By Devi Sridhar
In September 2016, a new major project funded by the Wellcome Trust titled ‘The Economic Gaze: The World Bank’s Influence in Global Pubic Health’ was launched at the Global Health Governance Programme in Edinburgh. In this blog post, I outline our central research questions and the relevance of the project to both academia and policy.
What are we studying
Over the past 43 years, the World Bank has become (in most years) the largest financial contributor to health related projects and is arguably the most important player in international health cooperation. Other than as a lending agency, the Bank has innumerable unofficial functions in global health such as an advisory body, an intellectual research institute and a training centre for developing country civil servants. Symbolically, the World Bank is the arbiter of development norms and meanings combining intellectual prestige and financial power. But the Bank’s legacy is controversial with academics and NGOs critical of its role in perpetuating inequality, such as through its former support of structural adjustment programmes and user fees.
We started planning this project in 2014, the 40th anniversary of the Bank's first loan to health for the onchocerciasis (riverblindness) control program. We examine two broad questions of relevance not only to international institutions but also global public health policy.
First, what has the Bank contributed over the past 40 years in terms of finance, ideas and networks, and how effective has this contribution been?
Second, how has the Bank's increasing involvement in health as an international financial institution transformed how we think about health? What have been the positive (e.g. quantifiable, measurable, relevance to Ministries of Finance) and negative (e.g. neglect of social justice, equity and local concerns) aspects of this involvement?
We have identified five periods in the Bank’s history to reflect changes in its approach. Throughout each of these periods, we are conducting analyses on what the Bank effectively contributed with a particular focus on how its involvement as an economic institution impacted the field of health policy globally as well as the conceptualization of health. Specific case studies have been chosen within each of the three areas of finance, knowledge and cooperation.
Economics & Health Policy
In my first book the Battle against Hunger: Choice, Circumstance and the World Bank, I focused on the creation of nutrition metrics in the late 1970s.
Econometrics is the application of statistical and mathematical methods in the field of economics to describe the numerical relationships between key economic forces such as capital, interest rates and labour. In the push to convince Bank managers to fund nutrition, a metrics of nutrition was created in which theoretical models were used to draw relationships between nutritional gains, labour, discount rates and productivity. Using these models, the previously unquantifiable such as the value of years of lost life, or disability-free life years could be numerically expressed and thus be entered into calculations. This dialogue is the only one that is permitted and used in the Bank. This can be viewed as an econometrics of suffering, the situation where mathematical analysis of production relationships was used to determine the magnitude of nutritional deprivation which provides justification for spending to alleviate this destitution.
This preoccupation with quantitative analysis within the Bank influenced approaches to health and development widely. Particularly the 1993 World Development Report: Investing in Health solidified economics as one of the main tools used by governments to design health policy. Within the powerful institution of the Bank, the twin hegemonies of biomedicine and health economics interlaced to form what became an unquestioned approach to development within key donor countries. When examining the history of public health policy, a shift can be observed from the dominance of medicine (the clinical gaze, which Michel Foucault discussed in his 1963 book The Birth of the Clinic) to epidemiology (the community gaze which David Armstrong discussed in his 1983 book Political Anatomy of the Body), and finally to economics (the economic gaze).
The economic gaze refers to the process by which those individuals working within public health, as well as the beneficiaries of public health projects, are disciplined and regulated through an overriding concern with productivity and economic growth. This results in a situation where policy makers must design projects in a manner consistent with human capital and other economic principles. For beneficiaries, the body is constructed as having little to no value outside of its role in the global economy.
A manifestation of the economic gaze is the emphasis placed in health policy on human capital, which conveys a metaphor of an individual having worth solely as a result of his or her contribution to the economy. Human capital theory is used to justify the creation of target groups, such as preschool children or pregnant women, in whom improved health will have the strongest impact on productivity. These target groups are economic constructs in which individuals become beneficiaries or individuals at risk on the basis of on a single characteristic, such as age or pregnancy status.
Such groups are defined by the age and gender that will have most impact on economic growth in the future. For example, during the 9 months of pregnancy and first 6 months of breastfeeding, a woman becomes a target for nutrition interventions. The predominant reason for this inclusion is that it is during these stages that a woman is constructed as a mother or future mother. She must ensure the health of a future member of the work force. If only her health were to be valued, then a woman would receive health services and food supplements irrespective of her pregnancy status. This is not the case as non-pregnant, non-lactating women are often not included as beneficiaries.
However, this logic is problematic as it trivializes pain and suffering and treats health as if it is like any other commodity. For example, former World Bank lead economist Philip Musgrove said in an interview, "What's unusual about health is just that it’s a peculiar asset, because you can't sell it, you can't give it away, you can't get many spare parts for it, and while your body is in the hospital, you can't go get a loaner body the way you can when your car is in the shop. The biology never goes away, but the economics has to be there". How does one reconcile pricing health as a commodity with the fact that there is no monetary amount that most individuals would accept to give up his/her life? We cannot produce disability-adjusted life years (DALYs) or buy them on the market.
We hope the research from our project over the next few years will be useful not only to those concerned about the World Bank, but all those who think about the value of human life and the dominant role of economics in decision-making around the world.