322 ALFRED GELLHORN

VICENTE NAVARRO Department of Health Policy and Management. School of Hygiene and Public Health,

The Johns Hopkins University, 615 North Wolfe Street. Baltimore. MD 21205.

U.S.A.

Why this ‘killing without end?’

Professor Alfred Gellhom’s article, “National Security and the Health of the People”, represents an eloquent cry against a cruel reality in today’s world which encompasses a frightening militarization of intergovernment relations and desperate poverty in the majority of the world. He deserves to be congrat- ulated for daring to touch on key and urgent matters. His moral outrage animates his description of what has gone wrong, why, and what can be done about it. His description, analysis and prescription re- produce a perception of what is happening in today’s world that is widely held among large sectors of U.S. academia. According to this perception, the world is threatened by a worldwide militarization carried out by “our governments [which] have equated national security with military might” [l]. It is this militar- ization that is perceived to be responsible for the actual and potential civil wars that exist all over the world as well as for the torture, killings and reigns of terror that accompany them. To the question, “Why this killing without end?’ [2], Gellhorn’s answer is clear. Militarization is an outcome of the East-West conflict in which the two superpowers, the U.S.A. and the U.S.S.R., are using proxy countries as pawns in the resolution of their conflicts [3]. Once that conflict appears, it remains undiminished as a result of “militarism’s life of its own [which] breeds a fascination with the use of force” [4]. This internal logic of militarism within the East-West conflict ‘is leading, according to Gellhorn, to the actual possi- bility of a nuclear holocaust that could affect not only the developed world-which presumably will contain the targets of the nuclear attacks-but also the underdeveloped world, since the planetary effects of such attacks determine that a nuclear war will “pro- duce retrogression to the dawn of mankind every- where” [S].

This position also assumes that a consequence of worldwide militarization is the underdevelopment of large parts of the world. By taking away resources much needed for development, the buying of guns means the lesser availability of food, schools, health centers, etc. A logical conclusion of this inter- pretation of our reality is that there is an urgent need for a reversal of militarization, with transfer of resources from the military to areas of social need. Moreover, this worldwide reversal of priorities should be accompanied by implementation of the recommendations of what is widely known as the Willy Brandt Report, which calls for cooperation and collaboration between the northern (rich) and south-

*I use the term ‘liberal’ in a merely descriptive manner in order to define ‘the sector of U.S. academia which appears as an alternative to the larger conservative sectors and whose primary recommendations emphasize the need for reforms within a set of class power relations whose existence and continuation are unquestioned.

ern (poor) countries to create a new international economic order. To resolve the problems of hunger and malnutrition, for example, the Report recom- mends that a global food program be designed to increase Third World food production, provide emergency food aid and develop a process for long- term international food security. These reforms, it is posited, need to be accompanied by major reforms of the international economic system, including (a) the development of an effective international monetary system and (b) the improvement of the trade condi- tions for products of the Third World [6].

Gellhorn, too, believes that the predominate cleav- age in today’s world is between the northern and southern countries. A call is made to the governments and peoples of the North and South to collaborate to resolve these problems. This call is based both on moral imperatives and an assumed mutuality of interests between rich and poor countries in an increasingly interdependent world. It is believed that it is to the advantage of northern countries to resolve the problems of poverty in the southern ones [7]. In the health sector Professor Gellhorn encourages the implementation of the WHO Alma Ata Report on Primary Care as a way of resolving the urgent health needs of the majority of today’s population [8].

The limitations of liberalism as explanation of today’s realities

I have summarized, although briefly, some of the main elements of Gellhorn’s position-a position that is widely held in liberal circles* of the U.S. academic establishment or, to use Gellhorn’s words. among “we, the elite,. . those who bear a major responsibility to know about the problem of the planet earth and to do our part in working toward their solution” [9]. I believe, however, that the moral outrage at the ‘heart of this position is not matched by an accurate analysis of the roots of that reality. The seeming unawareness of the social, economic and political roots of today’s problems reduces that moral outrage to a cry which is valid in its concern but ultimately powerless due to its inability to identify the roots of the problems. Contrary to what Gellhorn seems to believe, the major problems of militarization and underdevelopment are not due to the madness of our Eastern and Western governments. Rather, they are the outcome of the logic of the dominant power relations in today’s world, of which these govern- ments are mere exponents. The socioeconomic struc- tures and political forces that reproduce these power relations constitute the explanation for those policies. In order to understand the latter, we have to compre- hend the former.

Indeed, the current policies that determine both militarization and underdevelopment cannot be ex- plained unless one understands that the current world order is based on brutal exploitation-not of the South by the North, but of the dominated classes of workers and peasants of the underdeveloped world

National security and the health of people 323

by the dominant classes of both North and South. A worldwide war is taking place-not between the East and the West nor between the North and the South, but primarily between the disenfranchized majorities and their rulers in the South and their allies among the dominant classes in the capitalist North. One has to realize that since 1945 there has been a successful anti-imperialist revolution on the average of every 4 years [lo]. This rate increased to an average of two successful revolutions per year in the period 19741980*. These revolutions represent healthier strategies for breaking with the sickness of under- development. For the most part, dominant classes of the U.S. and other core capitalist countries have opposed by all available means these revolutionary processes. The outcome of this counter-revolution has included death (e.g. 35 million people since 1945), terror (e.g. 300,000 Communists and their sym- pathizers massacred in Indonesia in 1965), persecution (e.g. one-quarter of the Uruguayan and Chilean populations in exile) and torture (e.g. 1 of every 20 workers tortured and persecuted in Pinochet’s Chile) [ 11.1 This reality continues today in El Salvador, Honduras, Guatemala, Chile, etc., all of them among the most loyal allies of the U.S. Admin- istration. To perceive all these conflicts, as Gellhorn seems to, as part of the East-West conflict is simply wrong. To see, for example, the struggle in El Sal- vador as a conflict between the East and the West in which the Salvadorians are mere pawns of these two superpowers is to dismiss the long struggles of the Salvadorian workers and peasants against a hated oligarchy whose only means of survival has been through brutality and terror [ 121. That the West-the U.S. government-has always been on the side of the oppressor class in El Salvador is clear. But it is not clear that the U.S.S.R. or Cuba is the primary mover behind these popular struggles. The evidence denies that. Even today, and contrary to what the Reagan Administration claims, the assistance of those coun- tries to El Salvador guerrillas is very limited indeed.

In summary, terror and persecution are not, as Gellhorn indicates, the inner logic of militarism. Rather, militarism and fascism are outcomes of the inner logic of capitalism and imperialismi. Militarism and fascism represent the extreme form that these systems acquire in their struggle against revolu- tionary forces. It is worth stressing that it is also this inner logic of capitalism and imperialism which ex- plains the current danger of nuclear holocaust. In the past. all major threats by the U.S. government to use

*Ethiopia (1974). Cambodia (1975), Vietnam (1975) Laos (1975) Guinea Bissau (1974). Mozambique (1975). Cape Verde (1975). Sao Tome (1975) Angola (1975), Grenada (1979). Nicaragua (1979), Zimbabwe (1980).

tBy capitalism is meant a social formation in which a class-the capitalist class-has a hegemonic dominance over the means of production, consumption and legiti- mation. By imperialism is meant a worldwide system of power characterized by the political, economic, ideo- logical and cultural domination of one or more nations by another nation(s). a system of power which follows the interests of the dominant classes in the dominating nation and also sectors of the ruling classes of the dominated ones.

nuclear bombs have been directed against revolu- tionary forces in the underdeveloped world. Truman and Eisenhower threatened to use the nuclear bomb in Korea should the Chinese cross the forbidden line. It was the growing antiwar sentiment in the U.S. which played a major role in restraining U.S. policy makers, limiting the nuclear threat. The U.S. govern- ment also threatened to use the nuclear bomb in 1954, in the late 60s and in the early 70s against the Vietnamese revolutionary forces in Indochina. The U.S. again threatened to use nuclear force during the Cuban missile crisis in 1962 when the U.S. came very close to a nuclear confrontation. Today, the area singled out as the most likely target of nuclear attack by the U.S. is the Middle East in the event that ‘social unrest’ should endanger the vital U.S. interests [13]. Contrary to what Gellhorn indicates, the targets of nuclear holocaust are more likely to be in the under- developed than the developed world.

Collaboration or conflict? The limitations of the Brandt Report

Since I have elsewhere criticized the ideological assumptions of the Willy Brandt Report, I will not dwell on that point further [14]. Suffice it to say that I believe Gellhorn’s recommendations for solving the problem of underdevelopment share the main weak- ness of the Brandt report proposals: they do not touch on the key parameters that determine under- development, i.e. the internal class power relations of exploitation in which a dominant class, assisted by dominant classes in developed capitalist countries, dominates the exploited classes of workers and peasants in underdeveloped countries. These class relations are at the root of underdevelopment, pov- erty, and the ill health of the majority of the world’s population [15]. Neither the Brandt Report’s recom- mendations nor Gellhom’s prescriptions touch on the urgent need to change the class power relations within those underdeveloped capitalist countries. All their suggestions are aimed at encouraging greater rates of growth and productivity, without, as the Brandt Report indicates, “wishing to suggest that changes in domestic policy must be a prior condition for reforms in the global system” [16]. However, changes in domestic policies and the class power relations that determine them are key to the resolution of under- development. The reality in the. underdeveloped world has already shown that change in those inter- nal class power relations is indeed the necessary precondition for breaking with the sickness of under- development. Reform within an unchangeable set of national class power relations is unlikely to resolve the poverty in which the majority of the people in the world live today.

This unawareness of class analysis, incidentally, is also what limits the explanatory value of theories that see the primary polarization in today’s world as between northern and southern countries. According to those theories, Cuba and Haiti are both subsumed under the primary definitional category of southern countries, which in theory should explain and link their behavior. It should be clear to any observer of these two countries, however, that their policies are explained by the difference in the classes which are in power rather than their shared location in a geo-

324 ALFRED GELLHORN

graphical area or an all encompassing category of ‘poor countries’. The Brandt Report as well as Gell- horn seem to dismiss categories, concepts and terms such as exploitation, capitalism, imperialism, class struggle, socialism and the like. In their stead, they use concepts such as East and West, North and South which, while not non-ideological, are limited and insufficient as categories for understanding our real- ities and guiding our actions. To deny the reality of national and international exploitation among classes and to stress instead the need for cooperation and collaboration among rich and poor countries is to deny the overwhelming evidence that class struggle is, as Marx and Engels used to say, the main motor of history [7].

Change within unchangeable power relations: the Alma Ata Report

An unawareness of the political and economic forces that determine the underdevelopment of health seems to explain Gellhorn’s enthusiasm for the Alma Ata Report referred to somewhat hyperbolically in his article as a document that has inspired millions. As I have indicated elsewhere, the Alma Ata docu- ment also encourages changes within the realm of unchallenged power relations [18]. Change is sup- posed to take place by educating the public and by convincing the likely sources of opposition (i.e. the medical professions, the drug industry, the dominant classes) that such change is in their best interests. According to the Alma Ata recommendations, physicians, for example, will expand their area of responsibilities [19]. The drug multinationals need not fear the recommendations as they can make substantial profits from these changes [20].

The problem with this analysis and set of recom- mendations is that it assumes, as Gellhorn does, that collaboration and cooperation can in fact take place between the powerful and the powerless if they just realize their commonality of interests. However, they may not have such commonality of interests. It can be postulated that unless more substantial changes than the ones recommended by the Alma Ata Report take place, the situation is unlikely to improve much. Let me mention as one example the treatment in the Alma Ata Report of the situation of women, a situation that Gellhorn rightly pinpoints as an ex- tremely important one. The Alma Ata Report states a concern that women should enjoy the benefits of agricultural development as men do. The report recognizes that “women are engulfed simultaneously in agriculture, household management, and the care of infants and children” [21]. However, the report recommends that “women need appropriate tech- nology to lighten their work load and increase their work productivity. They also require knowledge about nutrition which they can apply with the re- sources available, in particular, concerning the proper feeding of children and their own nutrition during pregnancy and lactation” [22]. In brief, to liberate women, there is a need for more technology (appropriate form) and more education. Yet one could indeed conclude that what is needed is far more than that, i.e. the redefinition of the power of women and men within the context of a profound redefinition of all power in the society, including class

power relations. Studies have shown that in the world of underdevelopment, a revolutionary process has frequently been necessary for the liberation of both women and men [23].

The same limitations appear in the Alma Ata Report in its analysis of current realities and recom- mendations for resolving them. I believe that far more substantial changes are needed than the ones envisioned by the Alma Ata Report. Moreover, these changes will not occur without major changes in the class and other power relations within society and within medicine. Let us not forget that the Chilean Medical Association was the first association to applaud Pinochet’s fascist coup and that the drug industry helped finance that coup. Cooperation and collaboration indeed!

I want to conclude by clarifying that it is not my intent to castigate Professor Gellhorn’s article, nor, for that matter, the recommendations of the Brandt and Alma Ata Reports. All three represent serious attempts to confront the unbearable reality of op- pression existent in today’s world. However, I find their analyses of our current realities wrong and their recommendations insufficient.

As to Professor Gellhorn’s other recommen- dations, I also find myself in disagreement. His suggestion that part of the solution to today’s prob- lems lies in people-to-people assistance, bypassing government, is an extremely misleading one. To put all governments into the same category-subjects of suspicion-is an enormous simplification. Appealing as this approach may be to U.S. populists, it is irrelevant in today’s world. Indeed, there are govern- ments which are representative of their people’s inter- ests and others which are not.

Another point where I disagree with Gellhorn is his emphasis on education as a way of breaking with underdevelopment. It depends on what type of edu- cation. Again, Gellhorn’s tendency for abstraction seems to put all education in one box, packaging it as part of the solution. Is it? I doubt that having more schools of the type he recommends will make much of an impact in Harlem. Here again, his seeming unawareness of the structural determinants of pov- erty leads to the belief that the problems reside with the values held by the rulers or by the ruled ones. Values, however, reflect perceptions of interest which are, for the most part, structured by a matrix of economic, political and social forces that need to be defined and understood.

Similarly, the call to scholars “to join the tough- minded people who make history” avoids the key question of whose history? The majority of U.S. scholars see their primary role as that of rationalizing and legitimizing current power relations. As Pusey, the President of Harvard University in 1961, once said with remarkable candor, the “objective of all academic departments is completely directed toward making the private enterprise system continue to work effectively and beneficially in a very difficult world” [24]. This explains the discrimination of Har- vard and other leading U.S. academic institutions against Marxist and other voices who uphold anti- capitalist and anti-imperialist positions. In the School of Hygiene and Public Health at Harvard, where Professor Gellhorn teaches, one can count on the

National security and the health of people 325

fingers of one hand the professors who uphold Marx- ist and other ‘unorthodox’ positions.

In today’s U.S., voices like Professor Gellhorn’s need to be welcome by all because they keep touching on the key issues of our times. But, in order to provide guidance for action, their analysis must be rooted in a more radical position--radical in the sense of questioning the ideological assumptions that sustain the enormous edifice of oppression existent in today’s world. As Marx already indicated back in 1944, the role of the intellectual should include “the uncompromising critical evaluation of all that exists, uncompromising in the sense that our criticism fears neither its own results nor the conflict with the powers that be” [25]. That uncompromising radical analy’sis is needed to interpret and change the oppres- sive realities of today’s world.

9. 10.

op. cit.

II.

12.

13.

14. IS.

Davis M. Nuclear imperialism and extended deterrence. In Exrerminism and Cold War (Edited by Thomson E. et al.), p. 47. Verso Editions. New Left Review, 1982. Chomsky N. and Herman E. S. The Washingron Con- nection and Third World Fascism. The Political Economjl of Human Rights, Vols I and II. South End Press, Boston, 1979; and Herman E. S. The Real Terror Network. Terrorism in Fact and Propaganda. South End Press, Boston, 1982. Navarro V. Genocide in El Salvador. Monrh. Rev. 1, No. 32, 1981. See Davis M. op cit., and also Petras J. and Mosley M. Third World crisis is nuclear trigger. In These Times 26 October-l November, 1 I, 1983. See Ref. [7]. For a further elaboration of this point see Navarro V. (Ed.) Imperialism, Health and Medicine. Baywood, 1980.

16.

REFERENCES

1. Gellhorn A. National security and the health of the people: human needs and the allocation of scarce re- sources. Mimeograph. p. 1.

2. op cit., p. 6. 3. Ibid. 4. op. cit., p. 7. 5. op. cit., p. 5. 6. op. cit., p. 14. 7. For a critique of the Willy Brandt Report, see Navarro V. A critique of the ideological and political positions of the Willy Brandt Report and the WHO Alma Ata Declaration. Sot. Sci. Med. 18, 467-474, 1984.

8. Gellhom A. op. cit., p. 17.

17. 18. 19.

20. 21. 22. 23.

Willy Brandt Commission Report. Norfh and South. A Program for Survival. p. 126, 1980. Marx K. and Engels F. 1848. See Ref [7]. Alma Ata International Conference on Primary Health Care, Alma Ata, U.S.S.R., p. II, 1978. op. cif., p. 12. op. cit.. p. 16. Ibid. Molynewx M. Socialist societies old and new: progress toward women’s emancipation? Monrh. Rer. 34, No. 3, 56.

24.

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Pusey N. M. Age qf the Scholar; Observations on Education in a Troubled Decade, p. 171. Harvard University Press, Cambridge, 1963. K. Marx letter to A. Ruge, 1844.

THERE ANY DEFENSE AGAINST ,NATIONAL DEFENSE?

HARMON L. SMITH

The Divinity School, Duke University, Durham, NC 27706, U.S.A.

Personal and group security by means of arms is at least as old, and probably older, than recorded human history; killing, maiming, raping, pillaging and the rest are not new under the sun. As a matter of fact, we still learn the rudiments of fighting before we learn to read and write. Of course, the earliest weapons were extraordinarily primitive when compared with those available to us today: but they were effective just the same. The horror and revulsion evoked by watching filmed reconstructions of hand-to-hand combat be- tween two Neanderthals with wooden clubs may be tempered by recognizing that we’re not watching ‘the real thing’ and by the tendency to excuse such behav- ior for the same reasons we do when children fight (literally!) over toys. But that horror and revulsion is real, however repressed, and not different in kind from what many of us have experienced in the early 1940s and since.

If there is a difference between then and now, it is one of scale and (at present) humanly irreversible consequences. We have become proficient in de- signing the means for wreaking destruction to really

grand proportion, and the almost certain result of implementing those means will be to render the entire planet uninhabitable and probably irrecoverable. Why we, as our forebears, put such trust in the efficacy of arms is, at base levels, rather less complex than today’s weapons systems; and while this commit- ment can surely be expressed in many ways, it reduces to ‘You first, just after me’. It is ironic that such inordinate selfishness may be not only the cause of our nuclear dilemma but also among the short-term promises for its solution. The scenarios created by the prospect of nuclear exchanges ranging from 100 to 5000 megatons are understandably horrifying and repulsive; not only because of the immediate destruc- tion resultant from explosions, firestorms and radio- activity but also because of the lingering and long- term sequelae. Meantime, some of us wonder what it will take to demonstrate the futility of war in general, and nuclear war in particular. Alfred Gellhorn’s paper is an attempt to deal with that issue.

My initial impressions of Dr Gellhorn’s address, on hearing it at last summer’s VIIIth International Con-