World (New York: Oxford University Press, 2009), chapter 2; Marcos Cueto, ed.,Missionaries of Science: The Rockefeller Foundation and Latin America (Bloomington, IN: Indiana University Press, 1994).
  10. Howard Waitzkin, “Report of the World Health Organization’s Commission on Macroeconomics and Health—A Summary and Critique,”Lancet 361 (2003): 523–26, andMedicine and Public Health at the End of Empire(Boulder, CO: Paradigm Publishers, 2011); Anne-Emanuelle Birn, “Gates’s Grandest Challenge: Transcending Technology as Public Health Ideology,”Lancet 366 (2005): 514–19.
  11. Ellen R. Shaffer, Howard Waitzkin, Rebeca Jasso-Aguilar, and Joseph Brenner, “Global Trade and Public Health,”American Journal of Public Health95 (2005): 23–34.
  12. World Bank, “Poverty Overview,” updated April 6, 2015,
  13. Shaffer, et al., “Global Trade and Public Health.”
  14. Ilona Kickbusch, “The Development of International Health Policy-Accountability Intact?,”Social Science & Medicine 51 (2000): 979–89.
  15. The General Agreement on Tariffs and Trade (GATT 1947) (Article XVIII—XXXVIII),”
  16. Lori Wallach and Patrick Woodall,Whose Trade Organization? A Comprehensive Guide to the WTO (New York: New Press, 2004).
  17. WTO, “World Trade Report 2012,”
  18. Nick Drager and Carlos Vieira,Trade in Health Services: Global, Regional, and Country Perspectives (Washington, DC: Pan American Health Organization, 2002).
  19. Lori Wallach, “Accountable Governance in the Era of Globalization: The WTO, NAFTA, and International Harmonization of Standards,”University of Kansas Law Review 50 (2002): 823–65.
  20. Wallach and Woodall,Whose Trade Organization?
  21. Marcos Cueto,The Value of Health: A History of the Pan American Health Organization(Rochester, NY: Rochester University Press, 2007), chapter 1.
  22. Cueto,The Value of Health, chapter 2.
  23. Ibid, chapter 5; Elizabeth Fee and Theodore M. Brown, “100 Years of the Pan American Health Organization,”American Journal of Public Health92 (2002): 12–13.
  24. World Health Organization, “Declaration of Alma-Ata: International Conference on Primary Health Care,” Alma-Ata, USSR, September 6–12, 1978,; Marcos Cueto, “The Origins of Primary Health Care and Selective Primary Health Care,”American Journal of Public Health 94 (2004): 1884–93.
  25. Commission on Macroeconomics and Health, Macroeconomics and Health: Investing in Health for Economic Development (Geneva: World Health Organization, 2001),
  26. Ibid, 1.
  27. World Bank,World Development Report 1993.
  28. Jeffrey Sachs, “The Report of the Commission on Macroeconomics and Health,” presented at the annual meeting of the American Public Health Association, Atlanta, Georgia, 2001,
  29. Commission on Macroeconomics and Health,Macroeconomics and Health, 30–40.
  30. World Trade Organization Secretariat and World Health Organization,WTO Agreements and Public Health: A Joint Study by the WHO and the WTO Secretariat(Geneva: World Trade Organization, 2002).
  31. World Health Organization, Closing the Gap in a Generation. Commission on Social Determinants of Health (Sterling, VA: Stylus Publishing, 2008),
  32. Anne-Emanuelle Birn, “Gates’s Grandest Challenge: Transcending Technology as Public Health Ideology,”Lancet 366 (2005): 514–19; Birn, Pillay, and Holtz, Textbook of International Health, chapter 2.
  33. Rebeca Jasso-Aguilar and Howard Waitzkin, “Resisting Empire and Building an Alternative Future in Medicine and Public Health,”Monthly Review 67, no. 3 (July-August 2015): 130–43.
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