If you look at a modern map, the country of Tajikistan is wedged amidst all the other
stans. The more recognizable names, Pakistan and Afghanistan, lie to the south, while up
north, Uzbekistan and Kazakhstan cozy up against one another, and to the east lies
China. Formerly under the rule of the Russian monarchy, then communist Russia, the
country entered a jarring five-year civil war almost immediately following its
independence from the USSR.
Tajikistan boasts not only the beautiful Pamir mountain ranges which run through
Central Asia, but also some of the highest infant mortality rates of all former Soviet
states, as well as a weakened medical system, decline in life expectancy, and a high risk
of epidemic disease. But the question is, why? Why do they see poorer health outcomes
now than they did even under the communist government of Russia? There is no simple
answer as to why governments fail, why civil wars happen, why we allow death and
disease to spread even in the day and age where they are preventable. But the short
answer is capitalism.
The academic answer is neoliberalism. And the real answer is much more complex than
that. Non-governmental organizations and other groups were coming in to fill some of
the gaps, including the gaps in the health system, because the economy had collapsed
and the systems had collapsed.
And so there were huge gaps. And so this was an opportunity to actually see what it
looks like when this other system comes in. And so what is this other system? Now, this
is not to say that the Soviet system was right or any other system is right and what was
happening is necessarily wrong.
It was to say that if you're delivering health based on need, and arguably people could
say the Soviet system failed in that, they didn't do that well. But if your criteria for
distributing health is need, you get a certain outcome. If your criteria for distributing
health is whether you can pay, you get a different outcome.
Because what happens is that you're relegated to your place in the global economy
based not on the hierarchy of need, but whether you can pay. And I think that's the
significant thing. So the thesis of the book was, in Badakhshan, in the midst of this
incredible famine and incredible social transition, in a very geopolitically important part
of the world, which is at the border of China and Afghanistan, these ideas of
neoliberalism were introduced, and they put populations at risk.
And we know that poor health leads to instability, political instability. And so you've got
to ask yourself the logical question, why would one do this? And if you were even there
just for the health care, which is what a lot of the NGOs were there for, why would you do
this? And that basically gave rise to the fact, well, there were these ideological forces
that had shaped themselves in the 20th century that were really defining how care was
being given. And those forces we now call neoliberalism, but they were just new ways of
thinking about the world and new ways of thinking about the distribution of social goods.
That was Dr. Salman Kashafi, a medical doctor, anthropologist, published author,
researcher, and current lecturer at Harvard School of Medicine. He spent several of his
post-grad research years studying, up close and personal, the health care woes of
Tajikistan. In his book, Blind Spot, How Neoliberalism Infiltrated Global Health, he
discusses how his experience with NGOs, non-governmental organizations, filling in for
the once-publicized health care system in the country, revealed several pitfalls of global
neoliberal system, as well as privatized health care.
Today, he joins us. Ten years after the publication of his book, and nearly three decades
since his first track in Tajikistan, discuss not only the challenges Tajikistan continues to
face, but also the prolonged ramifications of a globalized neoliberal system on health
across nations. Well, you know, when I arrived, I was in my early 20s, and I wasn't a
doctor.
I was an anthropology graduate student, and I went in, you know, just to, you know, I
wanted to look at this whole idea of social change, and I wanted to look at how, you
know, as I told you, some of these ideas of, you know, of distribution of social goods
really was coming into a space. A former Soviet Union, remember, the government was
the distributor of social goods, right? And so how that changed the dynamic between
people, and between people in the government, and people in society, etc. So when I got
there, there was a civil war going on, and there were a couple hundred thousand
refugees that had come into Badakhshan, and there was a famine.
So there was no food. Everything was being given. All the food was being given by Agra
Khan Foundation, and the International Red Cross, and then healthcare was also being
provided by Agra Khan Foundation, and by Medecins Sans Frontieres.
And so, you know, it was a really tough situation there for the people, and there was, you
know, irregular electricity. Lots of social services had broke down, because the state had
really crumbled in the post-Soviet period, and then, of course, there was a civil war. So,
you know, the state wasn't functioning properly.
And so there were lots of issues, you know, when I went there. And, you know, I lived in
villages, and I lived in, like, this little town called Khorov, which had about 10,000 people.
That was, like, the main part of Badakhshan.
And, you know, I got to know people, and people in the community welcomed me. So I
was there for a year, and I worked with one of the local NGOs. The name was PRDP,
Primary Relief and Development Program.
And, you know, so it was an incredible experience. But then I came back, and after being
in the villages, and seeing a lot of people die from diarrheal diseases, and pneumonias,
and things that are preventable, by the way, with medicines. Yes.
Five cents. I went to med school, and as I emerged, my colleague, Paul Farmer,
colleague and friend said, you know, we're Partners in Health is going to be working in
Russia. And it's exactly the same dynamics as what you studied in Badakhshan, which is
that there's, you know, there's a double standard of care for treatment of tuberculosis,
which is, of course, airborne, and is even more, you know, so many more effects.
So I started working there in Russia, and in Tomsk, where we had a project for many
years, for 20 years. Tomsk, and other, you know, other provinces in Russia, and got very,
very involved in this whole double standard of care, and, you know, treating people
differently because of where they are in the global economy, etc. Same stuff that I was
doing in Badakhshan, and, and in Tajikistan.
But now it was happening in a place like Russia, where just the economy had gone down,
but they had the infrastructure, they had laboratories, they had hospitals, etc, etc. So,
you know, I became very, very steeped in that work. And that's why it took me a long
time to write the book, because I went from that project, and writing, you know, a very
long thesis, I went to med school, I did residency, and during my residency, I did
something called the Hamidov, where I spent a lot of time in Russia, working on drug
resistant TB, and, and, you know, and building programs.
And then I went from that to just kind of being a faculty member and working and doing
a lot of healthcare delivery work. And so at the end of the day, it took 14 years to finish
this book. But I don't think that was a bad thing.
Because in that time, I'd actually run programs, I had helped start, you know, one of the
first community based treatment programs for TB and HIV in sub Saharan Africa, I'd had
the experience of the Thomas program, you know, trying to figure out, you know, we
were providing care in the prison system initially, but then later into the in the civilian
sector, because people left prison and went into the community. And, and of course,
we're infecting infecting people in the community. And the prisons were almost like a
epidemiological pump, you know, yes.
So, you know, I learned a lot. And I then became in that period, I became a member and
then chair of the World Health Organization and Stop TB Partnerships Greenlight
Committee for drug resistant TB treatment rollout globally, and got to see many, many
programs. And I learned an incredible amount from that.
So by the time I came back and finished this book, I had run projects, and I think I had
kind of, I think I toned down my criticism about certain things, but not, not my concern
about about the effects of not focusing on health outcomes, but instead going into things
with an ideological bent. So I think, you know, and you'll, you'll, you'll see in blind spot, I
often use the term dogma over data. And unfortunately, we have a lot of things like that
in the world where people say, well, you know, we believe this is true.
But even if the data shows that it's not true, that, you know, the change doesn't happen.
And the idea, of course, is that, you know, the neoliberal idea, of course, is that you will
make people completely reliant on the market, as it's as the sole distributor of social
goods, and the state really just regulates the market. In some places that doesn't work
well.
In some places, these are not, by the way, poor places, these are impoverished places,
because they actually have a lot of natural resources, they're not poor, they're made for
circumstance by circumstances and certain social structures, but you suffering. Michael
Peretti, American leftist intellectual, political scientist and academic historian has
exclaimed in a previous speech, these countries are not underdeveloped, they are
overexploited. neoliberalism gives imperialism a new face, even well meaning
organizations that seek to provide care during power vacuums, instead of replace power
structures, like the ones present in 1990s, Tajikistan, are ruled by profit margins and
spending capabilities.
They are always asked to be sustainable, in the sense that they save an acceptable
amount of people without wasting too much money. Such is the value system. They
answer to outside powers and global interest instead of approaching healthcare with a
full scope of community health needs.
Dr. Kashavi explains in his book, how NGOs as administrations are not so much
moralistically bankrupt, as much as their power is purposeful under the advent of
neoliberalist politics, and their influence may be culpable for cultural blindness. Quote,
so while certain policies may appear pragmatic or instrumental, their application can in
the words of social anthropologist Chris Shore and Susan Wright, serve to cloak
subjective ideological and arguably highly irrational goals in the guise of rational,
collective, universalized objectives. This trap, which Dr. Kashavi later refers to as dogma
over data, ignores the real needs of a community, instead providing blanketed care at
the cheapest possible rate.
This is the nature of neoliberalism. It cannot make moral, communal or ethical calls. It
does not take into consideration human life, individual healthcare practices, and it most
certainly does not care for someone who can't afford a good.
In this case, healthcare. That's how you create a just society, right? You think, you know,
what, how do we maintain the well-being of the least amongst us so that the society can
thrive, right? And I think that that's what neoliberal, like the neoliberal ideology fails to
look at, because if you leave the market as the social good, it leads to very short-term
gains, right? And those short-term gains don't often look at long-term societal goods, and
goods as in like not products, but just the good of society. And the long-term good, like
for example, is educating children important? Is having, you know, having people in
healthy housing important in the long run for the type of society we want, for the
politically stable society we want? You know, those are things that are, that they're not
short-term gains.
It's not about how much money you make today, right? And so, for example, I'm just
throwing this out there. Let's just say we were to say we want to cut down carbon
emissions from cars, because 2.5 micron air particles, the carbon emissions, of course,
hurt the environment, but 2.5 micron air particles are known to drive things like
diabetes, early heart disease, certain cancers, etc., right? So let's just say we wanted to
do that. We could decide as a society that public transit should be free.
We could say that, you know, we want to invest in public transit and make it free,
because it's like the roads. It's part of life. It should be covered by taxation.
That's a societal decision, right? And if we thought that, you know, getting people off the
roads was very, very important, we would invest in that, right? And some countries do
that. Some countries invest in like incredible bike lanes. I mean, there's different things.
I'm not saying that that's the one solution, but you look for something that's going to
give you the right outcome, right? And so I think that that's the kind of thing, not Dicey
as in like, it's not true, but this is where things do become kind of what your worldview
is, right? So preventive things, let's take the example of the HPV vaccine that prevents
cervical cancer, right? There are a lot of data that show that people switch health plans
quite often, right? So why would you want to give somebody, men and women, boys and
girls, the HPV vaccine when they're 12 or 13, when you know they're not going to be part
of your health plan 10 years from now, and that they're really only going to get cervical
or oral cancer, you know, when they're 30, right? Well, because it's part of their long-
term health, right? But it's not in the market interest to necessarily do that. There are
actually some market interests that make you do that, but not in general, okay? So, you
know, so you think of preventive care across the board, like, you know, is it in the market
interest to do that? You know, so that's like kind of like one aspect of it, right? When you
think of the redistributive power of the state, if you are trying to help the least amongst
us, or the bottom quartile, or the people most vulnerable, maybe somebody was rich,
and by becoming sick, they became poor, right? Or they have a health condition that
doesn't allow them to work. As you know, we distribute health insurance in this country
based on work.
So let's just say somebody had opioid use disorder, which is leading to, like, you know,
it's for the first time in 200 years, the life expectancy of white American men has
dropped. We have a life expectancy of men, I think it's roughly 76 right now. You go to
Singapore, it's in the high 80s, okay? So, you know, if you start to look at these things,
well, let's say you lose your job because you have an addiction disorder.
Well, how will you ever get out of it? Well, there are medicines that you need access to
them, you need access to doctors, you may need access to community support. We
don't have any of that. If you don't have health care, we don't have any of it.
And some of it, like community supports, we don't have at all, or they're very limited in
many places. So when you start to think about it, you know, you have to build a system
that allows some redistribution of social goods, like where if I'm healthy, or you're
healthy, and person three is not healthy, but has been healthy, or may be healthy in the
future, you say, well, why don't we pool our risk, right? That's like what insurance is,
you're pooling risk. So you have to start to, I think we as a society have to think more of
health care as a risk pool, and not just as a profit center.
And of course, a production, it's something that's necessary to life, it's necessary to the
functioning of a just society, it's necessary to stability of our, of our government and our
state. And there are, again, data that support all of the things I'm just telling you. And so
I think that's, we have to kind of change our orientation to that too.
Noam Chomsky, renowned political scientist, lecturer and author says, the very design of
neoliberal principles is a direct attack on democracy. But for health researchers, such as
Dr. Keshav V, neoliberalism is a direct attack on equitable health, and an equally
important human right concern. Life, liberty, and the pursuit of happiness.
And I would argue that without health, you don't get life properly, you don't get liberty,
because you're, you can't be an active participant in civil society, and a free society
requires that. And you certainly don't get the pursuit of happiness with the morbidity of
many diseases that we have. So just even, even those basic things that we as a society
have said, are critical, require that we say that certain things are social goods that, and
then that language of sustainability disappears.
Like if I told you that let's make this transit system free, and as a society, we all agreed
that, oh my God, we've got to get rid of cars on the road, we're going to stop building
new roads, we'd rather invest this in a really, really reliable transit system, like Europe
has, you know, like Germany has, or Holland or whatever. We wouldn't say, oh, it's not
sustainable. We'd say, yeah, we have to build the tech space to do that.
Because it's critical. It's as critical as having an F-35. I mean, and again, I'm not putting
down, I'm not saying, oh, it's defense versus health or whatever.
I'm saying, these are choices. We are saying having an intelligence agency is important.
Having F-35s is important.
Having border guards is important, right? Having roads in our cities are important.
Having interstate highways are important. So is healthcare important? Is education of
our young important? Are sports facilities so that kids can actually play sports and be
healthy important? Those are things we need to decide.
Somebody has said that the fire service is important. Somebody has said that having a
police force is important. Right? So why would we suddenly say, oh God, yeah, you know,
why isn't the police force sustainable and run market forces? Like if I call the police,
shouldn't I pay them $200? But if I call the doctor, because I think I'm dying from a heart
attack, I got to pay a 750 copay at the emergency department.
So we make choices all the time. So the idea that, oh my God, this is, you know, you're
interfering with commerce and we're going to become communist if we do this. That's
not the case at all.
This isn't about who owns the means of production. This is about how do we distribute
essential social goods? And can it be a mix between private and public and where should
the public play a role, you know, when we, you know, to protect the weakest amongst
us. And, you know, how do we do that? That's what this is about.
But in fact, it's often construed as, oh, I'll never be able to choose a doctor. This is like
the Soviet union. And it's like, no, no, it's not.
It's not. That's those are, those are false constructs. In America, such false constructs are
symptoms of a greater political ailment and deeply entrenched political history.
But in Tajikistan, the ills are far worse than political misconstructions. Lower respiratory
infections and diarrheal infections account for the greatest proportion of disability
adjusted life years or DALYs, loss in the nation. While the most under five deaths are
caused by preventable communicable disease.
Meanwhile, as other European world health organization regions see falling rates of
chronic non-infectious disease, the numbers are merely stagnating in Tajikistan. As you
see, at the end of the book, the private market, pharmaceutical market dominated and
people couldn't afford medicines. And the health care statistics in the region are still
really, really poor.
Yes. And so, you know, I think that they haven't had, you know, and a lot of these Central
Asian states have had really weakened health systems because it's been shifted from,
you know, from a more public centered system towards private and whoever can afford
it. And these are poor places.
In fact, you look at Tajikistan, most of the income comes in through remittances. So
anyway, I think you'd look at almost any of these companies, even our own, that people
who can't afford insurance, people who can't afford medicines, you mentioned your
grandfather, you know, they, they suffer. And in certain cases, in the case of like
diabetes, you can die with cases like pneumonia and, and, and, and diarrheal diseases
for children, you die, you know, and so, and TB also, you know, like, we've been pushing
for years now to do proper TB care, just like we've done in the United States and other
places.
And now other countries are starting to do that. But if you don't do it, you die. Like you
die.
80% of the people that don't get care die. So, you know, and if you don't die, you're you
get lung damage and are injured and same with a lot of other diseases. So, you know, to
cut a long story short, I think Tajikistan has suffered and you look at a lot of the countries
that have not really moved towards having dealing with some of these distribution
questions, including our own, have had people that are vulnerable suffered.
Tajikistan is not an individual case, but rather a case study. An example of how sudden
changes in healthcare management coupled with pre-existing inequities and disease in
tandem with healthcare privatization caused well-intentioned foreign global and
individual actors to provide less than exemplary care. These issues are only expanded
upon under a neoliberal power structure whereby profit margins reside in the periphery
of all non-governmental operations and cost effectiveness preoccupies the policy makers
mind.
Understanding the pitfalls of the system is only the first step to dismantling it and
tackling the issues which plague global health today, but it is most certainly a good start.
This global health podcast was produced for Guilford College's global health class spring
of 2024.