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LETTER |
Correspondence: Requests for reprints should be sent to Jennifer Prah Ruger, PhD, Yale University School of Medicine, Department of Epidemiology and Public Health, 60 College St, PO Box 208034, New Haven, CT (e-mail: jennifer.ruger{at}yale.edu).
The main purpose of my article was to bring to light a gap in the literature on the history of public health, which has in many respects neglected larger multinational entities such as the World Bank. My aim was to open up a history of the World Bank on its own terms to stimulate a new way of thinking about the history of public health as it relates to such entities.
A second aim was to highlight a learning process that has evolved in development theory, philosophy, and practice over several decades. The paradigm shift in development has been slow, perhaps too slow for those seeking immediate change, but it offers hope for future efforts to enhance individual freedoms worldwide. As I stated in my article, the Bank’s learning process, like that of many institutions, has had costs, particularly economic costs and social suffering resulting from misguided policies and borne by individuals in developing countries whom the bank aspired to help. This, to me, is the worst irony emerging from a study of the Bank’s history over several decades.
Regarding specific comments raised in the letter, first, as I noted in the article, the Bank’s structural adjustment programs have been criticized, were misguided, and are believed to have caused considerable hardship, forcing a change in Bank policy.
Second, as I wrote, the Bank has been criticized for supporting privatization. As I have noted elsewhere1,2 and as I stated in the article, "Research focused on private markets . . . has demonstrated that a strong government is necessary to address market failures."
Third, on the issue of user fees, I wrote that "evidence demonstrates that user fees reduce the demand for both necessary and unnecessary care and . . . disproportionately affect poor and sick people."
Fourth, it is well known that the Bank’s governance structure is undemocratic, owing to its creation as a financial, not a political, institution. I agree that these inequalities are problematic, but the subject of reforms was not central to my article’s specific purpose. Elsewhere, however, I have discussed the importance of political structures3,4 and individual and collective agency5 for health and social justice.6,7
Fifth, as I have argued before, equity and efficiency in health and its distribution6,7 are insufficiently examined by many organizations, including the World Bank. The comment about converting "price tags . . . into inflation-adjusted dollars," however, oversimplifies and misinterprets theoretical and practical issues surrounding the role and limitations of cost-effectiveness and cost-benefit analyses, issues discussed by Gold et al.8
Finally, the comment on methodology draws a false dichotomy between archival research and materials accessible through the World Bank’s Web site. Many sources accessed through the Web site were archival documents (World Bank Historical Chronology and Oral History Program) made available by the World Bank Group Archives free of charge. Unlike the letter’s authors, I see making such documents widely available as a move toward greater transparency and accessibility, leading to greater democratization of information.
References
1. Ruger JP, Jamison D, Bloom D. Health and the economy. In: Merson M, Black R, Mills A, eds. International Public Health: Diseases, Programs, Systems, and Policies. Gaithersburg, Md: Aspen Publishers Inc; 2001: 617–666.
2. Ruger JP. Catastrophic health expenditure. Lancet. 2003;362(9388):996–997.
3. Ruger JP. Democracy and health. Q JM. 2005; 98(4):299–304.
4. Ruger JP. Millennium Development Goals for health: building human capabilities. Bull World Health Organ. 2004;82(12):951–952.
5. Ruger JP. Combating HIV/AIDS in developing countries. BMJ. 2004;329(7458):121–122.
6. Ruger JP. Ethics of the social determinants of health. Lancet. 2004;364(9439):1092–1097.[CrossRef][ISI][Medline]
7. Ruger JP. Health and social justice. Lancet. 2004; 364(9439):1075–1080.[CrossRef][ISI][Medline]
8. Gold MR, Siegel JE, Russell LB, Weinstein MC. Cost-Effectiveness in Health and Medicine. New York, NY: Oxford University Press; 1996.
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