Blind Spot

Blind Spot: How Neoliberalism Infiltrated Global Health

Salmaan Keshavjee
Foreword by Paul Farmer
Copyright Date: 2014
Edition: 1
Pages: 288
https://www.jstor.org/stable/10.1525/j.ctt7zw08k
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  • Book Info
    Blind Spot
    Book Description:

    Neoliberalism has been the defining paradigm in global health since the latter part of the twentieth century. What started as an untested and unproven theory that the creation of unfettered markets would give rise to political democracy led to policies that promoted the belief that private markets were the optimal agents for the distribution of social goods, including health care.A vivid illustration of the infiltration of neoliberal ideology into the design and implementation of development programs, this case study, set in post-Soviet Tajikistan's remote eastern province of Badakhshan, draws on extensive ethnographic and historical material to examine a "revolving drug fund" program-used by numerous nongovernmental organizations globally to address shortages of high-quality pharmaceuticals in poor communities. Provocative, rigorous, and accessible,Blind Spotoffers a cautionary tale about the forces driving decision making in health and development policy today, illustrating how the privatization of health care can have catastrophic outcomes for some of the world's most vulnerable populations.

    eISBN: 978-0-520-95873-9
    Subjects: Anthropology

Table of Contents

  1. Front Matter
    (pp. i-x)
  2. Table of Contents
    (pp. xi-xii)
  3. List of Illustrations
    (pp. xiii-xiv)
  4. Foreword
    (pp. xv-xxviii)
    Paul Farmer

    It is rare that a scholarly work can be called soul-searching as well as wrenching, butBlind Spot, by physician-anthropologist Salmaan Keshavjee, is just such a book. Based on ethnographic research conducted after the collapse of the Soviet Union, in a remote and mountainous part of Central Asia at the margin of armed conflict, this is a haunting account of a goodwill effort to replace an inadequate public health system with a “sustainable” (and privatized) one. This new system is to be based, Keshavjee learns, on a post-Communist ideological framework even more impervious to course correction than the one preceding...

  5. Preface
    (pp. xxix-xxxii)
  6. Acknowledgments
    (pp. xxxiii-xxxviii)
  7. MAP
    (pp. xxxix-xl)
  8. 1 Introduction: A WORLD TRANSFORMED
    (pp. 1-18)

    Spring in Badakhshan can be hauntingly beautiful. Ahmed and I had been traversing Tajikistan’s Pamir Mountains for a week in an old Russian jeep when we paused at a juncture in the road to look at our map. I gazed out at the desolation of an almost treeless mountainside—endless rock formations standing in stark contrast to a powder blue sky—whose heights concealed roaring rivers, fertile pastures, and in the lower areas, small orchards. The local people say that when God created the world, he gave everybody something they could use. But by the time Badakhshan’s turn came, almost...

  9. PART I THE BEGINNING OF THE ENCOUNTER:: THE SOVIET WORLD MEETS ITS GLOBAL COUNTERPARTS
    • 2 Health in the Time of the USSR: A WINDOW INTO THE COMMUNIST MORAL WORLD
      (pp. 21-37)

      Even a casual reader of Russian and Soviet literature is likely to be struck by its frequent and detailed invocations of country doctors, epidemics, surgery, sanitariums, infection, bloodletting, consumption, asylums, midwives, and madness. The works of Pasternak, Gogol, Dostoyevsky, Pushkin, Turgenev, Solzhenitsyn, and Tolstoy reflect an interest in medical subjects that occasionally borders on the obsessive. Several of Russia’s greatest literary figures—notably Chekhov and Bulgakov—were themselves physicians. Perhaps it is fitting that a society at once so culturally advanced and so linked to a history of rural poverty should be preoccupied with medicine, which represents a kind of...

    • 3 Seeking Help at the End of Empire: A TRANSNATIONAL LIFELINE FOR BADAKHSHAN
      (pp. 38-46)

      It is nearly impossible to travel to Badakhshan without pausing to wonder how anyone came to live there in the first place. Whether taking the long-abandoned Silk Road route through the Murghab Desert from Osh in the Kyrgyz Republic—a rugged thoroughfare once patrolled by leopards, vultures, and the magnificent Turanian tiger—or the equally forbidding mountain passes stretching east from the Tajik capital of Dushanbe, one is forced to conclude that such a journey into the void would only be made under duress. And indeed, the history of human settlement in the region is a dismal catalogue of conquest,...

  10. PART II LIFE AT THE END OF EMPIRE:: THE CRISIS AND THE RESPONSE
    • 4 The Health Crisis in Badakhshan: SICKNESS AND MISERY AT THE END OF EMPIRE
      (pp. 49-66)

      My field assistant Ahmed and I sat with Moom, Rais’s mother, in his traditional Pamiri house.¹ Soot covered the walls and ceiling, leaving a smoky scent in the air, though no fire was burning. Rais and Rahmatekhudo, his best friend from childhood, served us tea while Rais’s children looked on from behind one of the five posts holding up the roof. As we sat on cushions laid on the floor and sipped from our cups, Moom, Rais, and Rahmatekhudo reminisced about the many ways Kuhdeh had changed during their lifetimes—their recollections clouded, no doubt, by the turbulent times they...

    • FIGURES
      (pp. None)
    • 5 Minding the Gap? THE REVOLVING DRUG FUND
      (pp. 67-82)

      As we walked out of a meeting with the team from the Canadian International Development Agency in the summer of 1996, Robert Middleton, the architect of AKF’s humanitarian assistance program in Badakhshan and a senior member of AKF’s Geneva office, patted me on the back. “That went well,” he said.

      I was not sure what to think. The meeting, held at the Pamir Relief and Development Programme (PRDP) guesthouse—set along the shore of the Ghund River, its green waters providing a low rushing sound in the background as it flowed into the much bigger Panj River—was the culmination...

  11. PART III TRANSPLANTING IDEOLOGY:: VILLAGE HEALTH MEETS THE GLOBAL ECONOMY
    • 6 Bretton Woods to Bamako: HOW FREE-MARKET ORTHODOXY INFILTRATED THE INTERNATIONAL AID MOVEMENT
      (pp. 85-99)

      Bretton Woods, New Hampshire, is far from Bamako and even farther from Badakhshan. Yet it was there, ensconced amid the beautiful views and craggy ridges of the White Mountains of the northeastern United States, that the seeds were planted for what emerged in the revolving drug fund proposal more than fifty years later.

      The United Nations Monetary and Financial Conference, held at Bretton Wood’s regal Mount Washington Hotel—a Spanish Renaissance-style building whose interior was said to have taken 250 master craftsmen two years to complete—was no small event, drawing together 730 delegates from 44 nations for the first...

    • 7 From Bamako to Badakhshan: NEOLIBERALISM’S TRANSPLANTING MECHANISM
      (pp. 100-110)

      In his 1904 account of the second Danish expedition to the Pamir Mountains,Through the Unknown Pamirs, explorer Ole Olufsen described Badakhshan’s interaction with the outside world as being “slight,” “partly by reason of the secluded situation of the provinces, shut off as they are from civilization by the most mighty mountains of the world, and partly on account of the poverty of the people.”¹ As mighty as they were, the mountains of Badakhshan were not high enough to prevent neoliberal ideas from penetrating into one of the remotest parts of the Soviet empire in the aftermath of its collapse....

  12. PART IV THE AFTERMATH:: NEOLIBERAL SUCCESS, GLOBAL HEALTH FAILURE
    • 8 Privatizing Health Services: REFORMING THE OLD WORLD
      (pp. 113-123)

      British prime minister Margaret Thatcher famously noted that “freedom is not synonymous with an easy life…. There are many difficult things about freedom: It does not give you safety, it creates moral dilemmas for you; it requires self-discipline; it imposes great responsibilities.”¹ This could not have been truer than for the inhabitants of Badakhshan, the older generation of whom likened the post-Soviet period to the famine and hardship following the Second World War.

      And in the midst of that struggle, it was clear by the summer of 1996 that the revolving drug fund proposal was moving forward regardless of whether...

    • 9 Revealing the Blind Spot: OUTCOMES THAT MATTER
      (pp. 124-135)

      It took almost a year after deciding in 1996 to proceed with the revolving drug fund before it was implemented. By the time the program began in Khorog in 1997, I had left Badakhshan. Under a new name—Rationalizing Pharmaceutical Policy and Management (RPPM)—the revolving drug fund program expanded one district at a time over the next four years, until by December 2000 all of Badakhshan’s seven districts were included. In its final project evaluation, AKF reported that by January 2004, only 50 percent of the cost of the medicines purchased for the program were being recovered from patients;...

  13. 10 Epilogue: REFRAMING THE MORAL DIMENSIONS OF ENGAGEMENT
    (pp. 136-144)

    Neoliberalism has been the defining paradigm in global health since at least the late 1970s. Because of the untested and unproven belief that the creation of unfettered markets constitutes an economic form of political democracy, neoliberalism—particularly neoliberal economics—was conceived as a bulwark against totalitarianism and the rise of a strong, centralized state.¹ The ideology reached its political and policy zenith in the late 1980s, overlapping the collapse of the Soviet Union. For many, this was no coincidence and represented the victory of capitalism over communism, of the individual over the communal, and of liberalism over totalitarianism.²

    For the...

  14. Notes
    (pp. 145-184)
  15. Bibliography
    (pp. 185-230)
  16. Index
    (pp. 231-240)