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.
