Protecting Consumer's Health in Developing Countries
Dr. D. Banerji, is Professor Emeritus, Jawaharlal Nehru University and Founder- Director of Nucleus for Health Policies and Programmes, New Delhi

The Great Divide
The terms ‘developing’ and ‘developed’ countries is used here in a broad generic sense. It is not necessary here to enter into a semantic debate concerning definitions. It is also recognized that there are considerable diversities among the countries put under these two groups. The emphasis here will be that, taken as groups, these are ‘poles apart’ in more senses than one. Their relationships are based on unequal terms.
Developed countries generated conditions which created the phenomenon of European Renaissance. Development of science, technology, industry and commerce gave them a head start over the developing countries. This enabled them to acquire strong political and economic control over the other group. This gap has been widening all through the centuries. Developing countries are made to lose their autonomy in decision-making on issues that vitally concern them. They are left behind to follow the mirage of ‘catching up’ with the developed ones.

The Western Medical System
Western medicine has developed under such a setting. It registered spectacular breakthroughs, particularly during the past century and a quarter. From a scientific angle, it has reached dizzy heights. The great German medical thinker in the mid-nineteenth century, Rudolf Virchow, had observed that ‘medicine is a social science; it is greatly influenced by social forces’. Three major social forces which have influenced medicine will be very briefly referred to in the following paragraphs. The issue of access of medical and public health services to the people had come up since the time of Bismark, when he developed ‘socialized medicine’ in Germany. People in the present developed countries had to struggle hard to obtain universal access at least to fundamental health services/insurance.

Today, in most of the developed countries the state accounts for above eighty per cent of the total cost of health/insurance services. Even in the US, it is over fifty per cent. In a startling contrast, in a massive developing country like India, the percentage is less than twenty five.
To further compound the situation, now, under the Structural Adjustment Programme (SAP) pressure is being exerted on the country to further ‘downsize’ state intervention in the field of health. There has been considerable unease over the way Western medicine is being practiced even in the developing countries. Ivan Illich is among those who made a comprehensive, well-documented critique on this vital area. He starts his famous book, ‘MEDICAL NEMESIS’, by asserting that ‘medicine has become a threat to the health of the people’. He substantiates his arguments by drawing attention to various kinds of iatrogenic diseases - diseases caused by practitioners of medicine. Medicalisation of lives of people, mystification of medicine, professionalisation and centralization, dependence creation and actively promoting addiction to medicine, are some of the terms he has employed for making a devastating denunciation of the practice of Western medicine.
This was the structure and content of Western medicine which the developing countries encountered when it was inducted into these countries by some of the developed countries in the wake of colonial/imperialist conquest. This encounter has to be considered here both in terms of time and space, against the overall social, economic and political dynamics. When Western medicine was imposed on the different developing countries, the people there had their own, indigenously developed mechanisms for coping with their health problems. The motive behind the induction of Western medicine in these countries was to provide protection to the ruling class. It was also made accessible to the military, the colonial administrators and the traders, besides to the wafer-thin uppermost level of the native gentry, which collaborated with the exploiters. Thus, right from the initial phase, Western medicine was used to strengthen the exploiting classes. The increasing impoverishment of the exploited as a consequence of colonialists joining the local gentry to extract some extra revenue created conditions for increasing the already heavy load of diseases and deaths among them. At the same time, with the natives elites developing a fascination for Western medicine, the quality of the indigenous practices, developed over centuries, suffered because of lack of nurturing. The vast masses of the people, the ‘forgotten’ people, thus suffered additional disadvantages when Western medicine was introduced in these countries.

The Business in Western Medicine
So powerful have been the economic interests behind the ‘sale’ of Western medicine to the consumers that the overwhelming evidence adduced against these aspects of the practice were simply ignored or ‘forgotten’ and they have succeeded in generating an exponential growth of the highly faulted medical system all through the years. This has substantially added to the Gross Domestic Products (GDPs) of the developed countries. Medicine has now become a commodity. Big corporate organisations have come into being to sell medical services to customers, ‘suitably motivated’, by subjecting them to relentless bombardment with well-designed media onslaughts. For instance, an entirely new and booming ‘fitness’ industry has now come into being to sell ‘fitness’ to such intellectually sanitized people, who are conditioned to rush to buy designer made paraphernalia of various kinds.
After ensuring that markets are thrown asunder to ‘free trade’ by imposing the SAP on developing countries, the developed countries have expanded their markets by including the much vaunted burgeoning middle class in the developing countries in its brain-washing agenda. To the ‘forgotten’ people of the developing countries, these business ventures in medicine conform to what Illich had observed long ago - a menace to their health. Perhaps unwittingly, physicians have often become sales agents of this massive ‘medical industrial complex’. That President Clinton could not push through even the very highly diluted health care programme for the people of the US, despite most solemn promises, attests to the awesome power of the business interests. Those who live on the other side of the moon in the US were bluntly told that there was ‘no free lunch’. This conforms to the famous saying of the US President just before the Great Depression that ‘the business of the US government is business’.

Result of the Western Medical Influence
Two recent very carefully conducted national sample surveys (one by the National Sample Survey Organization of the Government of India, Forty-Second Round, 1992 and another by the prestigious National Council for Applied Economic Research, New Delhi, 1992) on the pattern of utilization of medical services in rural and urban populations present a most disturbing account of the consequences of the neglect of the health services in the country. One of most deplorable findings is that both rural and urban people have almost completely lost their indigenously developed mechanisms of coping with their medical problems and as many as 90 per cent of them opt for Western medicine. The public health infrastructure, even for providing medical services to the people, has virtually disappeared and the hapless people are forced to depend on the exploitative private sector. It was found that for the same type and quality of services, the poor have to spend substantially larger amounts of money than the rich and that among them expenditure on medical services is the second largest most frequent cause of indebtedness, next only to dowry. Similar, and often worse, predicaments are faced by people in many other developing countries. This sums up the problems for consumers health in the developing countries.
However, here too there was a dialectical response from the people. Conditions generated by the anti-colonial and anti-imperialist struggles impelled the ‘leaders’ of the movements to think of ways to meet the health service needs of the vast masses. Significantly, because of fundamentally different socio-cultural, economic, political, epidemiological and technological conditions, the response too had to be fundamentally different, thus laying the foundations for what is now being termed as ‘New Public Health’. It had been a long, grinding struggle for the masses. The idea of a ‘Barefoot doctor’ took the final form in the post-revolutionary China, while the leaders were groping for alternatives. During the anti-colonial struggle, India evolved the idea of the ‘Primary Health Centre’ to provide low-cost, efficacious, comprehensive health services to the unserved and the underserved populations by ‘entrusting people’s health in people’s hands’ through ‘Community Health Workers’ elected by the communities. Scholars from other countries also contributed to the growth and development of this new, people-oriented health services which were tuned to the specific conditions prevailing there; which in fact was ‘health by the people’.

WHO Initiatives
Under the leadership of Halfdan Mahler, WHO not only encouraged this trend, but it actively acted as a catalyst to give the movement considerable momentum, which culminated in the World Health Assembly (WHA) adopting the famous resolution on ‘Health For All’ by adopting the approach of Primary Health Care by the year 2000 AD and getting all countries of the world to specifically endorse the new philosophy in the Conference on PHC at Alma-Ata in 1978. The Alma Ata Declaration marked a watershed in the history of public health practice in the world. Health was declared as a fundamental human right for all the people of the world. WHO also initiated a programme on Essential Drugs and approved for enforcement of a code for marketing of baby foods in the poor countries of the world.
The response from the rich countries to the poor countries daring to declare self-reliance in health was swift and sharp, as it affected their economic and political interests. They ‘invented’ the very untenable concept of ‘Selective Primary Health Care’. They used their financial clout to mobilize international organisations like the World Bank, WHO and UNICEF to let loose a virtual barrage of ‘international initiatives’ on the poorer countries, which almost swept away the tentative steps which were underway in these countries in implementing the HFA strategy. These programmes are the very antithesis of the Alma-Ata Declaration. They are technocentric, and were meant to subserve the commercial interests of the developed countries who made the poorer countries dependent on resources from outside. These initiatives were certainly not cost-effective but often patently unsustainable. The Universal Programme of Immunization, the Global Programme on AIDS and the Global Programme on Tuberculosis are the outstanding instances of such
initiatives. Not unexpectedly, each one of them has failed to fulfill the promises that were made at the
time of their launching. In the ‘bargain’, assigning over-riding priorities to such programmes had a devastating effect on the Primary Health Care services in the developing countries.

Consumers - the End Losers
As is evident from the foregoing, access to health services by consumers in the developing countries has been getting restricted well before the world acquired an unipolar power structure. SAP dwelt yet another blow to the battered system. Sharp slashing of the already meagre budgets of the public sector health services, dismantling of the barriers to ‘free’ trade, including giving up even the pretense of controlling manufacture and trade in drugs, and encouragement of rapid expansion of the private sector, have been some of the hallmarks of the SAP detrimental to consumer’s health.

Over time, even the most determined supporters of free market in the developed countries have been forced to adopt very stringent mechanisms to regulate licensing and practice of medicine.
In developing countries, however, the jungle law of the free market is given a free play. As in the sale of any other commodity, the professionals in the private sector are given enormous latitude to fleece the ‘clients’. In the absence of properly enforced regulatory mechanisms, in many countries prices of many essential drugs have sky-rocketed, their little supervision of the quality of drugs, drugs that are banned in the developed countries are being sold freely in the market and there are innumerable brand names, a large number of which have little therapeutic value.

An Enduring Struggle
An account of the hundreds of millions of premature deaths from easily preventable diseases faced by the ‘consumers’ of health, accounting for almost the entire populations of many developed countries, is a part of the account of long running confrontation between the ‘haves’ and ‘have-nots’ on grossly unequal terms. Political leaderships of the developed countries provided the major striking force for the oppression of the have-nots; the haves among the natives actively collaborated with them in carrying out this oppression. Inevitably, despite their tremendous disadvantage, as they have little to lose, the ‘haves-nots’ have mounted a sustained struggle against injustice and exploitation. The consumer movement for health in the developing countries will take the side of the wronged people. Their demands are enshrined in the Alma-Ata Declaration - this includes struggle for a rational drug policy, access to people-oriented health services and a more humane and broad-based, empowering population policy. This is a part of the struggle for human rights of the have-nots. History ordains that this struggle will continue.
Paper presented by Dr. D. Banerji at the International Consumer Conference held at Santiago, Chile in November, 1997.

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