D Banerji, New Delhi
Using Scientific Critiques as an Instrument to Resist Foreign Domination
CONSTRAINTS IN DEVELOPING SCIENCE AND TECHNOLOGY
The composition of the WHO sponsored the Macroeconomic Commission on Health (MCH) and the sheer range of their terms of reference had tempted me to undertake the rather forbidding task of writing a critique on their Report. I had looked forward to the outcome of their work of two years to get to know what is their prescription for dealing with the health problems of the poor of the world. From a scientific point of view, the Report was a great disappointment.
As students, we were taught about the European Enlightenment which had laid the foundation of modern science and technology. We were taught to expand our knowledge by using the well established method of experimentation, observation and drawing inferences. It appears from hindsight that I had taken science too seriously. Even when I was barely 20, I felt considerably disturbed at the enormous gulf that existed between fast accumulating medical knowledge and its access to the people – the people of Calcutta, of West Bengal, of India and, later of the world at large. Looking back, I realise that this commitment to the unserved and the underserved was my original sin. I could not help ruffling quite a number of feathers. As on so many occasions in the past half a century, my analysis of the Report of the MCH is a part of the `sinful’ activities which have so often been frowned upon by the dominant power elites. It turns out that because of the pronounced shift in the balance of power in favour of the dominant power elites, this Report has turned out to be an example of a particularly advanced form of distortion of discourse on science and technology to subserve the interests of the power elites. Though there has long been a marked tendency to disregard facts and figures in scientific discourse for quite sometime, this trend has increased at a rapid pace in the recent years.
Most of the scientists have been so programmed by their fund providers that it took considerable time for them to realise that science and technology are not value neutral. However, notwithstanding this realisation, most of the scientists have been willing to `sell’ their `talent’ in the market place for a price; indeed, they have become willing partners with the power elites. As an observer of the scene for such a long time, this trend had worried me a great deal. It is in this context that I had felt that the victims of this manipulation by the power elites have to mobilise intellectual resources from among themselves to wage the obviously unequal struggle against the misuse of science. The resources that are needed for this purpose are of three kinds. First, those who choose to be on the side of the oppressed ought to have the capacity to challenge the scientific postulates of the agenda that is dished out by the oppressors. Second, there ought to be an alternative, scientific agenda presented from the side of the oppressed. Third, the oppressed ought to be ever vigilant and constantly monitor the gains they have achieved is not eroded or completely wiped out by the power elites.
Sketches of my work include items from each of the foregoing categories. However, as they span over a period of over half a century, they provide a dramatic panorama of the changes that have occurred over this period. In the early fifties, there was still some enthusiasm left at the socio-political level to fulfil the longstanding dream of doing something substantial to improve the health of the people of the country. The health administration of the country, led by officers of the Indian Medical Service (IMS), had the needed motivation and competence to work towards its fulfilment. The Report of the Bhore Committee provided the inspiration for putting on the ground institutions like primary health centres as a component of the the overall Community Development Programme, social orientation of medical education and, backing up the All India Institute of Hygiene and Public Health, with institutions like the National Institute of Health Administration (NIHAE) and the National Tuberculosis Institute (NTI). At the other end of the time spectrum we have the gloomy picture of almost total abdication of responsibilities by the political leadership, withering away of the IMS, domination of the health services by bureaucrats, fewer and sudued raising of the voices of dissent and servile acceptance of the prefabricated agenda imposed on the country by external agencies.
Apparently stimulated by the academic atmosphere prevailing at that time, as a starry-eyed junior most official of the National Tuberculosis Institute (NTI), I could venture to raise with some of the most venerable specialists certain critical issues about logistics, fragility and protective power of the liquid BCG vaccine and the long term epidemiological impact of the programme in the implementation of the world wide programme of Mass BCG Campaign. There was considerable debate on the issues raised. Finally, considering particularly that they had been committed to the programme for a decade or more, they did not want any change. However, some two decades later, when it was conclusively proved that the vaccine had no protective value, the programme was abandoned.
The same prevailing spirit of enquiry made me question certain scientific, economic and sociological justification of advocating use of mass miniature mobile radiography for case finding for tuberculosis control in India. Probably, the instinct generated in me from my work with the deprived people in remote areas in Himachal Pradesh and Western Tibet made me design a field study to find out what tuberculosis patients in rural India do and we found that more than half of them had visited government health institutions where they received no help whatsoever. Who is chasing whom? we asked. The vigour with which some of the foreign consultants were pushing the case of mass radiography gave me an early opportunity to understand political economy of decision making: a strong motive force behind the advocacy was the creation of market for the equipment in a big country like India.
The sociological data obtained by us led to the formulation of a number of important concepts whose relevance went over a wide area of public health practice. Formulation of people oriented technology for tuberculosis diagnosis, developing social dimensions of epidemiology, assigning primacy to the felt needs of the people, dealing suffering due to tuberculosis to be an integral component of dealing with suffering due to other health problems, making the programme more acceptable, opening up new vistas for concepts and practice of health education, were some of the outstanding among them.
Inspired by P C Mahalonobis’ ideas on the use of the approach of operational research for social planning, we joined others in NTI in undertaking the big task of using this approach in formulating the National Tuberculosis Programme (NTP). The data produced by the NTI also had had a major influence in formulating the recommendations of the WHO Expert Committee on Tuberculosis of 1964. NTI also got involved in becoming the focal point for training different categories of the personnel of the team for implementing the NTP and for monitoring it.
We went to the patients to find out why some of them did not take the treatment under NTP. We found that in most of the cases it was due to flaws in the organisation and management and in the definition of a case.
The mandate to work for the deprived, insisting on high quality of research on the relevant disciplines, intense in-house debates on research plans and the findings, blending of the findings to formulate the NTP, and providing training and monitoring and evaluation, were the hallmarks of the activities of NTI. Halfdan Mahler, when he became the DG, WHO, had termed it as the `NTI Philosophy’; he had also stated how deeply it had influenced the articulation of the Alma Ata Declaration. My five years at NTI (including 15 months at Cornell to get a Master’s degree in cultural anthropology) had made a deep impact on my working life. It gave an academic base for the cause I had chosen to follow. I got irrevocably committed to scientifically sound research on the health of the deprived.
RAPIDLY CHANGING SCENARIO
With the formulation of the NTP I sought out opportunities where I could explore applying in the approach we had developed at NTI to other major health issues such as family planning, other communicable diseases, maternal and child health and optimisation of rural health systems. I discovered to my dismay that a sea change had taken place at the national level. At the advice of consultants from the USA, the family planning was given the overriding priority over all other programmes, including NTP. From the political leadership downwards, the entire government machinery at the Centre and states conformed. This was an antithesis of the NTI Philosophy. I stood by my convictions because I considered the programme so obviously flawed and against the interests of the deprived. I wrote extensively, including my first book, FAMILY PLANNING IN INDIA: A CRITIQUE AND A PERSPECTIVE (1971). Among many others, I strongly opposed the following aspects of the decisions: breaking up the ministry of health into two separate departments of health and family planning; handing over the control of the much more favoured and rapidly expanding department of family planning to generalist administrators, both at the Centre and in the states, who neither had the technical comptetence and who could not be held accountable for their decisions; mobilising the infrasturcture of the health services to attain family planning targets, leading to the decimation of the general health services (including NTP!); use of coecive practices to get people sterilised which culminated in the massive forcible sterlisation of nine million people during the Emergency. Very few, including the intellectuals and parliaments stood up against this unacceptable onslaught on the hapless people by their own government. Despite almost exponential
rise in the allocations, the population the population of the country shot up from 301m in 1951 to over one billion in 2001.
The Alma Ata Declaration offered a small window of opportunity of serving the deprived. However, it was tightly shut by `inventing’, with little scientific data, what was called Selective Primary Health Care (SPHC). I had written paper called CAN THERE BE A SELECTIVE PRIMARY HEALTH CARE?. Taking note of this, the Institute of Public Health at Antwerp had called a meeting of over 80 scholars to discuss the paper. They declared that that SPHC is a contradiction in terms. David Nabarro, the present Chief Executive in WHO, was the rapporteur. All these did not make any impression on the exponents of SPHC. In connivance with the key national personnel, they let loose a number of vertical programmes on a global scale. They were assigned high priority, thus further eroding the infrastructure of the health services, The Universal Programme if Immunization was one of them. A Task Force in India had hailed it, without producing any evidence, as `the most cost effective method ever known to mankind’. I had written extensively, expressing fears about its viability. Expectedly, it failed to attain the objectives set for it. When the AIDS pandemic broke out, I had written a monograph entitled, DEALING WITH AIDS AS A PUBLIC HEALTH PROBLEM. This was meant to be a discussion document, but it was simply ignored. Perhaps the hardest blow came in the form of the World Bank/WHO Global Programme on Tuberculosis, which involved the DOTS approach. I wrote a an extensive monograph under the title SERIOUS IMPLICATIONS OF THE REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME.. I could not have any dialogue with the proponents. The programme was pushed through. The latest information in the form of the WHO’s annual report on the programme (2002) and the report of the Comptroller and Auditor General of India confirmed the fears expressed in the monograph.
Over the 38 years, the NTI Philosophy got expanded considerably. However, it continued to be a source of strength and inspiration for me to counter, almost single-handedly, some of the very pernicious elements in the practice and research in public health that were imposed on the country by foreign agencies. Finding inadequate interest among the younger generation of scholars (a danger signal for the future!) I have made conscious efforts to record accounts of my work to expose them to academic scrutiny.
RECORD OF THE WORK
I had undertaken a field research to extensively study 19 villages from eight states of the country over a period of 26 years. I published part of the report in a book, POVERTY, CLASS AND HEALTH CULTURE (1982). Subsequently, I have used the data collected extensively in my other writings. Realising that the I had done considerable amount of work, using the expanded form of the NTI Philosophy,. I had been tempted to put them down systematically in a book form. I had found it a formidable task. I pay tributes to Dr Tarlok Singh whose sustained persuasive efforts led to the publication of my magum opus: HEALTH AND FAMILY PLANNING IN INDIA: AN EPIDEMIOLOGICAL, SOCIO-CULTURAL AND A POLITICAL ANALYSIS AND A PERSPECTIVE (1985). I then put together what I considered the newer thinking in health social sciences by bringing out, SOCIAL SCIENCES AND HEALTH SERVICE DEVELOPMENT IN INDIA: SOCIOLOGY OF FORMATION OF AN ALTERNATIVE PARADIGM (1986). Health policy analysis was the focus in my next publication: ANALYSIS OF HEALTH POLICIES AND PROGRAMMES IN INDIA IN THE EIGHTIES (1990). I undertook even a more ambitious than my magnum opus when I was commissioned to write: INDIA’S FORGOTTEN PEOPLE AND THE BREAKOWN OF THE PUBLIC HEALTH SERVICES IN INDIA: A PRESCRIPTION FOR THE MALADY (1996). The manuscript contained 84 chapter and it covered 1,400 computer pages. This time I resisted the temptation of publishing it. I had published the summary of the manuscript in three parts in HEALTH FOR THE MILLIONS. It did not evoke a satisfactory response. My last publication was: LANDMARKS IN THE DEVELOPMENT OF HEALTH SERVICES IN COUNTRIES OF SOUTH ASIA (1997)
These publications as well as the others which have been cited earlier in the paper contain long lists of references, which can give an idea of my other publications in learned journals and as chapters in edited books. I would also refer to three papers in the INTERNATIONAL JOURNAL OF HEALTH SERVICES which were published specially to give a wider international exposure to my views:
(i) Report of the Commission on Research on Health and Development and the Countries of the South;
(ii) A Simplistic Approach to Health Policy Analysis: The World Bank Team on the Indian Health Sector; and
(iii) A Fundamental Shift in the Approach to International Health by WHO, UNICEF and the World Bank: Instances of Practice of ” Intellectual Fascism” and Totalitarianism in Some Asian Countries.
The Editor of the IJHS had invited me to write a critique of the Report of the Macroeconomic Commission on Health for his journal. It is expected to be published soon.
The turmoil created in the health services of the poor countries by the rich ones is a part of the wider convulsions that are taking place in the world order or disorder. Loan conditionalities, ensuring market penetration by aggressively promoting globalisation and unequal and unfair terms of trade pushed by the WTO, are examples. The deprived sections of the population get further marginalised in each case. A modest effort to take the side of the deprived will be to expose the scientific infirmities in the programmes suggested and in making an analysis of the political economy may be of help in eroding their credibility appears to be one way of doing so.