Blind Spot: How Neoliberalism Infiltrated Global Health. SalmaanKeshavjee Oakland: University of California Press, 2014, 240 pp.
Salmaan Keshavjee’s Blind Spot: How Neoliberalism Infiltrated Global Health provides an account of the ways in which neoliberal values and assumptions shape the goals and effects of global health interventions. The book is organized into four sections that follow developments in the global health industry, Soviet collapse in Badakhshan, and the local introduction of the Bamako Initiative, a revolving drug fund that encourages user fees as the basis for ensuring a reliable supply of medicines and sustainable health system support. The book is clearly written, making the anthropological analysis accessible to those in public health and other fields who might not have a background in anthropological theory and methods. The ethnography is enriched by concise historical analyses of neoliberal economic and political value structures and pre-Soviet and Soviet socialist medical systems.
Keshavjee has a Ph.D. in Anthropology and Middle Eastern Studies and an MD. His analysis is based on anthropological research he conducted in 1996 in the region of Badakhshan, where he also held a staff position studying social aspects of health care programs for the Aga Khan Foundation (AKF). In this role, he evaluated health infrastructure and monitored the distribution of vaccines, vitamins, and pharmaceuticals. This job gave him unique opportunities to travel to remote villages in the region, providing a privileged perspective about the everyday lives of local residents and their experiences with issues such as scarcities of food and medicines, starvation, civil war, humanitarian assistance, and the abrupt disappearance of the centralized Soviet state support in Badakhshan’s remote and mountainous geopolitical location.
In Badakhshan—as in much of Eastern Europe and Eurasia—the demise of Soviet socialism plummeted the standard of living, as infrastructure collapsed and citizens struggled against poverty, energy crises, civil wars, and profound political and economic transformations. As numerous other anthropologists who have documented the nuances of post-Soviet life demonstrate, and as Paul Farmer notes in his Preface to Blind Spot, these transformations also gave way to the “collapse of systems of meaning” (p. xxviii) with which people make sense of their lives.
Keshavjee’s attention to the insights of village leaders and residents, health workers, and NGO workers highlights the significance of local knowledge for global public health and development projects and of anthropology as a vehicle for bringing that knowledge to the table. Such experience-near insights are often ignored in policy design and implementation and in public health analyses. Moreover, because “ethnographic information can be misused to mask the real causes of suffering” (p. 61), such as poverty and development projects, taking that information out of context (as was the case with a report that Keshavjee prepared for AKF) can contribute to the “trap of neoliberal programmatic blindness” (p. 135) in which well-intended program goals often get lost in the dogmatic assumptions that drive global health.
The vast and diverse geopolitical region that formerly comprised the Soviet Union is a fascinating terrain for studying those processes. Particularly salient to the critique of market-driven medicine is the author’s account of late 19th-century Zemstvo (district) medicine and Soviet Semashko medicine. Although not entirely successful in providing universal or equal access to basic health services, Zemstvo and Soviet socialized medicine were explicitly designed as fundamental rights for all citizens, provided by the state as a moral commitment to society, rather than as a commodity to be purchased by costumers. Proponents highlighted the obvious connections between poverty, illness, and suffering. This viewpoint lost its sway when, beginning in the 1990s, neoliberal political and economic worldviews were amplified across Eastern Europe and Eurasia. NGOs—predominately funded by bilateral and multilateral institutions—occupied increasingly important roles not only in emergency humanitarian relief programs, but also in longer-term development projects intended to facilitate democratic and market-based transformations.
Yet, on one visit to the village of Kudeh, for example, Keshavjee found that post-Soviet “assistance” was basically nonexistent. As Keshavjee demonstrates using data from surveys, interviews, and observations, the Bamako Initiative’s fundamentally neoliberal approach to health came with dangerous side effects. The problem was not that people were unwilling to pay for medicines or that they were resistant to market-oriented changes. It was that they were unable to pay for even the most basic necessities. As a result, a purportedly rational system based on user fees might not only alienate vulnerable potential patients (consumers). It might also discourage them from utilizing the system. Paradoxically, the difficult decisions vulnerable people have to make often translate into assumptions that people living in poverty are unable or unwilling to act in their own best interest as citizens who appropriately take care of themselves.
Indeed, as Keshavjee illustrates, this is one of the most harmful underpinnings of neoliberal approaches to health care that have at their root unwavering and blind faith in privatization and corporate-like managerialism. In one particularly vivid ethnographic example, Keshavjee tells the story of Misha, the head dentist at the Central Dental Clinic in the town of Khorog, as he fought to make services accessible in the new fee-based system. Misha sought assistance from AKF, requesting a modest grant (US $500) so that he could keep the clinic open and treat people for free. The emergency grant was secured, but when Keshavjee returned two weeks later, the grant had been transformed into a small-business loan, funded by an AKF-sponsored project designed to boost local business and, ultimately, privatization. Individuals with dental problems delayed seeking services and were forced to compromise their health at the hand of “a significant moral transformation in global health” in which patients “were now viewed as customers” (p. 116).
In addition to the effects of neoliberalism on contemporary global health, two important insights come from the ethnographic vignettes such as Misha’s. First, as much scholarship in medical anthropology richly documents, pharmaceuticals are imbued with meaning; they are significant social actors involved not only in the cultural, political, and economic changes that drive global health initiatives such as Bamako, but also in the intricacies of everyday life and peoples relationships with one another. Second, global health and other types of development projects and policies bring about unintended and often harmful consequences for those struggling to provide and receive medical care. Such side effects are rarely considered in program design or implementation. There is a wealth of scholarship in medical anthropology that speaks directly to these points.
Keshavjee’s ethnography and its relevance to anthropology and global public health would have been strengthened if he had engaged with these important literatures as well as with the significant medical anthropological literatures about global health and cultural and political aspects of health and health care reforms in Eastern Europe and Eurasia, much of which speaks directly to Blind Spot’s attention to the often paradoxical outcomes of NGO-driven interventions that fail or cause harm. The importance of Keshavjee’s book (and anthropology) for improving global health efforts would also be bolstered if he had included a brief but more in-depth discussion of the research methods he employed and why anthropology should be a part of all development projects.
Despite these shortcomings, the book demonstrates consequences of privatization and neoliberalism for global health and the importance of anthropology for public health and development work. Blind Spot will be of interest to scholars and students who work in Eastern Europe and Eurasia and those who specialize in medical anthropology, global health, and development studies as well as non-academic global health professionals.