This assignment entails a critical reflection and analysis of an issue. This is a brief (3 pages; APA Style) discussion, rather

Global Prescriptions Gendering Health and Human Rights

Rosalind Pollack Petchesky

Zed Books LONDON & NEW YORK

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United Nations Research Institute for Social Development

Global Prescriptions was first published in 2003 by Zed Books Ltd, 7 Cynthia Street, London N1 9JF, UK and Room 400, 175 Fifth Avenue, New York, NY 10010 www.zedbooks.demon.co.uk

In association with the United Nations Research Institute for Social Development (UNRISD), Palais des Nations, 1211 Geneva 10, Switzerland www.unrisd.org

© Rosalind Pollack Petchesky, 2003

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Second impression, 2005

Managing Health Under Globa! Capitalism Equity vs Productivity

Poor people have few assets in part because they live in poor countries or in poor areas within countries. They also lack assets because of stark inequalities in the distribution of wealth and the benefits of public action. (The World Bank 2000/2001: 77)

In the end, it may very well be that global business rules, while govern­ ments and international organizations are left to manage people and soften the harshest consequences of globalization, especially for marginalized groups, including women. (Meyer and Prugl 1999: 16)

‘Globalization’ = global capitalism

In the previous chapter, I situated the lags in South Africa’s recent policies regarding access to treatment for HIV/AIDS, and specifically the policies of its current President, Thabo Mbeki, within a historically specific sexual and gender culture. But Mbeki’s reluctance to adopt a strong and aggressive stance vis-a-vis the Northern pharmaceutical companies and on behalf of South African people’s right to the highest attainable standard of treatment has other motives as well: winning South Africa’s acceptance as a first-string team player within the existing power structure of the global economy.

Timed to coincide (and gain favour) with the G-8 meeting in Canada in June 2002, Mbeki announced the plan of African heads of state across the political spectrum to form a new regional governance entity called the African Union (AU), linked to a ‘New Economic Partnership for Africa’s Development’ (NEPAD). This entity would be based on principles of democracy, free elections, human rights, self-reliance and open markets. It would maintain the right of collective intervention to stop genocide and war

crimes in the region. Above all, it would seek to secure debt relief and ‘increased access to Western markets and foreign aid and investment’ in African countries ‘that embrace democracy’. Replaying the historical game of imitating the colonizers, its leaders boast that the new African Union will be ‘modelled on the European Union’, including a regional parliament, a central bank and a standing army to handle disputes (Swarns 2002a, 2002b; Mbeki 2002). Mbeki – as the AU’s foremost spokesman – remains conspicuously silent on the subject of HIV/AIDS as he courts the masters of global capitalism to be recognized as a ‘partner’ (if a junior partner) in their club. An opposition statement by African civil society organizations contends that, behind its rhetorical homage to ‘democracy’, the AU/NEPAD is ‘a top-down programme driven by African elites and drawn up with the corporate forces and institutional instruments of globalization, rather than being based on African peoples’ experiences, knowledge and demands’ (‘Declaration on NEPAD’ 2002). It thus becomes just one more sign of the hold that global capitalism, or ‘globalization’, has on nearly all governments in the South.

Critics of the macroeconomic and cultural trends commonly referred to as globalization disagree about the extent to which those trends represent deep- rooted continuities with previous forms of capitalism and imperialism or a fundamentally new historical era.1 Some recent analysts even raise unsettling questions of nomenclature, suggesting that the very term is an obfuscation that means everything and hence nothing; in Bauman’s words, ‘a fad word fast turning into a shibboleth, a magic incantation, a pass-key meant to unlock the gates to all present and future mysteries’ (1998: 1). Others make a more radical structural critique, arguing that this catch-all term is really a euphemism meant to cover over the enormous inequities, power imbalances, and forms of capitalist exploitation now centred in a US-based empire and a new form of international sovereignty: ‘a unitary power’ that purveys ‘a new notion of right’; that centrally regulates ‘both the world market and global power relations’; and that treats every imperial war as ‘a civil war, a police action’ (Hardt and Negri 2000:9, 11).

The term ‘globalization’ certainly obscures more than it reveals, lending an aura of inevitable progress and irreversibility to very diverse phenomena that are often both regressive and changeable. At the same time, without denying the vastly disproportionate power and imperialist aims wielded by the US state and US-based corporations within this matrix, I find the concept of ‘empire’ both fatalistic and not particularly useful to describe a historical period of capitalist hegemony that is still more porous, fluid, contradictory,

and multi-centred than that concept implies. So throughout this discussion I shall substitute the term global capitalism for globalization, while sympathizing with those who see in the recent anti-globalization movement, with all its polyglot fragments and perspectives, a vibrant force for positive change.2 Wherever they stand on terminology, the various critiques of global macroeconomic and cultural patterns in the twenty-first century seem to unite around several common themes:

• ‘hypermobility of capital’ (Smith 1997: 175) (‘capitalist markets penetrate and exploit every pocket of available space’- Eisenstein 1998: 121), along with the commodification of everything and the integration of capitalist markets and financial transactions everywhere;

• ‘liberalization’ of trade, abetted by international organizations like the WTO and the IMF, whose role is to administer structural adjustments, tariff reductions, the transition to export-oriented economies, and the opening of markets (Barker and Mander 1999);

• a unipolar world, since the fall of the former Soviet Union has left the US as the single superpower and self-appointed commercial, military and ideological centre of global capitalism;

• explosion in the use of electronic communications and information technology, contributing to the acceleration of financial flows, cultural flows and transnational organizing;

• loosening of national and regional boundaries, so that people, goods, money, information and ideas – but also viruses, pollutants and arms – move more rapidly and fluidly around the globe (Appadurai 1996; Smith 1997);

• weakening of the modern nation-state, which has ceded much of its power to both transnational corporate and international financial actors (O’Neill 1995; Appadurai 1996; Eisenstein 1998; Sassen 1998); and

• centrality of privatization to the entire process, involving abdication by the state of its public welfare and social service functions to the private sector and transformation of the state into primarily a conduit and increasingly a police and military apparatus to ease the transnational flow of capital and goods (Taylor 2002).

Rather than an ‘empire,’ which still connotes an overarching structure whose shape is hierarchical and whose centre is clearly visible, this panorama

suggests an amorphous but all-encompassing network – Hardt and Negri analogize it to a rhizome – in which the staple distinctions and boundaries of modernity dissolve. As Richard Parker (1999) puts it,

notions of North and South, the developed as opposed to the developing world, center and periphery, the first world and the third world, and so on … fail to describe the ways in which the world is in fact experienced today…. [T]he contemporary globalized or globalizing, late-modern or postmodern world … is marked by processes of social, cultural, economic and political change that ultimately link both the West and the Rest as part of an interacting system.

Along with this erosion of boundaries across societies, regions and cultures comes an evaporation within societies of the distinction between public and private spaces, between ‘the social’ and ‘the individual’ or ‘personal’, that was modernism’s principal way of understanding itself. And with the demise of that distinction comes, not only the vulnerability of individuals and communities to constant (commercial, sexual, ideological, military) invasion and scrutiny, but also the converse: the disappearance of what Eisenstein calls the ‘idea of publicness’, that is, a sense of public obligations and social rights concerning the health and well-being of people and their environments (Eisenstein 1998; Hardt and Negri 2000). Approximating a form of neo­ feudalism, public obligation and social right devolve into charity.

Like modem industrial capitalism, global capitalism is not just a series of inexorable historical trends; it is also a set of neoliberal doctrines and precepts – called by some economic or ‘market fundamentalism’ – intended to legiti­ mate and consolidate those trends. The most orthodox among these is a belief – indeed a kind of blind faith – that ‘free, unfettered, “liberal” markets work perfectly’ (Stiglitz 2002: 74). Enfolded within this belief are several unproven assumptions: that, in the long run, markets and competition are the best solution to nearly all human needs; that the sine qua non of a good life for all societies is economic growth; and that there is ‘an automatic and inherently positive link between trade, growth and development’. In other words, trade and trade liberalization constitute the engine that will drive growth and therefore bring prosperity, magically creating the apocryphal ‘level playing field’ while assuming it already exists (Williams 2001a). As for the state, it shrinks to its irreducible function of maintaining public order, national security and a hospitable environment in which markets will prosper (including itself serving as a lucrative market for the private sector, in its

military procurement and sub-contracting capacities). Even in the realm of social service provision, the state does not disappear entirely. Rather, it becomes just one more vendor in a marketplace of competing providers; it loses its ‘public’ character.3

During the 1990s, many feminist transnational groups – such as DAWN, the International Gender and Trade Network, the Women’s International Coalition for Economic Justice and WEDO – joined other global justice organizations in challenging this neoliberal dogma on empirical as well as ethical grounds. In statements confirmed by volumes of UN data as well as the protests of poor people throughout Latin America, Asia and Africa, they have pointed out that, under conditions of corporate globalization, world poverty and the gaps between rich and poor both within and among countries continue to increase.4 At the upper end of this divide, ‘the 15 richest people in the world enjoy combined assets that exceed the total annual GDP of all of sub-Saharan Africa. At the end of the 1990s, the wealth of the three richest individuals on earth surpassed the combined annual GDP of the 48 least developed countries’ (Yong Kim et al. 2000: 14; UNDP 1998). Even more significant than individual wealth at the macroeconomic level is the increasing concentration of capital in private corporations. Reflecting this trend, the Human Development Report for 2000 states that ‘transnational corporations and their foreign affiliates produced 25 per cent of global output in 1998, and the top 100 … had sales totalling $4 trillion’. Put another way, more than half of the world’s 100 largest economies are corporate conglomerates, not nation­ states (Barker and Mander 1999). Meanwhile, small, low-income countries in Africa and the Caribbean find that their products – especially textiles, clothing, and agricultural goods – are still shut out of lucrative markets by Northern governments trying to protect their own farmers and industry (‘free trade’ for us but not for you). The ‘benefits’ of global market integration and liberalization accrue disproportionately to the most powerful countries and people, and these inequities receive tacit approval from the multilateral trade regime of the WTO (UNDP 2000a; Williams 2001a & b; Social Watch 2001).

How does all this translate into privatization? Citing World Bank figures, the UNDP also reports that ‘private investment as a share of gross domestic investment in low- and middle-income developing countries’ rose during the 1980s and 1990s ‘from 54 to 72 per cent in South Asia, 70 to 84 per cent in Latin America and the Caribbean, 52 to 68 per cent in sub-Saharan Africa and 51 to 55 per cent in East Asia and the Pacific’. The result is ‘a shortfall in public spending of up to $80 billion a year’ relative to what would be needed

for ‘universal provision of basic services’. This is made worse by ‘serious discrimination’, so that public subsidies for health care, education, sanitation and water in many countries overwhelmingly benefit the rich rather than the poor (UNDP 2000a: 79, Box 4-5 and Figure 4.1).

Numerous writers and UN reports have commented on the adverse snowball effects of these trends, which are now well known. National governments in both poor and middle-income countries, fearing capital flight and denial of IMF loans, give way to pressures to enact structural adjustments, deregulate business, cut taxes as well as social spending, stabilize local currencies, and clamp down on trade unions (see Stiglitz 2002). The result – compounded by huge burdens of national debt5 – is (1) the reduction of public sector programmes, on which working people and people in poverty depend; (2) rising unemployment, as the anticipated economic growth fails to ‘trickle down’ or keep pace with the loss of public sector jobs, and local small producers (many of them women) become displaced by export production and foreign goods; and (3) the inability of the state even to provide ‘safety nets’ any longer, due to the shrinkage of public revenues from lowering of tariffs on imports and taxes on capital.6 It may seem obvious that poverty exacerbates ill health, but it is less frequently recognized that privatization directly exacerbates poverty: ‘In India, the increased cost of medical care is the second most common cause of rural indebtedness’ (Sadasivam 1999: 11). Privatization, in turn, means commodification – including commodification of the most basic elements of life. The World Commission on Water for the Twenty-first Century reports that ‘the poorest people in the world are paying many times more than their richer compatriots for the water they need to live, and are getting more than their share of deadly diseases because supplies are dangerously contaminated’ (Crossette 1999: 15).

While ‘the super-rich get richer’, they also get healthier and live longer relative to the super-poor and even the not-so-poor (UNDP 2000a: 82). Researchers and international agencies have accumulated data that map the deleterious health impacts of global capitalism in its recent ascendancy. A study by the Center for Economic and Policy Research (CEPR) in Washington presents a ‘Scorecard on Globalization’ comparing the 1960-1980 decades with the hyper-globalizing period between 1980 and 2000. Overall, it finds ‘no evidence in these data that the policies associated with globalization have improved outcomes for most low to middle-income countries’. In fact, the CEPR study finds a ‘very clear decline in progress’ since 1980 in nearly all countries in both per capita income growth and such standard public health

indicators as life expectancy and infant, child and adult mortality. And on all the indicators, the CEPR report tells us, women are ‘harder hit by this deterioration than men’ (Weisbrot et al. 2001: 2-3, 11). Its findings are echoed in the widely publicized CMH report, which speaks of ‘incipient backsliding’ in public health outcomes worldwide, including a slowing and, in some of the poorest countries, a reversal in infant and child mortality rates and the per­ centage of women whose births were assisted by skilled attendants (CMH 2001:46).

These declines are especially severe in sub-Saharan Africa – not only because of the AIDS pandemic, civil wars and corrupt governments, but also because of development policies that stress growth and exports over human well-being, and foreign direct investment and loan policies that virtually red­ line much of Africa.7 In Sierra Leone and Malawi the life expectancy is now below 40 years (compared to nearly 80 in Japan, Europe and North America). In Africa’s poorest countries, 10 per cent of all newborns will die before they reach one year old (UNDP 2000a: HDI 1). In Zimbabwe, the imposition of user fees for public health services has been linked to the doubling of maternal mortality in that country, while structural adjustments have entailed lay-offs of thousands of nurses and doctors (Epstein 2001, citing Gaidzanwa 1999). Severe shortages of public sector health workers from both layoffs and the AIDS epidemic’s devastation contribute in turn to higher rates of death from AIDS and other infectious diseases (including ones that are curable, such as tuberculosis and malaria) as well as infant mortality and maternal mortality and morbidity. And, to complete the vicious circles, unaffordable charges for health care also result in greater malnutrition, hence worse health and greater poverty — especially, under conditions of gender subordination, for women and girls (Farmer 1999; Stillwaggon 2001).

The uneven impact of global capitalism’s harsher side is thus not only geographical but also distinctly racialized and gendered. Those who languish in the shadows outside the glitter of the global shopping mall (or the closed- down hospital) are overwhelmingly Africans and dark-skinned and indigenous peoples in Asia, Latin America and the urban ghettos of the North. And they are disproportionately women. As many feminist economists note, women are surely over-represented among the world’s absolute poor, although indicators to measure precise trends in the ‘feminization of poverty’ are still lacking (UNIFEM 2000). Women are also those whose caretaking burdens multiply when public health and other social services are cut; who, because they are more likely than men to be employed in the state sector, suffer higher

unemployment rates due to privatization; and who are most vulnerable to prostitution and sexual trafficking under these conditions (Wichterich 2000; UN/General Assembly 1999; Sassen 1998; Elson 1995, 2001). A recent UNICEF report on 27 countries in Eastern Europe and the former Soviet Union found that free markets have an adverse impact on gender equality, leaving women and girls ‘worse off.' Rising female unemployment and loss of income bring reduced life expectancy due to ‘increased smoking, alcohol consumption, drug abuse and unsafe sexual activity’, and consequently high rates of HIV/AIDS (UNICEF 1999; Olson 1999).8 Moreover, as young women become the workers of choice in globalized electronics, food and clothing factories, they confront the growing health hazards that come with trade liberalization and unregulated working conditions – including exposure to toxins, long hours, lack of any health benefits, and sexual abuse (Wichterich 2000; Sadasivam 1999; Williams 2001b).

Women pay for the cumulative social deficits of global capitalism and privatization in another way as well, in so far as these trends undermine the very international instruments that were designed to promote gender equality. O’Neill, referring mainly to the Women’s Convention and the ICESCR, points out that these international conventions, with their provisions for ‘better social protection through social security programs, health and safety regulations, day care centers and accessible health care’, were written with the model of a strong, interventionist state in mind, based on principles of solidarity and social rights. One could make the same observation about the UN conference documents of the 1990s, despite their unbinding legal status, in so far as they continually call upon signatory governments to take positive actions to implement gender equality, women’s empowerment, eradication of poverty and access to health care, including comprehensive reproductive and sexual health services. O’Neill’s point is that there is a fundamental incom- patibility between such provisions and global economic trends, contributing to the failure of states to carry out their commitments (1995: 62-3). With the best will in the world, the privatized state, caught between debt and the global marketplace, may simply shrug its overburdened shoulders and say, ‘Fine, but who is going to pay for these human rights?’

Yet it is important to realize that global capitalism is far from inexorable and states are far from powerless. Global capitalism is a complicated mix of real social processes and multinational corporate dreamworks, giving both the illusion and the promise of a better life and greater communion among peoples.9 One has only to look at the waves of mass protests – in Tanzania,

Bolivia and Paraguay as well as Seattle, Prague and Genoa; the successful resistance of a country like Malaysia to IMF strictures against capital regula­ tion10 or the insistence by Southern governments on putting public health before patents in TRIPs, to see the fissures in the global market and that states and popular movements still have power to contest it. Of course, deficient economic resources can become a convenient excuse for lack of political will. ‘The vagueness of international instruments and rights to health’ and loopholes regarding ‘available economic resources’ too easily let governments off the hook: ‘It is left to governments and their economic advisers (usually from the World Bank or the International Monetary Fund) to set the bench­ marks for what is the “highest attainable standard of physical and mental health” within the constraints of resources’ (Heywood and Cornell 1998: 75). But the global campaign for access to medicines has shown that ‘benchmarks’ are a matter of political struggle, and civil society groups must take the lead.

Some months after the 2002 World Social Forum in Porto Alegre had gathered together tens of thousands of community activists from all over Latin America, mass protests in Paraguay blocked the President’s attempt to privatize the state telephone company; similar resistance in Ecuador and Peru stopped the governments there from selling off the state-owned electricity facilities to private foreign companies; and Bolivians came close to electing an anti-privatization indigenous leader as President. The mayor of the Peruvian city of Arequipa commented: ‘We privatized and we do not have less poverty, less unemployment. On the contrary, we have more poverty and unemploy­ ment.’ His words echoed the findings of a survey conducted throughout the region by the Inter-American Development Bank in which 63 per cent of respondents said the effects of privatization had been negative (Forero 2002).

Feminist writers have stressed the double-edged character of globalizing processes in regard to the expansion of women’s movements for equality, health and empowerment. Lene Sjørup reminds us that ‘women may be victims in one respect, while being global actors in other respects’, and that ‘the economic landscapes are not just exterior forces which crash upon women’ but that ‘women also participate in [them]’ – as family and com­ munity members, as workers, and also as transnational feminist activists (1997: 95-6). Family planning clinics may still be driven by population­ reduction goals and remain oblivious to reproductive rights and ‘choice’, but women in developing countries everywhere use their services in order to realize their own aspirations for fewer children (Petchesky and Judd 1998). The ubiquitous ‘free trade zones’ dotting border towns in Central America

and cities in Asia are definitely means for transnational corporations to exploit women and girls as cheap, tractable labour; but in some places they also become the best available alternative for young women seeking a modicum of independence from impoverished, tradition-bound rural families (Wichterich 2000). In Nigeria, in what even the media called a ‘peaceful protest’, 150 unarmed village women managed to shut down the operations of the giant multinational oil company ChevronTexaco, occupying the plant and holding 700 employees hostage for over a week. They threatened to remove their clothes and stand naked – a traditional method African women use to shame those in power – unless the company met their demands: jobs for villagers, schools, clinics, electrical and water systems, and fish and chicken farms so the women could make their own livelihoods. And ChevronTexaco complied (NY Times 2002).

Ruptures in the hegemonic surface of global capitalism may have destabi­ lizing consequences, unleashing religious fanaticism and terrorist violence. But they also open up spaces for alternative visions and liberatory social action – action that moves back and forth between the local and the global. Political globalization – of which the UN conferences in the 1990s were a kind of microcosm – has provided a medium through which transnational women’s movements have come together across their many cultural, regional and class differences to develop common goals and strategies. Eisenstein, citing the Beijing conference as the hallmark of such movement, remarks on its potential power:

Many women across the globe are building dialogues that contribute to a deliberative public discourse that deploys public-mindedness in the fight against violence, hunger, poverty, the destruction of the environment, and sexual/racial oppression…. Such dialogue – which both mutes and invites conflict – can build a transnational public of women’s and girls’ voices that creates the very same liberatory democratic process it imagines. (1998: 163)

Global capitalism reforming itself: the World Bank on poverty and health

Already in the late 1990s, serious cracks began to show in the global capitalist veneer. The failure of the ‘Asian tigers’ in 1997; chronic economic and health crises in Russia and other transitional economies; and the onset of recessions and widespread bankruptcies, downsizing, lay-offs and plunging stock markets in many of the leading capitalist countries sent shock waves through the central institutions that manage the global economy. These unanticipated economic downturns, along with the mounting size and visibility of mass

protests, muffled the optimism of many of global capitalism’s champions and triggered a period of self-searching and ideological revision. Even the unipolar configuration of global power seemed fractured and unstable. By late summer 2001, the US – still the world’s single most powerful country economically and militarily – had also become its chief outlaw and rogue nation: refusing to comply with evolving international legal and normative standards on just about any issue; isolated from its closest allies in Europe and Japan; derelict in paying its large backlog of UN dues; voted off the UN Human Rights Com­ mission in Geneva; rudely walking out of the World Conference Against Racism (WCAR) in South Africa; and widely distrusted for its cowboy, go-it- alone political leadership.

Although the 11 …