PUBLIC HEALTH FOUNDATION OF INDIA
Redefining Public Health?
The setting up of the Public Health Foundation of India marks the coming together of interests that are inimical to public health. The PHFI and its institutes – albeit located in India and with the blessings of the Indian government – will in effect function as an extension of American interests. It is to be governed by technocrats/bureaucrats and nominated NGOs and will be subjected to little or no accountability/scrutiny by the Indian polity.
C SATHYAMALA
T
The foundation plans to set up five “world class” institutes – Indian Institutes of Public Health (IIPH) – in carefully chosen locations to provide training and conduct research in prioritised, “high impact” areas of public health. Standardisation of public health education in India, another role envisaged for the foundation, will be achieved by establishing an independent accreditation agency along the lines of the ASPH, bypassing the Medical Council of India, the body set up by an act of the Parliament to oversee medical education in the country. Although no joint degrees will be awarded, the ASPH will help design the course. Senior and middle level faculty will be sourced from overseas and the next generation of faculty will be groomed by sending about 100 candidates, over the next three years, for higher studies in public health in the US, with all expenses met. These candidates will be aided by the “pull to return” by creating an attractive career path as leading future faculty of IIPHs, as well as other attractive packages.
Amartya Sen, a PHFI board member,3 described the launch as a “great moment” while observing, rather enigmatically, “India was important to public health, as public health was important to India” [Express News Service 2006a]. For Srinath Reddy (2006), slotted to become the first president of the foundation, the 350 public health professionals that India produces every year are “woefully” inadequate for India’s needs. The IIPH intends to fill this need by training more than 10,000 persons annually, thereby raising “an army” of public health professionals [Rashid 2006]. For McKinsey, the consultancy firm which has worked on a pro bono capacity (!) to set up the foundation, it is to “stimulate a demand for public health professionals”, by creating a “mandate for public health qualification in government machinery… unlock demand in emerging private sector”, and make public health education an “attractive stand alone profession” [PHFI 2006].
The demand for this specialist course has, however, already been “unlocked” in the public sector, by the Commission on Macroeconomics and Health [GoI 2005]. In its report published last year, the commission recommended that there is a need to “(e)stablish an All India Cadre of Public Health…earmark posts that must be manned by people who have basic public health qualifications; and establish six schools of public health to serve as centres of excellence for training in public health in addition to strengthening PSM departments of medical colleges and existing public health institutions” (p 10).
The rationale for this recommendation comes from a study undertaken in 2000 by the Indian Council for Research on International Economic Relations (ICRIER), to provide inputs into the Commission on Macroeconomics and Health [Misra et al 2003]. Besides the existing public sector research infrastructure, and a pharmaceutical industry, the following were identified as some of the special advantages for health research in India:
(a) huge and diverse clinical material (sic)for research giving the country a uniqueopportunity to turn an acknowledged disadvantage into a research advantage.…a strong claim to being an appropriatesite for clinical trials and that as companiesseek to conduct global trials contractresearch organisations in India areideally placed to take advantage of thisopportunity.A large and diverse population steeped intradition has ensured that many rarergenetic disorders have survived in India,and this can become the subject matter ofvaluable research. The future belongs to bio-informatics. The sequencing of the human genome would hardly have been possible without the strong inputs from information technology. India with its strong IT base, can take a lead in research areas which requirestrong software inputs (p 192).
Apart from providing special incentives and improving compensation to attract professionals, the group underlined the urgency for capacity building to undertake clinical trials for new molecules likely to be introduced for various communicable diseases.
Fulfilling US Demands
The “demand” for an increased production of human resources in public health coincides with that of the American government – some years ago the latter had identified an urgent need for a vast number of public health specialists of all categories. These were for employment not only in the US, but more specifically for the developing countries to handle the emerging threats to health.
In 2001, a Committee on Emerging Microbial Threats to Health in the 21st Century was set up by the Institute of Medicine of the National Academies, US and was charged to review the current state of knowledge regarding factors in the emergence of infectious diseases; to assess the capacity of the US to respond to emerging microbial threats to health; and to identify potential challenges and opportunities for domestic and international public health actions; and respond to microbial threats and human health [Smolinski et al 2003].4 Noting that “infectious diseases are a global threat which requires a global response” the committee recommended that the US should seek to enhance the global capacity to respond to infectious disease threats, focusing in particular on threats in the developing world
Economic and Political Weekly July 29, 2006
which should include a significant investment in the capacity of developing countries to monitor and address microbial threats as they arise.
To this end, the committee recommended that the Centers for Disease Control and Prevention (CDCs) in the US should enhance their regional infectious diseases surveillance; the US department of defence (DoD) should expand and increase in number its global emerging infections surveillance (GEIS) overseas programme sites; and the US National Institutes of Health (NIH) should increase their global surveillance research and the overseas disease surveillance activities concerning relevant US agencies (CDC, DoD, NIH, US Agency for International Development (USAID) and US department of agriculture) should be coordinated by a single federal agency such as the CDC5 (pp 8-12).
The committee stated that the US capacity to respond to microbial threats was contingent upon a public health infrastructure, which had suffered years of neglect and that there was a need to rebuild domestic public health capacity. It also felt that upgrading current public health capacities would require considerably increased investments as the number of qualified individuals required in the workforce for microbial threat preparedness was considered to be dangerously low. In 2001, for instance, the need for at least 600 new epidemiologists in public health departments across the US was identified to meet the requirements for bio-terrorism preparedness alone. Yet, only 1,076 students had graduated with a degree in epidemiology in the previous year, and the largest percentages were trained in chronic disease, not infectious disease epidemiology. Between 1999 and 2000, the most needed occupations identified in the US were public health nurses, environmental scientists and specialists, epidemiologists, health educators and administrative staff.
Setting up schools of public health in India helps solve the human resource problem of the US in two ways. First, and the obvious one is that it would supply lowcost qualified professionals trained in public health according to the ASPH standards. Supplying qualified human resources to the west at low cost is what the country’s several training “institutes of excellence” in medicine, set up since independence in accordance with Bhore Committee’s recommendations (1946) have been doing. Developing countries “donate” a full 56 per cent of all migrating physicians and receive less than 11 per cent, the principal donating countries for physicians being India and the Philippines [World Bank 1993]. But the more important and the not so obvious advantage is that the future IIPHs are intended to produce a cadre of public health personnel (Indian made, but with a foreign chhap) who will be the extension of American vigilance on Indian soil without evoking distrust.6 This strategy in any case has been the modus operandi for the last several years.
For more than 20 years, CDC has collaborated with ministries of health around the world to establish field epidemiology training programmes (FETPs) and have trained more than 900 international public health leaders in epidemiology and outbreak investigation [Smolinski et al 2003]. The Committee on Emerging Microbial Threats recommended the enhancement of the FETPs by providing all with laboratory support in the diagnosis of infectious diseases as was being done in the case of Thailand. In addition to this, the recommendation was that “CDC, DoD and NIH should develop new and expand upon current intramural and extramural programmes that train health professionals in applied epidemiology and field-based research and training in the United States and abroad” (p 183).
The American government’s desire to influence policies and programmes of other countries has never been in doubt and one of their most important and successful strategy has been through financing educational support and providing research inputs. The political coup in Indonesia, spearheaded by the Ford Foundation (FF) in the late 1950s/early 1960s is a specific example of how such influence works [George 1978]. The first step was to create a “modernising elite” by training Indonesian students in several top American universities, notably Berkeley,7 MIT, and Harvard. After the extermination of the core of the communist party in the CIA staged coup, the American trained Indonesian elites moved in to restructure the Indonesian economy to suit American interests.
In India too, the FF has come to exercise considerable influence through philanthropy [Sathyamala and D’Mello 2003]. Apart from supporting educational and fellowship programmes, the FF and other such donors, operate through funding NGOs for both research and other programmatic purposes. Till the 1980s, activist groups did not consider foreign funding, particularly FF money, an appropriate source to finance their activities and those who did, were scathingly attacked [James 1995].8 But in the last 15 years, this position has changed drastically with many institutions in the country (even those with left leanings), working in the areas of gender, reproductive health, and human rights, accepting funding from FF for their activities. In a short period, FF has attained acceptance and respectability which is a consequence of the FF’s close association with individuals and groups, many of whom are persons of integrity and social commitment, at the forefront of several progressive movements.9 With such advocates, FF has no need to defend its past or its present. Moreover, since groups and individuals in opposing camps are supported, the funding policy appears non-discriminatory and non-directive and as stated by several autonomous women’s groups, in India it is more a question of co-option than suppression of progressive movements [Saheli et al 1991]. The experience of the last two decades in the country has also demonstrated that FF and other such private donor agencies from the US do aim at deliberately influencing policy-making in the country through “evidence” generated by their funded partners [Population Council 2005].
Interests Inimical to Public Health
All this may seem little to do with PHFI, as the major player here is not FF but the Bill and Melinda Gates Foundation (GF), which having come into existence only since 2000, is not sullied by history of the kind FF has in furthering imperialism. In contrast, in the short period of its existence, it has become the world’s largest charitable foundation by disbursing more than US $ 3.2 billion for health programmes aimed at AIDS prevention and neglected diseases of the third world (http:// en.wikipedia.org/wiki/ Bill_%26_Melinda_Gates_Foundation, accessed on April 24, 2006).10 One reason for such largesse appears to be rather prosaic, as the foundation, whose annual income is that of a small country, needs to donate at least 5 per cent of its assets, amounting to over $ 1 billion at a minimum each year to maintain its status as a charitable organisation.
However, this is not the compelling reason and to understand Bill Gates’ interest in matters of health, one needs to understand his business needs and practices. Bill Gates’ interest in philanthropy is said to have coincided with Microsoft’s battle with the American government over its Windows monopoly during which he lost out on a lot of public good will.11 In 1999, the ruling in the antitrust case against Microsoft was that its dominance of the
Economic and Political Weekly July 29, 2006 PC operating systems market constituted a monopoly and that Microsoft had taken actions to crush threats to the monopoly, including Apple, Java, Netscape, Lotus notes, Real networks, Linux and others (http://www.usdoj.gov/atr/cases/f3800/ msjudge.pdf accessed on June 19, 2006). The judge remarked: “Microsoft was a company with an institutional disdain for both the truth and for rules of law lesser entities must respect” [Thurrott 2001].
What does the GF, built on the fortunes of a company that has thrived by ruthlessly destroying all competition, bring to the understanding of public health?12 As legend has it, it was an interest in family planning that brought the Bill and Melinda Gates to a Seattle-based organisation, Programme for Appropriate Technology in Health (PATH) [Paulson 2001]. By breaking the cycle of disease and poverty that contributes to the high birth rate, Gates hopes to “get at the problem that originally motivated his philanthropic impulses – overpopulation”.
On October 17, 2003, the Foundation for the National Institutes of Health and the GF announced the first 14 challenges that were to be the focus of the “grand challenges” in health that the GF considers
as “roadblocks” standing in the way of its
medical objectives. According to The
Economist: The challenges in question… range from the mundane (“Prepare vaccines that donot require refrigeration”) to the esoteric (“develop a genetic strategy to deplete or incapacitate a disease-transmitting insect population”). The latter will require both serious genetic engineering and a public relations campaign designed to persuadepeople that it is safe and sensible to unleash engineered insects into the wild. Nor are basic matters neglected… half of childhood deaths in a poor world have malnutrition as an underlying cause. So one of the challenges is “to create a full range of optimal,bio-available nutrients in a single staple plant species”. More genetic engineering there, in all probability, or a revolution in plant breeding techniques. So, if a new, healthy crop called Billgatesia graces your table one day, you will know who to thank(italics in the original) [Anon 2005a]. The Economist further remarks: …Gate’s speciality is software…And heseems to have realised what biologiststhemselves are only starting to come togrips with – that biology is basically asoftware problem in which biochemical pathways stand in for computer algorithms.
From this perspective, disease is the result
of software failure or inappropriate data
input – a fact that is very evident when
listening to a conversation between
Mr Gates and his scientists about the
weak points of, say, the malaria parasite
[Anon 2005b].
The GF has also reportedly purchased shares in nine big pharmaceutical companies,13 valued at $ 250 million which are a new type of investment for the foundation [Bank and Buckman 2002] with obvious conflicts of interests. A GF representative is one of the 18-member board of the Global Fund to fight AIDS, tuberculosis and malaria, and the chief executive of Merck is one of the board members of Microsoft. Importantly, the GF was a major sponsor of the Commission on Macroeconomics and Health, which had made a strong recommendation that intellectual property protection was critical for the continued investment in drug research and development.14
The GF is said to be worth $ 25 billion, ten times the size of Rockefeller Foundation and three times the size of Ford Foundation (http://www.iicd-volunteer.org/ newsite/tce/tce_news_000.html, accessed
Economic and Political Weekly July 29, 2006
April 26, 2006) and therefore its influence is probably greater.
In conclusion, the setting up of the PHFI is the coming together of interests that are inimical to public health. The PHFI and its institutes, albeit located in India with the blessings of the Indian government, will in effect function as an extension of American interests, to be governed by technocrats/bureaucrats and nominated NGOs,15 and as an “autonomous” body will be subjected to little or no accountability/scrutiny by the Indian polity, termed “political interference” in newspeak. Since the 1990s, this kind of institutional arrangement is becoming increasingly the norm as can be seen from the example of the “autonomous” body, the National AIDS Control Organisation (NACO) [Saxena 2006].
Lack of accountability and transparency in such institutional arrangements has meant that technocrats with the support of bureaucrats have a free run in implementing programmes that may not be in the best interests of those who are at the receiving end. The HIV vaccine trial on healthy volunteers is a case in point which has been viewed with serious misgivings relating to the absence of compensation to the volunteers in case of vaccine failure, and more importantly, the proof of efficacy in this trial being based on the implicit need for the volunteer to practise unsafe sex [Kumar 2002]. The lack of transparency about the contents of the MoU signed by the GoI and International AIDS Vaccine Initiative (IAVI) is equally disturbing, as despite repeated requests, the document has not been made available in the public domain.
Shaping Public Policy through Funding
One of the “key charters of the PHFI is to be policy shaping think tank” [PHFI 2005], which plans to advice both government and the private sector on critical policy issues on matters related to public health policy [Express News Service 2006b]. Zafrullah Chowdhury (1981), writing about research as a method of colonisation, gives the example of the proposal to set up an International Institute for Health, Population and Nutrition Research in Bangladesh in the late 1970s which, according to him, was primarily planned for the benefit of US researchers. He concluded that Bangladesh will end up serving as a laboratory whose population may or may not benefit from the experiments and all will be done in collaboration with, under the management of and through funds and personnel in the control of the US.16
Funding is known to influence policies in critical aspects of health, be it the WHO formulating guidelines for hypertension, stifling debate on infant feeding [Ollila 2004], revision of the Diagnostic and Statistical Manual, the official manual for psychiatric diagnosis in mental illness in the US [Cosgrove et al 2006], or in voting patterns at the Food and Drug Administration, US [Lurie et al 2006]. Shaping policies through funding is true not only in the case of direct funding from the drug industry but with foundations too, even those calling themselves philanthropic, that have financial interests or are involved in developing healthcare products.17
The teaching and the practice of public health in the country have very little to recommend itself and health groups such as the Medico Friend Circle have grappled with these issues for the last three decades.18 But at no point in time was the need for public health as a “stand-alone” profession articulated as the strategy for overcoming the lack of a public health perspective in medical education. It is therefore surprising to see individuals who had vigorously championed for a reform in medical education now championing for a “stand-alone” public health perspective. Given that public health (the better known term is Preventive and Social Medicine) is not considered a worthwhile career (not only in India), the “compensation” being envisaged for the IIPH graduates as a “pull” factor can only mean that the need for such specialists has become critical to the development of the healthcare industry. The National Polio Surveillance Project (NPSP) is a good example of the kind of highly paid job opportunities possible in the future for the PHFI type of “public health” graduates. It is also more than likely that there will be more and more new threats, both real and generated (as witnessed in the case of the “terror” unleashed by the bird flu), that will require medical policing. Hence the need for an “army” that will function as a modern day medical police that will “educate” the “masses” that it is for their own good that they should follow expert advice.
EPWEmail: sathyamala@yahoo.com
Notes
1 Institutions providing postgraduate training in
public health in India, such as the Centre of
Social Medicine and Community Health,
Jawaharlal Nehru University, had not been
invited for the launch.
2 Of the initial capital of US $ 50 million, eight Indian “philanthropists” are to pool more than US $ 20 million, with the Indian government and the Bill and Melinda Gates Foundation donating US $ 15 million each [Chen 2006].
3 The other members of the board include Rajat Gupta (McKinsey), Montek Singh Ahluwalia (vice-chairman, Planning Commission), R A Mashlekar (director-general, Council of Scientific and Industrial Research), T K A Nair (principal secretary to the prime minister), Prasasda Rao (former health secretary), Sujatha Rao (head of the National AIDS Control Organisation), Srinath Reddy (head of department, cardiology, All-India Institute of Medical Sciences), Shiv Nadar (HCL), Gurudas Dasgupta (CPI leader), Lincoln Chen (director, Global Equity Center, US), and Jim Curran (chair of board of directors, ASPH, US), and Ravi Narayan (community heath cell, SOCHARA) [Indian Express, March 28, 2006; Rashid 2006; Narayan, personal communication].
4 The committee’s co-chair M A Hamburg is the vice-president for biological programmes, Nuclear Threat Initiative. Although, the Committee was set up earlier to the attack on the World Trade Center in 2001 this event as well as the anthrax scare that followed it, made the committee particularly sensitised to the threat of bio-terrorism as an imminent possibility.
5 The CDC mentioned here is the CDC Foundation, a federal agency of the US, established by the US Congress to “connect outside partners and resources with CDC scientists to build programmes that can substantially enhance CDC’s impact”. CDC foundation began operating in 1995. CDC Foundation is provided programmatic support by corporations, businesses and corporate foundations (among other sources). The list of such providers virtually reads like a “who’s who” in the pharmaceutical industry, agribusiness and oil companies (www.cdcfoundation.org/ accessed on April 22, 2006).
6 The Global Polio Eradication Initiative (GPEI) is a recent example in which CDC, a US institution, was accepted on par with the WHO and UNICEF, both UN institutions. Being a part of this triumvirate, CDC has access to surveillance data and to the virology laboratories of the entire world.
7 These Indonesian students came to be known as the “Berkeley” boys.
8 Writing in The Marxist, Prakash Karat viewed foreign funding as a “sophisticated and comprehensive strategy worked out in imperialist quarters to harness the forces of voluntary agencies/action groups to their strategic design to penetrate the Indian society and influence its course of development… to counter and disrupt the potential of the left movement” [James 1995].
9 It was during the World Social Forum (WSF) in Mumbai in 2004 that a clear opposition to such funding emerged in recent times (Research Unit for Political Economy 2003). After much soul-searching, the organisers of the WSF meet in Mumbai decided to decline funds from the FF.
10 The leaders of the foundation’s global health programme are those who have been closely associated with CDC and McKinsey (http:// www.gatesfoundation.org/GlobalHealth/ RelatedInfo/GHTeam.htm?version, accessed on April 15, 2006).
11 Rockefeller too is reported to have begun his
Economic and Political Weekly July 29, 2006
philanthropy after he was convicted several times in antitrust cases [Vanheuverswyn 2005].
12 With a net worth of $ 46.5 billion, cynics comment that while Gates gave 100 million to fight HIV, he spent 421 million to fight Linux, Microsoft rival, making Linux a more serious threat than HIV/AIDS (Green 2002)
13 Merck and Co, Pfizer Inc, Johnson and Johnson, Wyeth, Abbott Labs and others.
14 The GF had sponsored the report of the ICRIER, which laid the foundation for the recommendation that world-class institutes in public health be set up in India.
15 Although individuals from several NGOs in the country attended the launch of the PHFI and are closely involved as members of governing board and advisory committee, they cannot be said to represent the NGO sector or the health movement, as they are nominees of the founders of the idea.
16 The district of Matlab in Bangladesh has functioned as the research laboratory for the schools of public health in the US for decades, as much as the African country Gambia has for the Medical Research Center UK.
17 Often the direct relationship with the industry is obfuscated by organisations such as the WHO, acting as “middle men” in the “privatepublic partnership”. For instance, Norplant, a hazardous long-term invasive contraceptive was developed and registered by the Population Council, manufactured under licence from population Council by Huhtamaki Oy Leiras Pharmaceutical, Finland, and the clinical trials were conducted by the WHO and ICMR.
18 See Medico Friend Circle Bulletins Nos 97-98, 99, 264-265. Writing about the state of medical education in the country since 1833 (Bentinck’s Committee), it was pointed out the “Even though nearly four decades have passed since we achieved independence, the colonial mentality of the medical profession, the elite bureaucracy and the political leadership have not disappeared. The “brown sahibs” who rule India have very deep roots in their background and education which makes them see the dictates of western society as more important than the basic needs and aspirations of our own people [Narayan 1984].
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Cochin, September 19-20, 2006
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Economic and Political Weekly July 29, 2006
