Plundering the poor: the role of the World Bank in the Third World

The World Bank, the most important so-called development assistance agency, annually dispenses billions of dollars to Third World governments, ostensibly to "develop" their economics through a variety of loan projects. But even a superficial analysis reveals that the Bank is the perfect mechanism to help (i.e., subsidize) the large transnational corporations from the industrial countries to expand their industrial, commercial, and financial activities in the Third World, at the expense of the latter and particularly at the expense of the rural and urban proletariat. This article discusses Cheryl Payer's recent book, The World Bank: A Critical Analysis, in which she analyzes the Bank's role in the Third World and sets forth the major reasons why poverty, hunger, and malnutrition, as well as unemployment, and all the adverse social phenomena associated with them, are on the increase.     

The information needs of family physicians: case-specific clinical questions.

BACKGROUND. Physicians must be able to rapidly obtain information that answers specific patient-related clinical questions. This study describes the information-seeking process in the office practices of family physicians. METHODS. We observed and recorded the information-seeking and information-obtaining behavior of 30 family physicians in their offices. RESULTS. Based on 172 hours of observation and 602 patient visits, family physicians sought answers to an average of only one clinical question for every 15 patients seen. Urban physicians sought answers to more questions than rural physicians (one question for every 9 patients, as compared with one question for every 24 patients; P less than .05). The frequency of seeking information was not related to the physician's age. Busier physicians (those seeing more patients per hour) tended to ask fewer questions (correlation coefficient (r) = -.34, P = .06). Drug-prescribing questions were the most common type; second most common were orthopedic questions. Colleagues and the Physicians' Desk Reference were the most often used resources. Eight percent of the questions were not answered. CONCLUSIONS. Among family physicians, patient-related questions are infrequently asked and highly specific. Most questions are rapidly answered using colleagues and books, not journals or computers.     

Health information imperatives for Third World countries

The role of health information in the health delivery services of a nation is stressed with examples from the advanced nations. Factors responsible for the poor state of health information systems in the Third World and the effects on health delivery services are identified. probable factors that may Lead to the development of health information systems in the Third World in the future are posited. Recommendations for the establishment of health information systems based on funding, staffing, functions and networking are made.     

Knowledge resource preferences of family physicians

Because of the pivotal role of medical knowledge in clinical problem solving, it is important to understand how clinicians decide to seek additional knowledge for patient care decisions and how they choose among the resources available to them. Using a self-administered questionnaire, 126 family physicians reported their use of 11 types of knowledge resources for answering patient-specific questions arising in clinical practice. They reported almost daily use of the Physicians' Desk Reference and more often than weekly use of colleagues. There was little use reported of Index Medicus or computer-based bibliographic retrieval systems. The research literature of medicine was used infrequently and rated among the lowest of resources in terms of credibility, availability, searchability, understandability, and applicability. In deciding among a subset of knowledge resources for answering a clinical practice question, resource cost variables related to clinical availability and applicability of the information to the problem at hand appeared to be more influential in the minds of physicians than factors related to quality of the resource. These findings have important implications for the development and deployment of knowledge resources intended to be useful and used in clinical practice.     

Influenza and the work of the World Health Organization

Before World War I, influenza was not considered a particularly serious problem. The great pandemic of 1918-1919 changed all that, and the possibility that such a catastrophe could occur again has conditioned all subsequent developments. In epidemiological terms, the hallmark of an influenza is the excess mortality that it causes combined with an enormous burden of ill-health that saps the energy of individuals, families and communities throughout the whole world. In order to engage in influenza prevention and control, the global influenza surveillance network was set up by World Health Organization (WHO) in 1948 as a worldwide alert system for the identification of new influenza viruses, gathering information from 110 participating laboratories in 82 countries and four WHO Collaborating Centers for Influenza reference and research: Centers for Disease Control and Prevention, Atlanta (USA), National Institute for Medical Research, London (UK), WHO Collaborating Centre for Influenza Reference and Research, Melbourne (Australia) and the National Institute for Infectious Diseases, Tokyo (Japan). This network helps WHO to monitor influenza activity all over the world and provides the organization with the viral isolates and information it requires to decide which new virus strains will be used to produce influenza vaccines during the following season. Each year, information about the isolates over the previous 12 months is analyzed and used to determine the composition of the influenza vaccine to be administered during the coming influenza season both for the northern and southern hemisphere. If necessary, the recommendations for the southern hemisphere differ from the ones formulated for the northern hemisphere vaccine. The information supplied by this network enables the organization to regularly update its World Wide Web (WWW) site (FluNet), which reports on the situation of diseases. This network will also enable the WHO to detect a new influenza pandemic as early as possible.     

Third World experiences in health planning.

In response to an invitation by the American Public Health Association, the author discusses his experiences in health work with particular reference to the Third World. These cover a period of four decades of activities in many countries, the discussion being primarily directed toward the North American audience attending the panel organized by the International Health Committee at the 104th Annual Meeting of the Association in Miami Beach in October 1976. First the paper deals with the legacy of broad social teaching resulting from the years of international collaboration from the time of Franklin D. Roosevelt to that of Richard Nixon. Public health problems, whether new or old, are essentially social in character and can only be solved in terms of social policy. Attention is directed to the current mistake of placing the emphasis on individual behavior, divorced from its social base, in the work of health professionals servings in Third World countries. The weakness of national average values and the consequent need of measuring the differentials between social groups and classes are widely illustrated. Finally, positive and negative lessons learned by experimenting with health technology consistent with the expected development of countries are examined as a basis for a genuinely emancipatory approach to the health problems in the Third World.     

Antibiotic resistance in the tropics. 3. Medical responsibilities of the pharmaceutical industry with respect to use of antibiotics in the tropics

The pharmaceutical industry has three major medical responsibilities: the efficacy and safety of its products, the accuracy of the statements it makes about them, and the provision to governments and health workers of full and proper information concerning these products. The development of new antibiotics is very costly, and their provision to Third World countries alone can never be financially rewarding; furthermore, only about 20% of world-wide pharmaceutical sales are to Third World countries. The industry's interest in developing drugs for exclusive or major use in such countries is declining. However, support from industry for the World Health Organization's action programme on essential drugs is growing, and this should help to provide drugs more cheaply to the poorer countries of the world.     

How International Monetary Fund and World Bank policies undermine labor power and rights.

Based on reviews of hundreds of loan and project documents from the International Monetary Fund (IMF) and World Bank, this article provides detailed evidentiary support for critics who have long claimed that the international financial institutions require Third World countries to adopt policies that harm the interests of working people. After reviewing loan documents between the IMF and World Bank and 26 countries, the authors show that the institutions' loan conditionalities include a variety of provisions that undermine labor rights, labor power, and tens of millions of workers' standard of living. These include downsizing of the civil service and privatization of government-owned enterprises; promotion of labor flexibility: the notion that firms should be able to hire and fire workers, or change terms and conditions of work, with minimal regulatory restrictions; mandated wage rate reductions, minimum-wage reductions or containment, and spreading the wage gap between government employees and managers; and pension reforms, including privatization, that cut social security benefits. These labor-related policies take place in the context of broader IMF and World Bank structural adjustment packages that emphasize trade liberalization, with macroeconomic policies that further advance corporate interests at the expense of labor.     

HIV Infection and AIDS in Africa and the Third World

Acquired immunodeficiency syndrome (AIDS) threatens to undermine the health status and economic development of Third World populations unless there is global cooperation to prevent the further spread of infection. Poor people in developing countries are considered to be at greatest risk of developing AIDS because their immune systems have been compromised by prior infections. The poor are further placed at risk by their lack of accessibility to health care services and information about AIDS. Despite a host of competing health problems (e.g., childhood diarrhea and malnutrition) and scarce funds for mass educational campaigns, some Third World countries have launched government-sponsored prevention programs. Leaders in this area include Zambia, Rwanda, Uganda, and Brazil. The fact the 90% of those with AIDS are in the economically productive age group (10-49 years) has serious implications for the future of Third World countries. In Zaire, for example, it has been projected that premature deaths from AIDS will reduce the gross national product by 8% in 1995. The World Health Organization (WHO) is in the best position to spearhead the global campaign against AIDS and has called for the integration of AIDS prevention activities into family planning programs. The US's withdrawal of financial support from family planning programs that provide abortion and its reduction in recent years in its contributions to the WHO general budget are unfortunate, given the need for massive international assistance to stop the transmission of AIDS in developing countries.     

What clinical information resources are available in family physicians' offices?

BACKGROUND: When faced with questions about patient care, family physicians usually turn to books in their personal libraries for the answers. The resources in these libraries have not been adequately characterized. METHODS: We recorded the titles of all medical books in the personal libraries of 103 randomly selected family physicians in eastern Iowa. We also noted all clinical information that was posted on walls, bulletin boards, refrigerators, and so forth. Participants were asked to describe their use of other resources such as computers, MEDLINE, reprint files, and "peripheral brains" (personal notebooks of clinical information). For each physician, we recorded how often the resources were used to answer clinical questions during 2 half-day observation periods. RESULTS: The 103 participants owned a total of 5794 medical books, with 2836 different titles. Each physician kept an average of 56 books in the office. Prescribing references (especially the Physicians' Desk Reference) were most common (owned by 100% of the participants), followed by books on general internal medicine (99%), adult infectious disease (89%), and general pediatrics (83%). Books used to answer clinical questions were more likely to be up to date (copyright date within 5 years) than unused books (74% vs 27%, P <.001). Items posted on walls included drug dosage charts and pediatric immunization schedules. Only 26% of the physicians had computers in their offices. CONCLUSIONS: Drug-prescribing textbooks were the most common type of book in family physicians' offices, followed by books on general internal medicine and adult infectious diseases. Although many books were relatively old, those used to answer clinical questions were generally current.     

WHO Expert Committee on Specifications for Pharmaceutical Preparations. Forty-first report

This report presents the recommendations of an international group of experts convened by the World Health Organization to consider matters concerning the quality assurance of pharmaceuticals and specifications for drug substances and dosage forms. The report is complemented by a number of annexes. These include: guidance notes on related substances tests concerning the dosage form monographs of The International Pharmacopoeia; a list of available International Chemical Reference Substances and International Infrared Reference Spectra; a revision of the general guidelines for the establishment, maintenance and distribution of chemical reference substances; the procedure for assessing the acceptability, in principle, of pharmaceutical products for purchase by United Nations agencies; the procedure for assessing the acceptability, in principle, of quality control laboratories for use by United Nations agencies; and guidance on variations to a prequalified product dossier.     

Information-based rehabilitation for Third World disability

Rehabilitation and special education are usually conceived in terms of methods, gadgets, locations and professions. Generalist planners often have difficulty grasping the essentials of the field, while resource constraints in Third World countries severely limit the extent to which these four features may become widely available. Reconceptualization of the field as information-based rehabilitation opens new, low-cost possibilities for empowering disabled people and their families and communities. A basic approach is described from Pakistan, for methodical dissemination of appropriate information, with feedback, evaluation and on-going information systems. Some comparative merits of various media are discussed, together with the values inherent in information and some constraints on information-based rehabilitation.     

The World Bank and pharmaceuticals

Within less than a decade the World Bank has become the largest single source of finance (loans) for health in low and middle income countries as well as a major player in the field of pharmaceuticals. Often 20-50% of the recurrent government health budget in developing countries is used to procure drugs. Drugs are among the most salient and cost-effective elements of health care and often a key factor for the success of a health sector reform. However, pharmaceuticals are frequently being used irrationally, mainly due to market imperfections in health care, such as information asymmetries, leading to serious health problems and a heavy financial burden on the health system. Lending priorities set by the World Bank could be used to promote public health sector reform, leading to the rational use of affordable and available drugs of good quality in developing countries. This report provides the first analysis of World Bank activity in the pharmaceutical sector worldwide. The analysis of 77 staff appraisal reports, describing the planning phase of World Bank country projects, shows that 16% of the total World Bank health, nutrition and population budget, or approximately US$1.3 billion, has been committed to loans or credits supporting pharmaceutical activities in the programme countries between 1989-95. Roughly US$1.05 billion has been committed to procurement of drugs and medical equipment. Only 5% of the total pharmaceutical sector lending is committed to software components such as drug policy work and rational use of drugs. No more than 45% of the projects were developed in collaboration with pharmaceutical expertise. The World Bank is recommended to improve its pharmaceutical sector involvement by promoting drug policy research and development including national and international dialogue on pharmaceutical issues to ensure rational use of both drugs and loans. In this, the World Bank has an advantage given its experience from working with both the private and the public sector, its in-house expertise in health economics, and lastly its ability to be listened to by governments through its power.