Iatrogenic Imperialism

The following is an extract from Émile St-Pierre’s chapter, “Iatrogenic Imperialism: NGOs and CROs as Agents of Questionable Care,” published in Good Intentions: Norms and Practices of Imperial Humanitarianism (Montreal: Alert Press, 2014), pp. 37-55:

Overview: Émile St-Pierre examines the role of NGOs and Contract Research Organizations (CROs) in the formation and propagation of a neoliberal paradigm in health care. As St-Pierre explains, neoliberal policies beginning in the 1980s forced many states to retract from health care provision. NGOs and CROs have emerged as gap fillers in the wake of these policies. The activities of NGOs and CROs in conjunction with states and pharmaceutical corporations produce changes in the everyday lives of people, offering new possibilities for some at the same time that they dominate and classify populations in new ways. NGOs, CROs and the actors they are tied to, rely on patterns of illness and inequality to continue existing, and securing revenues. Iatrogenic imperialism is used by St-Pierre as an analytic to bring to light the way “good intentions,” expertise and humanitarianism play into efficiency-driven, neoliberal configurations of health care that fail to produce benefits for all, that undermine public health systems and that tend to reproduce global inequalities. In exploring the roles of lesser-known but increasingly important actors in health care worldwide, St-Pierre’s research critically analyzes some of the newest phenomena in the neoliberal turn health care has been experiencing and speaks to their penetration into the everyday lives of people.

NGOs and the Neoliberal Healthcare Regime

With the retreat of the state in many countries of the Global South, NGOs have stepped in to fulfill some of its roles. As organizations that are not elected by the people they are helping, their direct accountabilities lie elsewhere. In many respects NGOs do function a bit like modern states: NGOs often adopt managerial practices oriented towards efficiency to maximize their humanitarian objective to save as many lives as possible. It should be clear in stating this that I am not referring to all NGOs and all their practices, but certain influential NGOs and prominent tendencies in humanitarian practice. The practices of NGOs have many effects: they fill gaps and give legitimacy to the state while also undermining state governance (as previously argued), they can inflate housing costs, and they offer opportunities for advancement for middle-class, public sector workers in the Global South which reproduces global inequalities (Schuller, 2009, pp. 85, 87, 92, 97).

However, these are only some of the externalities of the capillary forms of therapeutic domination that take place when NGOs exert the power over life and death in situations of emergency. HIV/AIDS treatment programs offer a good example of what I mean. Lack of access to treatment for HIV/AIDS became a global humanitarian emergency in 2000. Vinh-Kim Nguyen (2009) argues that it was biomedical advances in therapy and diagnosis that allowed decades of neglect to be reframed as a crisis (pp. 196, 200). The newly-constituted HIV emergency invited intervention from NGOs in the name of saving lives. Ironically, their actors and even their tasks are increasingly seen as indistinguishable from those of intervening military forces. Indeed, both are concerned with the management of populations to ensure that lives are saved (Nguyen, 2009, p. 201). In the case of HIV, massive treatment programs have involved enrolling patients, deploying unprecedented funding, drugs and technologies to better manage the well-being of populations of individuals with the most intimate detail.

PEPFAR (President’s Emergency Plan for AIDS Relief) launched under George W. Bush, became the prime example for the administration of its humanitarian foreign policy (Nguyen, 2009, pp. 202–203). Its implementation was mostly left to local faith-based organizations advocating abstinence and fidelity as prevention measures, part of a set of intimate technologies deployed in order to save lives that change the way people care for and talk about their bodies and their families. Though PEPFAR differs in its singularity from assemblages of NGOs, it operates in a similar mode of therapeutic domination (Nguyen, 2009, pp. 204–205; McFalls, 2010, p. 318).

To prove the effectiveness of treatment, certain measures of efficiency like the number of lives or years of life saved then become the basis for experimentation and the generation of evidence in staying accountable to funders (Nguyen, 2009, pp. 209, 211). NGOs must often attract funding from external sources like USAID, which has led to accusations of them being subcontractors for foreign powers as their projects may reflect the priorities of their funders more than grassroots demand (Landolt, 2007, p. 707).

The measures used to explain effectiveness and intervention go beyond the usual humanitarian concern for bare life, that is the number of lives saved (McFalls, 2010, p. 324). Other measures such as quality-of-life have become important for NGOs working in India in the field of HIV/AIDS, moving beyond its past as a measure of development to become a justification for intervention. Measures such as these minimize the need for political coercion as people become empowered to see their actions as a sort of entrepreneurial maximization of their own health. Empowerment has a history in biomedicine going back to the 1970s. It emerged out of concerns for efficiency of public health promotion and the limits of biomedicine, leading to a focus on making people responsible for their own health and empowered to change unhealthy habits (Lock & Nguyen, 2010, p. 295). In this case of HIV/AIDS in India, quality-of-life empowerment is a strategy to regulate peoples’ behaviour embedded in a neoliberal program of health governance (Finn & Sarangi, 2008, pp. 1569–1570).

It is thus unsurprising that health should be advocated as important to US foreign policy. A report co-sponsored by the Council on Foreign Relations established that the US promoting global public health would be a means of preventing infectious diseases from reaching the US in a time of increased mobility. It would also improve political instability crucial to maintaining economic flows. Surveillance and treatment systems become justified in claiming strategic and moral benefits (Kassalow, 2001). The 2010 US National Security Strategy further emphasizes that pandemic diseases are threats to the US and its citizens, and that the US should seek to create a stable international order for its own interests, but also as an end to be sought in and of itself (White House, 2010).

Interestingly, some of the most influential NGOs have significant ties to US state agencies and major corporations. The ones I allude to here are fairly widely known: Christian Action Research and Education International (CARE International) and Save the Children. CARE’s areas of concern include water sanitation, economic development and emergency response. Their total assets and liabilities for 2012 amount to €500 million. Their partners include many UN agencies, including the World Bank, as well as development agencies, including CIDA and USAID, from many governments of the Global North. Their corporate sponsors are unlisted (CARE, 2012; CARE, 2014). However, the current Chairperson of CARE, Ralph Martens, is a former vice president at Merill Lynch (SourceWatch, 2014a) and the Chairperson before him, Lydia Marshall, had previously worked as a vice president for Citigroup (SourceWatch, 2014b).

Save the Children is another relief-oriented organization. It discloses its numerous corporate partners on its website. These include GlaxoSmithKline, the Merck Foundation, Disney, Mattel, Goldman Sachs and Johnson & Johnson (Save The Children [STC], 2014). However they also receive hundreds of millions of dollars from governments according to a 2005 financial form. Save the Children subsequently retracted the form from their website, obscuring the staggering US $149 million contribution by USAID (SourceWatch, 2014c).

GlaxoSmithKline, a multinational pharmaceutical corporation, recently partnered with CARE International and Save the Children to increase its presence in the Global South. GSK’s CEO framed this move in terms of investing in a region where profits were relatively low and where they could “make a difference” (World Pharma News, 2011). Save the Children’s Chief Executive called GSK’s move brave and said it would help their top priority of “saving the lives of some of the poorest children of the poorest communities” (World Pharma News, 2011).

Further blurring the line between profitable investment and humanitarianism is the Partnership for Quality Medical Donations (PQMD). The executive director of this organization, in a speech entitled, “The Evolving Role of NGOs in the Pharmaceutical Industry’s Product Donation Programs,” claims that the Global South’s markets offer not just an opportunity for future profit, but also the opportunity for “this magnificent industry to show its concern for the world community as a whole, even to the poorest among us” and ensuring some “victory for humanity” (Russo, 2004, p. 1). The mobilization of humanitarian sentiment is quite clear here.

After the WHO changed their guidelines for drug donations in 1999 in favour of the PQMD’s recommendations, a 2001 WHO study conducted in emergency countries like Mozambique and India found that those in violation were governments and local distributors, not major pharmaceutical corporations and experienced NGOs (Russo, 2004, pp. 2–5). Instead of examining the pressures the pharmaceutical industry-NGO alliance itself has placed on governments and local distributors and the way it has turned the pharmacy into the primary site of healthcare after the retraction of the state in countries like India, this statement makes an appeal to efficiency and an objective humanitarian good (Kamat & Nichter, 1998, pp. 779–780). Their position could be summarized in this way: our experts are better at delivering these inherently good drugs according to the best guidelines and those local amateurs are guilty of irrational and iatrogenic drug donation practices (since they may harm those who consume them). I use iatrogenic here to illustrate its usage as a term of power in medical discourse that pathologizes local practice while obscuring the influence of the experts in fostering these irrational and harmful practices.

References

CARE. (2012). Annual Report 2012. Geneva: Care International.
http://www.care.org/newsroom/annual-reports

───── . (2014). Partners and Donors.
http://www.care-international.org/about-us/partners.aspx#.U0cVxqLn_0l

Finn, M., & Sarangi, S. (2008). Quality of Life as a Mode of Governance: NGO Talk of HIV ‘Positive’ Health in India. Social Science & Medicine, 66(7), 1568–1578.

Kamat, V. R., & Nichter, M. (1998). Pharmacies, Self-Medication and Pharmaceutical Marketing in Bombay, India. Social Science & Medicine, 47(6), 779–794.

Kassalow, J. S. (2001). Why Health is Important to U.S. Foreign Policy. Council on Foreign Relations & Milbank Memorial Fund.
http://www.milbank.org/uploads/documents/Foreignpolicy.html

Landolt, L. K. (2007). USAID, Population Control, and NGO-led Democratization in Egypt: The Fate of the ICPD Programme of Action. Democratization, 14(4), 706–722.

Lock, M., & Nguyen, V.K. (2010). An Anthropology of Biomedicine. Oxford, UK: Wiley-Blackwell.

McFalls, L. (2010). Benevolent Dictatorship: The Formal Logic of Humanitarian Government. In D. Fassin, & M. Pandolfi (Eds.), Contemporary States of Emergency: The Politics of Military and Humanitarian Interventions (pp. 317–334). Brooklyn, NY: Zone Books.

Nguyen, V. K. (2009). Government-by-exception: Enrolment and Experimentality in Mass HIV Treatment Programs in Africa. Social Theory & Health, 7(3), 196–217.

Russo, J.B. (2004). The Evolving Role of NGOs in the Pharmaceutical Industry’s Product Donation Programs. The Partnership for Quality Medical Donations.
http://www.marcopolodesign.com/pqmd/resources_other_s2.html

Save the Children (STC). (2014). Corporate Partners.
http://www.savethechildren.org/site/c.8rKLIXMGIpI4E/b.6148397/k.C77B/Corporate_Partners.htm

Schuller, M. (2009). Gluing Globalization: NGOs as Intermediaries in Haiti. PoLAR: Political and Legal Anthropology Review, 32(1), 84–104.

SourceWatch. (2014a). Ralph Martens.
http://www.sourcewatch.org/index.php/Ralph_Martens

───── . (2014b). Lydia M. Marshall.
http://www.sourcewatch.org/index.php/Lydia_M._Marshall

───── . (2014c). Save the Children USA.
http://www.sourcewatch.org/index.php/Save_the_Children_USA

White House. (2010). National Security Strategy. Washington, DC: White House.
http://www.whitehouse.gov/sites/default/files/rss_viewer/national_security_strategy.pdf

World Pharma News. (2011). GSK Forms Partnership with Three Leading NGOs.
http://www.worldpharmanews.com/gsk/1689-gsk-forms-partnership-with-three-leading-ngos%20%28CARE%20and%20Save%20the%20Children%29

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