Global Health and US Imperialism
Interventions in the field of public health are a significant form of “soft power” by which imperialism extracts profits from the world’s poorest billions. US involvement in the health field is intended, inter alia, to help ensure efficient use of low-cost labor in transnational production chains; to support and rationalize military interventions; to create and exploit worldwide markets for health-care products, especially pharmaceuticals; and broadly to consolidate control over the lives and bodies of Global South people. Crucial to the enterprise is a complex network of charitable foundations, US government initiatives, international institutions, national health ministries, and NGOs, all steered by the interests of Western capital. By far the most influential force within this network is the Bill & Melinda Gates Foundation (BMGF), the world’s largest private charity.
Global health crises are held to originate from poor countries and constitute a threat to wealthy countries. Response to such crises is regarded as a security concern.
Westphalian national sovereignty is considered an impediment to effective management of transnational health issues.
Overarching health-care planning, policies, and programs for the people of poor countries are determined by the experts and financiers of wealthy countries. Foundation funding is used as leverage to ensure that national health systems cannot function independently.
Existing national and local health-care management is subordinated to, and must be cooperative with, the goals of Big Philanthropy and Western capitalism.
Militarization of health-care delivery and disaster management is deemed appropriate and necessary. Military forces involved are drawn from the United States, NATO, and allied countries.
Health philanthropy is modeled on the philosophy and practices of private corporations. Health-care funding is conceived as an investment activity; quantifiable return on investment is the guiding principle for grant-making.
Big philanthropy underwrites vertical initiatives potentially profitable to Western-based transnational corporations – for example, vaccines and other pharmaceuticals – instead of supporting primary care and strengthening national health systems. Drugs and other health-care commodities produced by Western TNCs are financed by the taxes of the poor.
Existing systems of international health-care governance are being superseded by new forms of supranational governance comprising the formal institutions of global capitalism – the World Bank, the G7 – as well as health-related TNCs, the major US- based foundations, and associated networks of NGOs. The scope for democratic participation by the people in their own health care is radically narrowed (Levich 2015: 732).
Health philanthropy is nevertheless widely seen as a creditable endeavor. Like the mission civilisatrice, it allows the global ruling class to conceal its operations behind humanitarian postures.
Systematic public health regimes originated as military programs during the era of colonial expansion. Florence Nightingale’s advocacy in the wake of the Crimean War inspired the establishment of the Royal Commission on the Health of the Army, which instituted sanitation measures in order to slow the death rate among British troops occupying India. Modern epidemiology can be traced back to the efforts of US Army physician Walter Reed, who studied yellow fever in order to facilitate the construction of the Panama Canal.
Disease still decimates native populations and sends men home from the tropics prematurely old and broken down. Until the white man has the key to the problem, this blot must remain. To bring large tracts of the globe under the white man's rule has a grandiloquent ring; but unless we have the means of improving the conditions of the inhabitants, it is scarcely more than an empty boast. (quoted in Brown 1976: 897)
Hence the formation of the Rockefeller Foundation, incorporated in 1913 with the initial goal of eradicating hookworm, malaria, and yellow fever. In the colonized world, public health measures encouraged by Rockefeller’s International Health Commission yielded increases in profit extraction, as each worker could now be paid less per unit of work, “but with increased strength was able to work harder and longer and received more money in his pay envelope” (Brown 1976: 900). As well as enhanced labor efficiency – which was not necessarily a critical challenge to capital in regions where vast pools of underemployed labor were available for exploitation – Rockefeller’s research programs promised greater scope for future US military adventures in the Global South, where occupying armies had often been hamstrung by tropical diseases.
As Rockefeller expanded its international health programs, typically in close collaboration with US government agencies, additional advantages to the imperial core were realized. Modern medicine promoted the benefits of capitalism to “backward” people, undermining their resistance to domination by imperialist powers while helping to create a native professional class increasingly receptive to neocolonialism and dependent on foreign largesse. Rockefeller’s president observed in 1916: “[F]or purposes of placating primitive and suspicious peoples medicines have some advantages over machine guns” (Brown 1976: 900).
Little imagination is required to visualize the great increase in the production of food and raw materials, the stimulus to world trade, and above all the improvement in living conditions, with consequent cultural and social advantages, that would result from the conquest of tropical diseases. (quoted in Packard 1997: 97)
Paul Hoffman, president of the Ford Foundation during the 1950s, regarded public health programs as defensive weapons in the Cold War: “[T]he Communist victory in the Chinese Civil War taught the ‘lesson’ that Communism thrived on social and economic disorder” (Hess 2003: 319); the mission of postwar philanthropy was therefore to encourage development schemes that might pacify Third World peoples. The seminal Gaither Report, commissioned in 1949 by Ford, explicitly charged the foundations with advancing “human welfare” in order to resist the “tide of Communism … in Asia and Europe” (Gaither 1949: 26).
Prestige in the field of public health became especially important to the United States as Third World governments and peoples learned of the tremendous achievements of socialist health programs. Inspired by the “barefoot doctor” program that revolutionized public health in the People’s Republic of China, the 1978 International Conference on Primary Health Care promulgated the Alma Ata Declaration, reframing public health as a collaborative effort among sovereign nations and embracing the goal of “health for all.” Alma Ata proposed a philosophy of primary care in which the people were held to have “a right and duty to participate individually and collectively in the planning and implementation of their health care” (Declaration of Alma Ata 1978). Wealthy states and philanthropists were encouraged to assist the developing world but only on condition of respecting local concerns and national sovereignty.
In response to Alma Ata, US foundations and ministries sought to strike a delicate balance, operating so as to placate Third World peoples without unduly encouraging real reform or de facto independence. In rare cases, the foundations relinquished control of infrastructure and trained personnel to national health ministries, but in no case were the health systems of imperialized countries permitted to become self-sustaining, and actual investment in Third World health care was meager in comparison with the extravagant promises of Cold War rhetoric. Nevertheless, manufacturing a semblance of collaboration with Third World governments was deemed necessary in the context of the postwar struggle for “hearts and minds.” With the end of socialism in Russia and China, however, both the theory and practice of international health assistance underwent a drastic change.
Global Health Governance
The concept of “global health governance” (GHG) arose in the West in the early 1990s, reflecting Washington’s confidence that the fall of the Soviet Union would usher in a unipolar world dominated by US interests. President Bush’s announcement of a “new world order” found its way into scholarship as “global governance,” describing a loosely defined transnational regime effectively led by the United States and consisting of both public institutions and some combination of private actors, including TNCs, private foundations, and NGOs. This was a vision of diffuse, omnipresent power to be exercised collaboratively by the institutions of global capitalism and guaranteed, in the last resort, by the US military. Such a regime would function most effectively without the traditional impediments of democratic accountability and Westphalian sovereignty (see Levich 2015).
In the field of public health, “nonstate actors” – meaning primarily foundations, NGOs, and public-private partnerships (PPPs) – were recognized as having significant scope and authority to function in an area once reserved to national governments. The Alma Ata principles became moot as structural adjustment programs demanded disinvestment in public health throughout the developing world. In their place arose a profusion of foundation- and state-sponsored NGOs, based primarily in the West and funded more or less directly by multibillionaires. As national health systems were hollowed out, health spending by donor countries and private foundations rose dramatically. Far from providing support for national health-care operations, the new global philanthropic regime systematically bypassed or compromised national health ministries via “public-private partnerships” and similar schemes. Western governments and foundations saw an opportunity to affect a “shift to a post-Westphalian framework” (Ricci 2009: 1).
The attenuation of national sovereignty is only rarely discussed as a conscious aim of GHG. Instead, global health governance is proposed as a necessary defense against disastrous transnational epidemics. The world, advocates say, now stands at a critical, unprecedented juncture – one at which the acceleration of cross-border travel, urbanization, and trade has made “emerging infections” inevitable and potentially catastrophic. The menace is framed in terms reflecting colonialist assumptions and summoning racial fears: communicable diseases are invariably discussed as phenomena emerging from poor countries and threatening to the Western world.
Hence, GHG was easily folded into the larger discourse of “security” that arose in the wake of the 9/11. Worldwide alarm about bioterrorism provided an opportunity to “link together two previously separate fields: health and national/international security” (Rushton and Youde 2015: 18). This linkage was envisioned as reciprocal: not only would health-care workers “open up a medical front in the War on Terror” (Elbe 2010: 82), but also military forces would routinely be mobilized as a response to health disasters. For example, global health security was a major pretext for the US response to the 2010 earthquake in Haiti, which entailed military invasion, occupation, and ruthless commandeering of national resources and governmental operations. Imperial interventions in the health field began to be justified in the same terms as recent “humanitarian” military interventions: “[N]ational interests now mandate that countries engage internationally as a responsibility to protect against imported health threats or to help stabilize conflicts abroad so that they do not disrupt global security or commerce” (Novotny et al. 2008: 41; emphasis added).
One of the things I am saying that is pretty radical – and people may disagree – I’m saying the military should be cross-trained not just for military action but for natural disasters and epidemics. … If you pair them with this so-called medical corps, you get something pretty dramatic without spending. (Fried 2015)
Gates’ endorsement was especially significant because his foundation had become the leading exemplar of philanthropy in the era of global health governance.
The Gates Foundation
Established in 1999 and initially endowed with a portion of Bill Gates’ Microsoft riches, the Bill & Melinda Gates Foundation (BMGF) is now by far the world’s largest private foundation; with more than $50 billion in assets, it dwarfs once-dominant players such as the Ford Foundation, the Rockefeller Foundation, and the Carnegie Corporation (BMGF 2017). Within the United States, BMGF invests in “education reform” (i.e., school privatization), but the bulk of its activities are directed at the people of the imperialized world, where its ostensible mission involves providing birth control and combatting infectious diseases.
BMGF exercises power not only by means of its own spending but also through steering an elaborate network of “partner organizations” including nonprofits, government agencies, and private corporations. As the third largest donor to the UN’s World Health Organization (WHO), it is a dominant player in the formation of global health policy. It orchestrates elaborate public-private partnerships – charitable salmagundis that tend to blur distinctions between states, which are at least theoretically accountable to citizens, and profit-seeking businesses that are accountable only to their shareholders. BMGF is the chief funder and prime mover behind prominent “multi-stakeholder initiatives” such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, and Gavi, the Vaccine Alliance (formerly GAVI), a public-private partnership between the World Health Organization and the vaccine industry. Such arrangements permit BMGF to leverage its stake in allied enterprises, much as private businesses enhance power and profits through strategic investment schemes.
The Foundation funds NGOs that lobby governments to increase spending on the very initiatives that it sponsors. The powerful NGO known as PATH (Program for Appropriate Technology in Health), which supports the development and distribution of vaccines, is funded by BMGF and is so closely linked to the Foundation that it functions effectively as a subsidiary. From time to time, BMGF also intervenes directly in the agendas and activities of national governments. Although Foundation publicity frequently bemoans the sorry state of public health care in the imperialized world, BMGF declines to spend its funds on rehabilitating the national health apparatus of poor countries. Instead, it invests almost exclusively in health-care “verticals” – initiatives targeting specific diseases and other health conditions that can be managed from top to bottom by the Foundation and allied organizations. The effect is to outflank and further disable health ministries already crippled by neoliberal disinvestment.
BMGF has been compared to “a massive, vertically integrated multinational corporation (MNC), controlling every step in a supply chain that reaches from its Seattle-based boardroom, through various stages of procurement, production, and distribution, to millions of nameless, impoverished ‘end-users’ in the villages of Africa and South Asia” (Levich 2014). It is a functional monopoly in the field of public health. In the words of one NGO official: “You can’t cough, scratch your head or sneeze in health without coming to the Gates Foundation” (Global Health Watch 2008: 251). The Foundation’s global influence is now so great that former CEO Jeff Raikes was obliged to declare: “We are not replacing the UN. But some people would say we’re a new form of multilateral organization” (Pickard 2010).
BMGF, Big Pharma, and the Vaccine Business
The chief beneficiary of BMGF’s activities is not the people of the Global South but the Western pharmaceutical industry. The Gates Foundation’s ties with the pharmaceutical industry are intimate, complex, and long-standing. Soon after its founding, BMGF invested $205 million to purchase stakes in major pharmaceutical companies, including Merck & Co., Pfizer Inc., Johnson & Johnson, and GlaxoSmithKline (Bank and Buckman 2002). The relationship has grown in subsequent years, creating a revolving door that now routinely shuttles executives between BMGF, Gates-controlled NGOs, and Pharma’s Big Five.
This symbiosis between BMGF and Big Pharma arises from the particular requirements of pharmaceutical capital. Despite annual revenues approaching $1 trillion, the industry has been unable to reverse a declining rate of profit and finds itself in a perpetual state of crisis. Pharmaceutical innovation is trending downward, and the search for exploitable new molecules is becoming increasingly frantic and expensive. As drugs become more expensive and less efficacious, profit margins are increasingly undercut by necessarily massive marketing operations. Therefore, Big Pharma seeks to supplement declining sales and rising costs in wealthy Western countries by exploiting largely untapped “pharmerging markets.” Since 70% of the world’s population lives in countries so designated, profits are potentially enormous. Thus, BMGF’s interventions, designed to create lucrative markets for surplus pharmaceutical products, are crucial to the industry.
BMGF’s collaboration with Big Pharma is strikingly evident in the area of vaccines, Bill Gates’s particular obsession and historically the central business of his foundation. BMGF entered the field in 1999 with a $50 million contribution establishing the Malaria Vaccine Initiative. Here, Bill Gates saw an opportunity for his fledging foundation to dominate, instantly and decisively, an entire field of charitable endeavor: “With one grant … we became the biggest private funder of malaria research. It just sort of blows the mind” (Strouse 2000). Since then, BMGF’s involvement in vaccine development and delivery has been transformative, integrating private corporations and investment capital into a field where, until quite recently, the profit motive had played a relatively minor role.
State-sponsored immunization programs spread widely during the twentieth century and doubtless saved millions of lives, especially in countries that were able to integrate immunization into robust public health programs. The most widely distributed vaccines were not patented. Although Big Pharma spokesmen were happy to take credit for immunization successes, vaccines were in fact a neglected corner of the drugs business; in the capitalist world, industry involvement was a matter of manufacturing doses and selling them in a buyer’s market shaped by government procurement programs that tended to depress prices. Margins were so slim that by the mid-2000s, many firms contemplated exiting the business altogether (“A Smarter Jab” 2010).
BMGF’s response has been to fund R&D aimed at creating new and reformulated vaccines that are patentable while eschewing involvement in the proven vaccines traditionally deemed necessary for robust immunization programs – those for diphtheria, mumps, pertussis, tetanus, etc. BMGF has consistently focused on promoting precisely the new and expensive “blockbuster vaccines” that pad Big Pharma’s profit margins. The bulk of its early investments were geared toward immunization against pneumococcal disease (with a vaccine developed by Pfizer), hepatitis B (GlaxoSmithKline and Merck), and the flu-like bacterial infection Hib (Merck and Sanofi); over time, numerous branded drugs have been added to its roster. As of 2017, four of the five projected top-selling vaccine products worldwide – Pfizer’s Prevnar-13, Merck’s Gardasil, Sanofi’s Pentacel, and GSK’s Bexsero – had been heavily subsidized and promoted by the Gates Foundation (EvaluatePharma 2017: 22).
An additional advantage of vaccines to pharmaceutical capital is the sheer size of the market. Whereas the profit potential of most drugs is limited by their addressable population, i.e., sick people, vaccines address the universe of healthy people and are therefore exponentially more lucrative. Revisions to national immunization calendars in Global South countries can expand the addressable population by hundreds of millions; therefore, BMGF employs a variety of strategies to pressure health ministries into adopting branded vaccine products. For Big Pharma, this creates a predictable annual return and obviates the need to spend hundreds of millions on marketing.
Because poor countries are often reluctant to commit huge tranches of their meager health budgets to vaccine purchases, BMGF has developed a variety of financing mechanisms designed to assimilate national health systems into the global market. In 2009, Gavi pioneered the use of a new type of development financing, the Advance Market Commitment (AMC), as a means of subsidizing the sale of Pfizer’s new pneumococcal vaccine, Prevnar, to low-income countries (Gavi 2009). Through Gavi, BMGF and five wealthy countries – Italy, the United Kingdom, Canada, Norway, and Russia – offered a contract guaranteeing a viable market for the drug, committing to buy new vaccines at a negotiated high price purporting to cover development costs. The pilot country was impoverished Rwanda, which was converted overnight into a market for 1.6 million doses of the patented vaccine (Misbah and Ngoboka 2009). As a condition of the vaccine program, Rwanda agreed to add Prevnar to its routine national immunization program, though it was unclear how the country might hope to finance its commitment to future purchases once Gavi subsidies lapsed Sheikh & Ngoboka (2009). Soon thereafter, Benin, Central African Republic, and Cameroon were also enlisted, expanding the market by further millions. AMC financing proved so effective that Prevnar became the world’s leading vaccine product, with projected 2022 sales of $6 billion (Evaluate Pharma 2017: 32). Gavi, meanwhile, had demonstrated “proof of concept” of an elaborate neoliberal scheme that transferred public funds to private coffers.
A more recent addition to Gavi’s array of services is “innovative development financing,” a debt-based mechanism that taps capital markets to subsidize vaccine buyers and manufacturers. Through an intermediary, the International Finance Facility for Immunisation (IFFIm), Gavi floats bonds on the Japanese uridashi market. The bonds are secured by the promise of government donors to buy millions of doses of vaccines at a set price over periods as long as 20 years. The system is hailed in development circles as a neoliberal “win-win”: although capitalists take a cut at every stage of the value chain, poor countries are said to benefit from access to vaccines that might not otherwise be affordable. Bondholders receive a tax-free guaranteed return on investment, suited to an era of ultra-low interest rates. For Gavi, this “organizational form without country presence” offers a powerful means of steering peripheral vaccine markets from the core while outflanking the political inconveniences of traditional development aid. Hence, IFFIm now annually supplies as much as 39% of Gavi’s cash (Atun et al. 2012).
By creating a predictable demand pull, IFFIm addresses a major constraint to immunisation scale-up: the scarcity of stable, predictable, and coordinated cash flows for an extended period. (Atun et al. 2012).
Although Gavi’s involvement in vaccine pricing is typically praised as though the organization is dedicated to setting price ceilings, in fact it acts invariably to raise the floor.
Recent BMGF/Gavi activities in Sri Lanka offer a virtual case study in what has been called “pharmaceutical colonialism.” Gavi targeted the country in 2002, offering to subsidize a high-priced vaccine supplied by Crucell, a subsidiary of Johnson & Johnson. The vaccine, known as pentavalent Hib, was a cocktail adding Haemophilus influenzae type b immunity to the traditional DTwP shot; it was this new formula that made the drug patentable and thus profitable. In exchange for Gavi’s support, the country agreed to add the vaccine to its national immunization schedule. (The agreement was reached; it should be noted, against the backdrop of a genocidal civil war that left Sri Lanka’s health ministry in desperate need of funds.)
Within 3 months of the vaccine’s introduction, 24 adverse reactions including 4 deaths were reported, leading Sri Lanka to suspend use of the vaccine. Subsequently, 21 infants died from adverse reactions in India. Critics pointed out that Hib is a minor public health issue in South Asia and that adverse reactions could be projected to cause the deaths of 3125 children for every 350 lives saved by the vaccine (Kalyanam 2013). Thus the customary argument in favor of new vaccines – that the significance of a few drug-related deaths is far outweighed by the number of lives saved – was flipped on its head. Nevertheless, WHO, a Gavi partner, promptly stepped in to declare the vaccine safe, whereupon Sri Lanka reversed the suspension. Presumably pressures were brought to bear both on WHO and the Sri Lankan government.
Once pentavalent vaccine was firmly ensconced in Sri Lanka’s national immunization program, Gavi began to phase out its financial support. Sri Lanka continued to buy the Gates-prescribed vaccines, presumably diverting money from other areas of the public health budget. In effect, Gavi secured Sri Lanka’s legal commitment to buy patented vaccines on an ongoing basis, using subsidized prices as a loss leader, and then left the country on the hook with a perpetual obligation to buy. Gavi calls this process “graduation.” In a write-up appearing on Gavi’s promotional website, Sri Lankan health minister Ananda Amarasinghe purported to reveal “the secrets behind the country’s immunisation success story.” Collaboration with the consortium has been effective, Dr. Anand suggests, because “our colonial masters established a good foundation” (Endean 2015; emphasis added).
Should financial schemes fail to create the markets required by pharmaceutical capital, imperialism may resort to more forceful methods. Actual or threatened military aggression is a reliable strategy. The de facto US/UN military occupation of Haiti following the 2010 earthquake provided an opportunity to thrust new health-care schemes on the country, including a massive immunization program entailing purchases of an experimental rotavirus vaccine as well as patented pentavalent vaccines for diphtheria, tetanus, Haemophilus influenzae type B, and hepatitis B. (Evans 2013). Another typical form of pressure is the shakedown: the World Bank has proposed making development aid and debt relief conditional on the achievement of vaccine targets (World Bank 2010: 33). The array of tactics available to the imperialists means that poor countries are all but powerless to resist. As public health journalist Srinivasan (2011) has written of PATH, “the agenda is to look for ways to introduce the vaccine into the national immunisation programme. The question is not ‘whether’ but ‘when’ and ‘how.”
The US medical industry routinely uses imperialized nations as laboratories for new and often dangerous treatments and drugs. The practice is rooted in domestic medical experiments in which slaves, and later poor African-Americans, Native Americans, and Puerto Ricans, were used as guinea pigs for surgical procedures, radiation tests, and risky pharmaceutical trials. The “Tuskegee experiment” is only the most notorious of countless similar operations (see generally Washington 2006). After the civil rights struggle curtailed such practices within the United States, offshoring of medical experimentation became common.
The geography of clinical testing is changing dramatically. In 2005, 40 percent of all trials were carried out in emerging markets, up from 10 percent in 1991. … GlaxoSmithKline ran 29 percent of its trials outside the United States and Western Europe in 2004; by 2007, that figure grew to 50 percent. Wyeth Pharmaceuticals conducted half of its trials outside the United States in 2004; that figure rose to 70 percent in 2007. (Petryna 2009: 12)
The consequences of this strategy were briefly publicized in 2010, when seven adolescent tribal girls in Gujarat and Andhra Pradesh died after receiving injections of HPV (human papillomavirus) vaccines as part of a large-scale “demonstrational study” funded by the Gates Foundation and administered by PATH. The vaccines, developed by GSK and Merck, were given to approximately 23,000 girls between 10 and 14 years of age, ostensibly to guard against cervical cancers they might develop in old age.
Extrapolating from trial data, Indian physicians later estimated that at least 1200 girls experienced severe side effects or developed autoimmune disorders as a result of the injections (Mehta et al. 2013). No follow-up examinations or medical care were offered to the victims. Further investigations revealed pervasive violations of ethical norms: vulnerable village girls were virtually press-ganged into the trials; their parents bullied into signing consent forms they could not read by PATH representatives who made false claims about the safety and efficacy of the drugs. In many cases, signatures were simply forged.
An Indian Parliamentary Committee determined that the Gates-funded vaccine campaign was in fact a large-scale clinical trial conducted on behalf of the pharmaceutical firms and disguised as an “observational study” in order to outflank statutory requirements. The Committee found that PATH had “violated all laws and regulations laid down for clinical trials by the government” in a “clear-cut violation of human rights and a case of child abuse” (Parliament of India 2013). Once the flurry of newspaper coverage died down, BMGF and Big Pharma resumed and expanded offshore trials. In India in 2011, more than 150,000 people were involved in at least 1600 clinical trials, conducted on behalf of British, American, and European firms (Buncombe and Lakhani 2011). R&D offshoring is now so widespread in the Global South that clinical trials are considered a normal part of health-care delivery. As a South African newspaper declared: “We are guinea pigs for the drugmakers” (Child 2013).
Contraception and Population Control
the influx of professionals into the cause [had] changed the goals of the birth control movement, from a campaign to increase the area of self-determination for women and all working-class people to a campaign infused with elitist values and operated in an elitist manner. These professionals were mainly of two groups: doctors and eugenists. (Gordon 1977: 10)
This transformation was enthusiastically sponsored by Western foundations and governments. The Rockefeller Foundation invested in eugenics research beginning in the 1920s and helped found the German eugenics program that undergirded Nazi racial theories (Black 2003). After a brief period during which widespread horror at Nazi atrocities forced eugenic theory underground – as neoconservative jurist Richard Posner lamented, Hitler had given eugenics “a bad name” (Posner 1992: 430) – a number of powerful white men, notably John D. Rockefeller III, became obsessed with “differential fertility.” Taking note of the higher birth rate in poor countries, some imagined a future world overrun by hungry, unruly brown masses – people who would inevitably demand food and justice, enforcing their will through the sheer weight of numbers. Rockefeller organized the Population Council in 1953, predicting a “Malthusian crisis” in the developing world and financing extensive experiments in population control. These interventions were embraced by US government policymakers, who agreed that “the demographic problems of the developing countries, especially in areas of non-Western culture, make these nations more vulnerable to Communism” (Critchlow 1995: 85).
In India, traditionally the laboratory of choice for Western demographic experimentation, the Ford Foundation worked with USAID to tie development aid to “contraceptive acceptor targets,” i.e., numerical quotas. Ford Foundation money, coupled with pressure from the Population Council and USAID, culminated in an era of unbridled aggression in the area of government-sponsored “family planning” and incentivized a brutal sterilization campaign that forcibly vasectomized 6.2 million men and killed at least 1774 during the 1970s (Biswas 2014). Thereafter India redirected its efforts toward women, using a “target-driven” approach that resulted in further thousands of deaths and countless coercive procedures, often conducted in camps designed for mass sterilizations.
Widespread horror at these policies inspired the 1994 International Conference on Population and Development (ICPD), which issued a Programme of Action that became known as the “Cairo Consensus.” The ICPD condemned coercion and repudiated sterilization quotas; however, much of the ICPD Programme reflected the values and imperatives of market capitalism, emphasizing above all “individual rights” that would permit “individual choice and responsible decision-making.” At the same time, the ICPD’s criticism of state actors meshed conveniently with a key part of the imperialist agenda: increased intervention by Western nongovernmental actors, not excluding private enterprise. The Population Reference Bureau declared with satisfaction that “NGOs, religious and community leaders, and the private sector (what the UN calls ‘civil society’) are now active partners with governments in deliberations on new policies and programs” (Population Reference Bureau 2004).
Thus Cairo set the stage for the 2012 London Family Planning Summit, at which representatives of more than 70 governments, NGOs, and private firms announced their financial commitments to a stunningly ambitious program of population control. Unlike the ICPD, which had made some gestures toward inclusion of Global South feminists, this was a top-down, ruling-class affair, organized and orchestrated by the Gates Foundation. Melinda Gates, who emerged as the world’s most visible spokesperson for access to contraception, revealed that BMGF intended to donate $1 billion toward supplying birth control to 120 million women and prevent 110 million unwanted pregnancies by 2020 (Goldberg 2012); an additional $3.6 billion was pledged by organizations ranging from Planned Parenthood to the foundations endowed by Michael Bloomberg and Hewlett-Packard. With one flamboyant stroke, commentators agreed, BMGF had moved contraception to the top of the global public health agenda.
The putative urgency of the project was puzzling to say the least. In fact the global rate of population growth had been in steep decline for more than four decades. From its peak of 2.1% in 1971, the rate had fallen to 1.17%, a postwar low, in the year of the London Summit (World Bank 2017). In order to marshal support for a crash contraceptive program targeting Third World women, BMGF and its allies had needed to manufacture a sense of crisis. This was done in part through a canny reframing of the issue of “differential fertility” that had so troubled an earlier generation of family planning advocates. The world’s poorest countries, mostly in Africa, still reported alarmingly high fertility rates (the highest of these include Niger, with an average of 6.76 children born per woman; Burundi, 6.09; and Mali, 6.06 (CIA 2015). These numbers were repeatedly deployed by BMGF and friendly journalists in what appeared to be a coordinated effort to rekindle overpopulation hysteria. In the post-Cairo world, however, it was advisable to avoid any taint of racism and eugenics. Thus publicity surrounding the Summit blithely revived long-discredited arguments that overpopulation is the cause, rather than the result, of poverty, climate change, and all manner of social ills. According to Melinda Gates: “When women and their partners have access to contraceptives, everyone benefits. Maternal mortality rates drop, children are healthier and better educated, and incomes rise” (Gates 2015).
In fact, human fertility rates reflect prevailing social conditions and vary greatly across class, time, and region (Rao 2004: Chapter 3). Following the Industrial Revolution, Western countries underwent a “demographic transition” from large to small family sizes; this transition was linked to an improved standard of living and had very little to do with the availability of contraception. This rise in living standards was attributable largely to massive transfers of wealth from the periphery to the core; but while the West prospered, the imposition of imperialist forms of production on the periphery had profound social and economic consequences for poor countries. Imperialism “brought down death rates through modern technology but … could not bring down birth rates because [it] increased social inequality and undermined the economic security and self-sufficiency of the masses” (Bandarage 1994: 43). Ironically, then, the West was able to complete demographic transition only through a system of exploitation that relied on the prevention of a similar transition in the South. Mahmood Mamdani’s research demonstrated that Third World agricultural laborers and middle peasants required large families because family labor was essential to their survival and prosperity: children were needed both to work the land and to provide support for their parents in old age (Mamdani 1972). At the risk of oversimplifying, it is not “overpopulation” that causes poverty but vice versa.
Yet the contraception industry and its supporters persist in touting population control initiatives as the key to alleviating poverty, a myth is further cloaked in quasi-feminist rhetoric about “reproductive health” and “women’s empowerment.” According to Melinda Gates, such empowerment is to be achieved via the widespread distribution of long-acting, reversible contraceptives (LARCs) – primarily injectables like the notoriously dangerous Depo-Provera and subcutaneous implants such as Norplant. In a 2012 Newsweek profile, Melinda Gates described visiting remote clinics in sub-Saharan Africa where, she claims, women literally begged her for Depo-Provera injections – supposedly their only means of hiding contraceptive use from “unsupportive husbands” (Goldberg 2012). Injectables are ideally suited to Third World countries, she opined elsewhere, because they enable women to “receive a shot behind [their] husband’s back” (quoted in Posel 2015). In the high style of imperial feminism, her putative support for poor women was yoked to disdain for poor men.
Publicly BMGF promotes LARCs in the name of freeing women to make responsible choices; however, there is reason to believe that Western family planners prefer these methods precisely because they afford Global South women the least choice possible short of actual sterilization. LARCs leave far more control in the hands of providers, and less in the hands of women, than condoms, oral contraceptives, or traditional methods. Some methods, like Norplant, can render women infertile for as long as 5 years.
Recent events in India suggest that LARCs are being promoted as a soft form of sterilization. The country’s mass sterilization programs, which persisted even after Cairo, became politically inconvenient after 15 women died as a result of botched “cattle camp” tubal ligations in 2014. After a highly publicized meeting between Modi and Mr. and Mrs. Gates, the prime minister felt empowered to introduce injectable contraceptives in the national family planning program as a next best substitute for sterilization (Barry and Dugger 2016). Seventy prominent Indian feminists, scholars, and health workers signed a statement in vehement protest of the decision, to no avail (Nigam 2015).
Additional support for this view can be found in BMGF’s close relationship with EngenderHealth, Inc., which is listed on the Foundation’s website as a family planning “partner.” Founded in 1937 as the Sterilization League for Human Betterment, the organization was frankly devoted to the eugenic project of “fostering all reliable and scientific means for improving the biological stock of the human race.” Later, with funding from Hugh Moore, it was rechristened Birthright and during the 1970s played a lead role in USAID’s sweeping sterilization campaigns in India and elsewhere in the Third World (Dowbiggin 2006). In the wake of Cairo, the organization rebranded yet again, downplayed promotion of sterilization as such, and shifted its focus to “long-acting and permanent methods” of contraception (LAPMs): intrauterine devices (IUDs), injections, and implants, as well as tubal ligations and vasectomies. To this end, EngenderHealth has received more than $36 million in BMGF funding. This close partnership between BMGF and an organization primarily devoted to the sterilization of Global South women makes little sense if “reproductive choice” is indeed the goal. Rather, in a post-Cairo ideological climate that makes open advocacy of sterilization indecorous, BMGF and its partners apparently see long-lasting, provider-authorized contraception – effectively a form of temporary sterilization – as a politically acceptable means of top-down fertility control.
Ideology: The myth of overpopulation supplies reliable cover for the ruling class as it expropriates ever greater shares of the people’s labor and the planet’s wealth. Recently, for example, imperial ideologists have discovered the advantages of blaming climate change on population growth on the Global South. As stated in Aspects of India’s Economy, “Malthus’s heirs continue to wish us to believe that people are responsible for their own misery; that there is simply not enough to go around; and to ameliorate that state of wretchedness we must not attempt to alter the ownership of social wealth and redistribute the social product, but instead focus on reducing the number of people” (Chakrabarti 2014).
Global “security”: The Western ruling class appears to share Dean Acheson’s view – famously ridiculed by Mao Zedong – that population growth engenders revolutions by “creating unbearable pressure on the land” (Mao 1949). During the Cold War, and especially in the wake of the Chinese Revolution, it was commonly thought by US planners that too many Third World “mouths to feed” would inevitably create conditions hospitable to Communism. The fall of the USSR failed to alleviate such fears but instead transferred them to a new set of adversaries: popular resistance groups primarily located in the Middle East and typically designated with the catch-all term “terrorists.” Thus the 1986 report of the US Vice President’s Task Force on Combatting Terrorism warned that “population pressures create a volatile mixture of youthful aspirations that when coupled with economic and political frustrations help form a large pool of potential terrorists” (Public Report 1986: 1).
The Reserve Army: Population control can be seen as a way of optimizing the size and distribution of the global reserve army, thereby assisting the West in striking the balance necessary to maintain sufficient leverage over workers while controlling emergent resistance. Ruling class management of surplus labor does not necessarily require reducing the size of the world’s population tout court; rather, the interventions contemplated are targeted toward specific regions and classes in a system of global “demographic arbitrage” recently proposed by European think tanks (European University Institute 2008).
Hegemony: Population control is, in a broader sense, one of the instruments of social control. It extends ruling-class jurisdiction more directly to the personal sphere, aiming at “full-spectrum dominance” of the developing world. Like laws regulating marriage and sexual behavior, such interventions in the reproduction of labor power are not essential to capitalists but remain desirable as a means of exercising ruling class hegemony over every aspect of the lives of the working people. Population control as such directly targets the bodies and dignity of poor people, conditioning them to believe that life’s most intimate decisions are outside of their competence and control.
As ever, the relationship between bourgeois ideology and imperialist practice is dynamic and mutually supportive. As David Harvey has observed: “Whenever a theory of overpopulation seizes hold in a society dominated by an elite, then the non-elite invariably experience some form of political, economic, and social repression” (Harvey 2012: 63).
In 2017, the World Health Organization granted BMGF “official relations” status, solemnizing its leading role in the international public health system. Later that year, when Tedros Adhanom Ghebreyesus was named WHO Director General, Bill Gates was widely understood to have been the kingmaker (Huet and Paun 2017). As a public health official in Ethiopia, Tedros had been deeply involved in BMGF initiatives, supportive of public-private partnerships, and given to bestowing lavish praise on the billionaire. Meanwhile, the militarization of health care proceeded apace: in 2018, amid escalating attempts to destabilize the Maduro government, the United States dispatched a 900-foot navy vessel to the coast of Venezuela, purportedly to provide medical care in aid of a “humanitarian crisis” (Daniels 2018). Current trends promise further expansion and consolidation of global health imperialism.
Yet resistance is growing. In 2016, after Filipino parents realized that a mass dengue vaccination program was making their children sick, protests and widespread vaccine refusal forced Sanofi to concede that its product, Dangvaxia, posed significant health risks. Subsequently, the Philippine government suspended the program, which unsurprisingly had been pushed and subsidized by BMGF (Editorial Board 2018). The Fourth Annual People’s Health Assembly, held in Savar, Bangladesh, in 2018, brought together some 1200 grassroots health activists in protest of the neoliberal NGO-ization of health care. They called for a revival of the Alma Ata principles and denounced the health impacts of corporate power (Baum 2018). Further people’s struggles for health justice can be expected. How much can be achieved in the absence of socialist revolution remains to be seen.
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