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Tariq Ali: Today we are going to discuss medicine and what is going on in Africa but not just there, in other parts of the world too, and how privatised medicine is now dominating the field except in a few oasis there are still left Cuba, Venezuela, etc. With me is Professor Allyson Pollock, one of the best known public health scientists and experts in her field anywhere. Ebola. What are its origins and how did it spread so quickly in these three African countries and is now causing panic elsewhere?
Allyson Pollock: Well Ebola is a virus, nobody quite knows what the origins are, some think it might be from the bat, and it is spread through bodily fluids, so that is an important mechanism. In most normal situations it should be very easily contained by quarantine and by isolation but the big problem in the countries where it is most prevalent, which is Sierra, Liberia and Guinea, is that these are very, very poor countries, where the infrastructure has increasingly been ripped out, especially in terms of health systems and the, um, virus is now in urban areas where there is close human contact, so it makes it very difficult to control and contain especially when it is happening in areas where there is a lot of overcrowding and poverty and poor sanitation.
Tariq Ali: And the Western health community, so to speak, the World Health Organisation, was slow to react, I felt, in terms of what could have been done at an early stage of this disease.
Allyson Pollock: Well I suppose the WHO was hoping, as in the previous outbreak – large outbreak in the 1970s, that it would be fairly easily contained. Perhaps what happened that they hadn’t reckoned with the fact that these countries where it is emerging are actually among the very poorest countries? Liberia and Sierra Leon have been through their own long periods of civil war, conflict with displaced refugees where the gross domestic product and the economy has very badly suffered and what we have seen in all these countries is a real hollowing out of all sorts of public services but especially health systems. So it is very, very difficult to contain it and we have got real issues of poverty. So, I suppose the first hope was that these would be fairly, err, the disease would be fairly easily contained but actually of course it is a virus that has a very high case fatality rate, they say about 55% chance of dying if you contract the virus. So this is very serious but one of the big problems is that the Western world, especially the US government is coming back with solutions of guns and magic bullets so we’ve been here before; the announcement by Obama that he is going to send in 3,000 troops and the parallel announcement that they are going to focus on rapid vaccine production. And this is a complete removal from the social and structural determinance of public health because the origins of all public health are in very simple and basic solutions. It’s about clean water, sanitation, good nutrition – so the evils of poverty. And, on top of that you need very good health systems with proper doctors and nurses and facilities that you can isolate people and you can also do what’s called ‘contact tracing’ so you need to go back into the community to find out who the affected individuals have been in contact with so that you can then quarantine and isolate those individuals to make sure that they actually then don’t get the disease and then pass it on during the incubation period. And all of that has been stripped out.
This is what these countries are looking at, they’ve had a total erosion and collapse of their public health care systems and this is the tragedy. So the population has very, very few doctors and nurses. They simply cannot cope and of course the public facilities that are there are overcrowded, they are in terrible conditions and they are completely and utterly understaffed. So this problem of an epidemic was going to hit them, it could have been Ebola, it could be something else – it could be cholera or whatever. This was actually going to come home to hit these countries very hard indeed. This was entirely predictable and it’s been predictable for more than 20 years and it is what the public health lobby and the public advocates have been talking about. The solution to these epidemics is not the magic bullets of vaccines and it is not sending in the troops. It’s structural, it’s social, it’s economic, it’s environmental and it is putting in all the public health measures.
Tariq Ali: But the entire world capitalist system as it functions is basically not in favour of public health services, they are in favour of privatised solutions, privatised facilities which means that in most countries increasingly you have a two or three tier system; you have very good quality hostpitals for the rich and people who can afford them, you have a second tier for more middle class people who also have to pay but not so much and their facilities aren’t so good and then you have public hospitals, not just in Africa but in countries like India and Pakistan and Sri Lanka, which are a total complete disgrace and nothing is done about it on a global level at all because this is not a priority. I mean it is just outrageous. Do you think, I mean, given that this is how the health system functions from what you said, the obvious solution, medium-term and long-term, is to create a strong social infrastructure in these countries but that is what the International Monetary Fund asked them not to spend money on, the last four decades so what do you think they can do?
Allyson Pollock: Well I think you are raising important issues; what is the role of the IMF, the World Bank, the African Development Bank because again if we look at Liberia and Sierra Leone and Guinea, which actually have a lot of natural resources, what is happening to these countries, in terms of their economics is that increasingly the lands are being privatised and being occupied by foreign investors who are coming in and they are simply stripping out the resource and the assets. Liberia has a GDP, gross domestic product, of a couple of billion dollars, and a population of five or six million, so how are they meant to rebuild when actually you’ve got foreign directors coming in and public private partnerships and great flows of money going out and you don’t have any mechanism for redistribution because redistribution means you are trying to build a fairer society and you are trying to put the resources back in.
So it starts with the economy, it starts with what’s happening to the land, it starts with the fact that palm oil and cocoa and rubber are important cash crops and there’s land, and these ownership, has been transferred and I mean this is very well documented by important organisations like Global Witness but also the Oakland Foundation in the US, who have actually chartered what is happening to the land and remember, many of the farmers, for instance in Liberia, 70% of the population, live in rural areas. They will be subsistence farmers so this is an issue and when you have the population spending 80% of the money on food and then you have all these cordons around them, then of course you have got a real problem because the poverty is actually going to be accelerated in these countries because of the Ebola virus, because the borders are closing and because you don’t even have economic flow any more. So I think we need to start with the economics because that is the cause of the structural problems and then we’ve got the World Health Organisation, which is the international global authority on health. It has the law making powers but systematically over 20 years it has been completely starved of funds and such funding as it gets are tied to all sorts of conditions and those conditions are being set by large, global NGOs such as the Bill & Melinda Gates Foundation, which have no democratic base, no accountability and which in turn are doing untold harm through their vertical disease programmes because they are not rooted in public health and the public health systems. And a good example of a vertical disease programme is when you take Ebola and then you bring in your operation to tackle Ebola and you ignore all the other causes of disease, such as TB or malaria, or poverty, malnutrition and at the same time when you focus all the efforts of the industry on vaccine development.
But actually vaccines are not what these countries need. It’s proper redistribution and public health measures and we learn nothing from history; that is what is shocking. All the great reforms, all the great collapse of infectious disease epidemics was actually not down to drugs and vaccines, it was to redistributive measures, which included sanitation, nutrition, good housing and actually above all a real democratisation. And with it came education and all the other measures that we need. Now I’m not saying we don’t need vaccines, but one of the big problems is that that vaccine developments itself is now in the hands of these large very powerful foundations like NGOs, like GAVI – the Global Alliance for Vaccine Initiative, who in conjunction with big companies like GSK and Merck, are out to seek patents and the reason why they like vaccines is it gives… because vaccines mean mass immunisation, it means numbers and numbers mean money. And of course is being paid for by the West and Western governments when this money could much more easily flow into the governments themselves to re-build their health systems because we are talking about re-building public health infrastructure and that includes putting in community primary health care, community health systems, infection control units at community level, putting in hospitals and training nurses and doctors. And the big, other big problem in all of these countries is not just a brain-drain, because a few doctors and nurses are there, they want to leave and that is happening also in Nigeria, or they want to work in the private sector or they want to work for these NGOs because the money is much better and so the whole public health system is completely hollowed out. And this is a real problem because the Gates Foundation, Bill & Melinda Gates, do not believe in the public sector, they do not believe in a democratic, publically owned, publically accountable.
Tariq Ali: So in fact the WHO, because of governmental policies, and the priorities of the Washington consensus, i.e.. neoliberalism, privatisation of medicine, inability to control Big Phgarma, has effectively ditched what it used to do? In the sense that it can’t do what needs to be done, shore up, strengthen, build if necessary in some of these countries public health systems.
Allyson Pollock: Well, there is a very important paper recently in the British Medical Journal, I think by David Legg, which actually sets out what has been happening to the WHO over two decades where the US refuse to give the funding that it should have done and then what you have is when Western governments and the US come in, they tie it to conditionalities, which is usually around the Bill & Melinda Gates priorities and not around the essential public health priories and the WHO has its hands tied. And actually it is the world health organisation, it has got the law making powers and yet it has never exercised these functions we are talking about democratic deficits that are happening when large global funds like the Gates Fund or the Buffett Fund can actually determine what the world priorities are and so distort what the priorities should be for public health because it is tied to the economics, they need to industrialise, they need to medicalise and they need to pharmaceuticalise. But there is a big backlash coming, a big backlash in the Western world, much more critical thought about the ethicacy and the safety and the appropriateness of the drugs and vaccines and medications and this group is beginning to be more and more articulate and more and more and more concerned. But one of the big problems is that because of this huge amount of money that the Bill & Melinda Gates Fund have, is that the technicians, like myself, the public health tribes, have been captured because of their success in predicated upon getting jobs, or research, tied to the interests of the Global Fund. So the critical thought is being hollowed out and so at the same time are the essential public health functions because public health is there as Ibsen would say, to be the enemy of the people, but actually it is there to be critical, to appraise and to think rationally and to remind everybody about what the social determinance of health are, and it is not rocket science. It doesn’t need magic potions or millions of dollars spent on genetics and the laboratories, it needs very, very basic things, but they are essential because they are what the public health infrastructures are built on.
Tariq Ali: Contrast this, what’s going on in the bulk of the world with a tiny country like Cuba, which has managed to construct a public health system, which is precisely many things that you are arguing for. It is very oriented to preventive medicines which stop a disease from spreading, and has now amongst the best record of both public health services and its affects in terms of what Cuban’s citizens and increasingly because the help they have given Venezuela, Venezuelan citizens and other South American citizens who never used to have health are now in much better shape than many people, for instance, in Eastern Europe which went in for big privatisation; leave alone Africa and large parts of Asia. You’ve studied the system I think?
Allyson Pollock: Well yes I think the Cuba’s system is very inspiriting and anybody who has been to Cuba can’t but feel the public health benefits of it. I mean they are a country that really know the meaning of austerity and yet their GDP, which is the equivalent of many of these poor countries, but they don’t have this extraordinary inequalities because their vision and campaign has been around public health and health for all. So they have done extraordinarily well and quite remarkably well. I mean the real problem comes as what’s happening now and will they get side-tracked by neoliberal policies and the need to get drugs to market, and the need to sell drugs; it is a very important time for Cuba to think about it. But actually they need to all the time be remembering what their GDP is and what they’ve achieved with their GP compared with some of these poorer countries in the world like Sierra Leone and Liberia – Liberia especially.
Tariq Ali: The other thing of course is that the Cubans have sent out a lot of their doctors to parts of Africa, South America, to whenever there is a disaster . I remember during bad floods in Pakistan, really bad, a whole team of Cuban doctors arrived and were taken to the remotest parts of the country where women were not allowed by their menfolk to see doctors because most doctors were male. And when they saw the Cuban team, which was 60% women, 40% male doctors, the men in these communities said ‘ah you have women doctors; you are doctors, and they said, ‘yes, yes’, they say, ‘okay you can see the women whenever you want’. So amazing rapport developed between them and the women were very pleased and so were their kids and a Cuban doctor told me that they said to us, ‘where do you come from you people?’ and she said, ‘we come from Cuba’. ‘Where is that?’, and she said, ‘it’s a tiny island in the Caribbean’ and they said, ‘who is your leader? I mean who/what is the government’. So they were careful because they were on a medical mission but they said, ‘do you want to see a picture of Fidel Castro who is our leader’ and said ‘yes’. So they showed a picture of Castro and the women said, ‘my god, he’s got a beard like they have in that village 20 miles from here, do you want to go and see those beards’. [laughs]. But they were incredibly impressed and the entire media in Pakistan was talking about what they’d done, they said we don’t want any help from the government, we arrive with our tents, our equipment, all we want is receptacles in which we can heat clean water and the rest we will do; we will bring our medicines with us. And the thing is this is the other point which rises that unlike the health services constructed in Western Europe after the 2nd World War including the National Health Service, the governments in these countries never actually set up pharmaceutical industries to compliment those health services. Nor did they even seriously consider nationalising them, because that would have brought the prices of medicine right down and they need never have charged prescriptions. So let’s come for a minute to a subject you know very well – the health service in Britain and in the European Union countries, I mean what is happening to that Allyson? It is one thing to talk about Africa but what is happening to the health services in Europe.
Allyson Pollock: What is happening now in Europe as many people are aware is that, we have got neoliberal policies coming from the US both the health care industry in the US, which have exhausted the funds of America because health care is running it about 18, 18% of GDP, compared with 9 or 10% average in Europe, so the European health care investors need to find new markets and they are busy attempting to penetrate and open up the health care systems of Europe. And of course the biggest trophy for them is the United Kingdom NHS because it was for a long time the most socialised of all the health care systems. So we’ve had devolution; so Scotland, Wales and England all have their own health care services and Scotland and Wales which are very tiny, they don’t cover more than 8 or 9 million people, they have retained a national health service but England, which many people don’t realise this, England abolished its national health service in 2012 with the Health and Social Care Act. What remains of the NHS is a funding stream, or a government pair, and the NHS has now been reduced to a logo and what the government is now doing is accelerating a break up of what remains of the national health service under public ownerships, so closing hospitals, closing services and privatising or contracting out. So just as we heard in Liberia and Guinea about how the public lands are being transferred like the enclosures to private owners from abroad, the same thing is happening with our pubic services, our public hospitals, our public facilities are also being enclosed in a way and given over to private-for-profit investors and this is happening in extraordinary speed in England. Faster than anywhere in Europe. And this is a major global neoliberal project, if you like.
Tariq Ali: To privatise health.
Allyson Pollock: Well to privatise not just the healthcare system but also ultimately the funding. Now in the US, just under half of that 18% GDP is actually paid for by the government but the government is in effect a tax payer and then channels the money into private-for-profit corporations. The government in England abolished the health and social care act because it wanted to open up new funding streams. So it wants to reduce the level of services that are available publically, create a climate of discontent with the NHS, forcing people who are in the middle classes, that’s like you and me Ali, to go and privately and pay either out of pocket or with our healthcare insurance, so that we desert, we exit what is left but at the same time the government is reducing all our entitlements because there is no longer a duty to provide universal healthcare. That duty that has been in place since 1948 was abolished in 2012. So that duty has now gone and so now the government can reduce all the entitlements, reduce everything that is available and increasingly we are going to have to pay out of pocket or though private health insurance. And the private health insurance industry are here, they are here form the US and they are absolutely gearing up with the new structures the government has put into place to move into private-for-profit health insurance; that is what we are going to be seeing. And actually the new system the government is putting in place is modelled on the US and yet that will come at huge loss and it will also be a public health catastrophe because it will mean that many, many millions will increasingly go without care and of course markets render people invisible, they are not seen. Nobody knows. The doctor in front of you only sees the patient that come to them; it doesn’t see the many tens of thousands who are being denied access to healthcare, which is why in the US the doctors are not out on the street campaigning. But in the UK the doctors are out on the street campaigning, they are putting in, they are standing now for the National Health Alliance Party, they are now putting in candidates to stand against the conventional parties. And so you see that the doctors are still prepared to fight for universal health care but once our NHS has gone completely, it’s been abolished, but once all the remnants have gone, you have to use the parallel of the oak tree, it seems to be blooming and flourishing but the roots have been severed and that can take many months or years for that to completely decay. But once it has gone the doctors will no longer be there. They’ll be like the doctors in the US interested in themselves, interested in their own pockets and not interested in universal access to healthcare. And this is the crime of the century, if you like, the way in which the English coalition, both Conservative and Liberal Democrat, have actually abolished our NHS but they have had a lot of help along the way from the Labour government before them.
Tariq Ali: Labour more or less set the basis for it when they were in power.
Allyson Pollock: Absolutely. Alan Milburn the Health Secretary did this in in 2000. In 1997 the Labour government had its, had its chance to reverse the privatisation and marketization policies, to get rid of the private finance initiative and they had a very good Secretary of State who was quite determined to some of that….
Tariq Ali: Frank Dobson?
Allyson Pollock: Frank Dobson. But they got rid of him extra quick and instead of which we got Alan Milburn and his ten-year plan and now he has gone off to join the very healthcare companies that he helped to build up. And I mean I think that is the tragedy as when that bill was going through parliament to abolish the NHS, many of the peers, and many of the MPs had conflicts of interests because they had actually interest in the healthcare companies that they were establishing.
Tariq Ali: It is outrageous really. And Milburn himself is one of them.
Allyson Pollock: Well, it is a travesty for democracy, it really is and as a public health doctor it is an absolute catastrophe because at the moment we know, people of all ages, with serious mental illnesses who cannot get access to health care, people with stroke, people with chronic illnesses, chronic diseases who are increasingly being denied access to healthcare and they are voices in the wilderness, they are not being heard because there is no collective mechanism for them to be heard any more. And the doctors and nurses are absolutely in despair. Now we do have solution; my colleagues we’ve written an NHS reinstatement bill which we hope that whichever party comes to power, they will actually run with to reinstate the NHS, so there is a solution out there, which is drafted and written and ready, that would restore and reinstate the NHS.
Tariq Ali: It is perfectly legitimate to make huge profits from the basic needs of ordinary people?
Allyson Pollock: Yes from people’s diseases and people’s illnesses. Well it began with a pharmaceutical industry and the vaccine production, it is perfectly acceptable to make profits from them, so why shouldn’t we now go and make profits from illness and care. But of course the NHS in England was set up, to be redistributive. It’s funded through taxation, which is meant to be progressive and the money is meant to flow according to need. But what we are now beginning to see is that money will flow according to the needs of shareholders and not patients, and that is a very real concern. Of course. It is all down to political will. Everything can be reversed but it comes down to politics, to democracy and people making their voices heard.
Tariq Ali: Agreed.
Allyson Pollock is professor of public health research and policy at Queen Mary University of London.
Tariq Ali is the author of The Obama Syndrome (Verso).