Interdependencies in Health Conditions between the Caribbean and Britain: a World-Systems Perspective

Paper presented at the Caribbean Studies Association Conference, May 2001

Caroline Allen, University of Warwick

Address for correspondence: Caroline Allen, Behavioural Science Advisor, Special Programme on Sexually Transmitted Infections, Caribbean Epidemiology Centre, PO Box 164, Port of Spain, Trinidad and Tobago Ernail: allen(ii%cablenett.net;cfa [email protected]; allencarcii)carec.~aho.org Tel: 868-633 1902 Interdependencies in Health Conditions between the Caribbean and Britain: a WorMSyrtems Perspecthre

ABSTRACT

The position of the Caribbean in the world-system established by colonialism has had major effects on health and health policy in the region. This paper aims to assert and illustrate the value of a world-systems theoretical framework in explaining health conditions in the Caribbean and how they compare with those in other parts of the world.

The paper begins by presenting basic tenets of world-systems theory and the historical methodology of Fernand Braudel on which it draws. According to the theory, the Caribbean exhibits myof the characteristics of an archetypal peripheral region while Britain illustrates characteristics of the core. Core and peripheral regions are linked by trade and investment patterns, reinforced by political and military means, which serve principally to enrich the core.

The impact of the establishment of a capitalist world-economy on local disease environments is examined. The triangular trade led to a confluence of pathogens fiom the Americas, Europe and fica within the Caribbean. Health conditions between the Caribbean and Britain began to diverge widely as the colonies contributed to the development of English capitalism. I show examples of effects on English public health of the economic exploitation of the colonies, particularly the Caribbean, which led to longstanding health status differences between the UK and Caribbean.

Differential public health provisions in Britain md the Caribbean are explained. World-system theory predicts that welfare provisions will serve to reinforce support for national capital in the we, while super-exploitation takes place in the periphery as core capitalists are unwilling to support the costs of labour reproduction.

The paper concludes by discussing the impact of recent world-economic developments on Caribbean health. This paper is based on the hndamental contention that health has no borders. Diseases are not constrained by national boundaries, and socio-economic conditions which contribute to health transcend the powers of the nation-state. The transnational character of health makes it suitable for analysis using world-systems theory. According to this theory, the relevant unit of analysis is not the nation-state but the world-system.

Health and the world-system are interlinked: health conditions contributed to the character of the modern, capitalist world-system and the structure and dynamics of this system affected health. The Caribbean was incorporated very early into this system as a peripheral area serving core states in Europe. Its health history can provide important pointers as to the future of health in places which were incorporated later. Britain's health history was conditioned by its colonial history in which the Caribbean played a crucial role.

The paper begins by presenting basic tenets of world-systems theory and the historical methodology of Fernand Braudel on which it draws. These are applied to the study of the impact of the establishment of a capitalist world-economy on local disease environments and public health in the Caribbean and Britain. Transnational economic and political relationships are shown to have established interdependencies in health conditions and standards. A third section uses the theory to explain differential public health policies and measures in Britain and the Caribbean. The final section examines recent trends in the position of the Caribbean in the world-system, and discusses the impact of these developments on Caribbean health.

1. Historical methodology: the world-systems perspective

Wallerstein (1974) argued that colonisation established a capitalist world-system which has encompassed the globe in a hierarchical network of states and economies. For world-system theorists the relevant unit for macro-social enquiry is not the nation-state but the world-system. Therefore it makes little sense to examine health conditions in an individual Caribbean country or even the region as a whole without examining how the Caribbean is positioned within this system. The emphasis on transnational flows makes world-systems theory usehl in examining how diseases are propagated across the world-system. There is a remarkable congruence between economic flows and patterns across the world-system and the spread and patterning of disease across the system.

The world-system is a structure which differentially conditions the capacity for economic growth (and thus health) of particular countries. Inequalities in economic conditions lead to inequalities in health conditions. The system has internal differences corresponding to the international division of labour. Different regions of the world produce different components of commodity chains which end at the point of purchase by the final consumer. The international division of labour is structured into a core, a periphery and a semi-periphery. This structure was initially established through colonialism following the encounter of Christopher Columbus with the Americas in 1492, with colonies in the Caribbean among the ktperipheral zones serving European powers. The strategy of incorporation into the world-economy involved military and political force in the early days but now the process is achieved primarily through patterns of investment, constituting the economic component of neo-colonialism

In the core of the world-economy, high valueadded production is concentrated: i.e. there is a wide difference between input costs and the price obtained at point of sale. Products and production processes are at the top end of the commodity chain, and tend to be capital- and knowledgeintensive. Reinvestment of profits has multiplier effects, raising incomes and generating an internal market. In the periphery, on the other hand, products and production processes are, typically, low value-added and around the bottom end of the commodity chain. Production is highly dependent on investments, inputs and expertise fiom the core. Therefme a large percentage of profits tends to be repatriated to the core. For example, in the case of bananas produced in the Windward Islands of the Caribbean in 1992, only 16 per cent of the final retail price was received by Windward Island fmers, with the remainder received by European firms engaged in ripening, distribution and retailing (Nurse and Sandiford, 1995). Thus We mean by "paiperipheries" those mesthat lose out in the distribution of surplus to "core" zones. (Wallerstein, 199 1a: 109)

Semiperipheral economies, located in the middle stratum, operate as higher value-added semi- industrial producers and enjoy a higher retention of capital than peripheral zones (Wallerstein, 199 1a). The growth of peripheral countries is arrested through the appropriation of surplus by the core, which diminishes investment and spending, reducing the capacity of the local market to absorb local production, reinforcing the necessity to export. The structural dependence of these countries effectively prevents them fiom following the same path of "development" as the core countries. The implication for health promotion is that transnational factors limit the sphere of national health action more severely in the periphery than in the core. Furthermore, we can expect a greater concentration of health problems associated with poverty in the periphery, not because of failure to "modernisembut because the capacity for enrichment is externally constrained to a great extent.

A further important aspect of world-systems theory is its grounding in the historical epistemology of Fernand Braudel. World-systems theory is "structuralist", in that it emphasises forces affecting human welfare and behaviour which are largely beyond individual control. While sociologists tend to concentrate on the impact of collective social forces on people, Braudel went beyond these to highlight the impacts of geography and biology. Such an approach is relevant to the study of health patterns (epidemiology) on a global scale, though it has not frequently been used in this way (Allen, 1999).

World-systems theory encourages researchers to look at the long-term, large-scale "relationships between realities and social masses" (Braudel, ibid.) as well as the impact of short- term events and individuals. Braudel contends that much of conventional history is concerned with discrete individuals and events and short-lived phenomena: what he called "I 'histoire &inementiellen (Braudel 1980.: 3). Attention to multiple realities and.collective forces, he argues, forces one to become aware of longer timehes: trends and fluctuations which affect even if they do not determine the fragile history of the event or the notable individual. Social history is "a history of gentle rhythms, of groups and groupings" (ibid.). Historical periods are conjunctures where social, geographical and biological factors interact to produce specific outcomes(Wallerstein, 1991 b).

This paper will look at three main conjunctural phases in the relationship between health and the world system. These may be summarised as:

1. The propagation of disease across the system

2. The development of inequalities in health between core and peripheral areas

3. Attempts in peripheral areas to "catch up" with the state of health and welfare in core areas.

These phases overlap but are useful for analytical purposes. 2. The spread of disease across the capitalist world-system

The establishment of European colonies fiom the fifteenth century was to have a drastic and lasting effect on global epidemiology and demography. It was to bring changes of "longue durde ": an alteration in "the history of man in relation to his surroundings" (Braudel, 1984: 3). The point of significant historical change is the encounter of Columbus with America, which not only launched a network of economic relationships with Europe (and later the USA) at the centre (Braudel, 1977 and 1984; Wallerstein, 1974) but drastically altered global disease environments (Pelling and Harrison, 1995; Doyal, 1979).

The annexation of America was a major factor enabling capitalism to emerge in a world- encompassing form. The periphery began to be used for the production of raw materials by a relatively unskilled and coerced labour force, and this became part of a world division of labour serving the centre (Wallerstein, 1974). Europeanised America became "the periphery par excellence" (Braudel, 1977: 91) in that its production and social structure became entirely subordinated to European capital. In the Caribbean, peripheral exploitation took a particularly extreme form, as highlighted in the following passage by TrouilIot (1981: 37-8): [Carl-] islands were.. . Europe's earliest and - for a long time - most 'dependent' colonies; colonies in the most complete sense, especially after the Amerindian genocide. populated, organized, shaped iiom the outside m accurdancc with the mercantilist dream of remote social entities whicb would exist.. .'only by and for the metropolis'. .. Here more &an anywhere else, m the hceof indigenous polities and cultures, one would expect only mechanical responses to world-historical forces, circunscribed by the external and homogeneous imposition of an almost total dependency.'

The archetypal peripheral status of the Caribbean makes the region a useful case for the analysis of relationships between colonialism and health.

Disease environments and the wesfern encounter with America

Health conditions in the three geographical regions subsequently linked by the "triangular trade" were to have profound historical effects.

Urbanisation contributed to successive waves of bubonic plague in Europe. The epidemic of the 14th century was aggravated by limits on agricultural productivity accompanied by a demographic explosion, and killed 20 million people in Europe in the years 1347-50 alone. The

Trouillot goes on to show that despite the extreme dependency of Caribbean territories, there were important instances of slave resistance - people are nd passive in the face of economic and political structures. However, my concern m this section of the papa is with health conditions and not with personal actions in response to them. population of England and Wales may have been reduced by anything up to one-half in 1348-9 (Ashton and Seymour, 1988; Gray, 1993). The plague contributed to a European economic depression which was to last 150 years and was aggravated by the Muslim and Turkish restrictions on easterly trade routes. This provided an impetus for Columbus' mission to find an alternative route to India by sailing west in 1492 (Braudel, 1984). Thus the disease environment in Europe, in conjunction with politically induced restrictions on economic activity, serve as important explanations for the establishment of European colonies fiom the late fifteenth century.

Health conditions experienced by Europeans in Africa consolidated the choice of the Americas for the expansion of tropical agricultural production. Though Afkica is nearer to Europe, voyages there became known to be very risky for Europeans. So many contracted endemic Afkican diseases that the continent earned the name "the white man's grave" (Pelling and Harrison, 1995; Sheridan, 1975 and 1985). By the time plantations began to be established by Britain in the Americas in the latter balf of the seventeenth century, the remaining Amerindians had many of the same immunities as the Europeans themselves; those establishing plantations therefore encountered few unfamiliar diseases. While Europeans of course exposed themselves to these diseases by transporting slaves from Africa to the Americas, the terrible codions on slave ships served to eliminate many people carrying disease, and the weaker among those who survived the journey generally died within a short period.2 Planters' residences were generally established at some distance fiom areas where slaves lived, Mershielding the Europeans (Sheridan, 1975). The difference in disease environments was reflected in widely differing death rates; British troops stationed in West Afiica in the early eighteenth century experienced death rates between 483 and 668 per thousand, as compared with rates of only 85 to 138 in the West Indies (Sheridan, 1985: 12).

At the time of the encounter with Columbus, indigenous people of the Americas were dangerously exempted &om the disease pools of the Old World. About 12,500 years ago their ancestors came across the Bering Strait from Asia to Alaska and were sealed off from the Old World by the end of the Ice Age about 10,000 years ago. In south and central America, as populations congregated, some kinds of tuberculosis developed, and intestinal parasites and hepatitis passed from person to person through water and food. The Americas had very few unique diseases, limited perhaps to rocky mountain spotted fever and Chagas' disease. The

Estimates &om various English colonies of the proportion of slaves who died during their first three years in the Caribbean range f?om 25 to 43 per cent (Sheridan, 1975). indigenous people had no immunity to most of the pathogens brought to the Americas by Europeans and Afiicans (Kiple, 1996).

The astounding catalogue of diseases brought fiom the "Old World" included smallpox, measles, diphtheria, trachoma, whooping cough, chickenpox, bubonic plague, malaria, typhoid fever, scarlet fever, dysentery, cholera, yellow fever, dengue fever and influenza. Colonisation also probably brought typhus, brucellosis, erysipelas, filariasis, mumps, onchocerciasis, relapsing fever, leprosy and hookworm disease (Kiple, 1996; Fraser, 1992). These infectious diseases continue to affect Caribbean and South American people, constituting an environmental change of longue dur6e3.

The decimation of the Amerinidian population was a catastrophe of far greater magnitude than the plague epidemics of Europe. It is estimated that about 90 per cent of the 1492 population of the Americas was eliminated, most killed not by military conquest but by foreign diseases. Estimates of the absolute number who died range fiom around 50 million to 100 million (Kiple, 1996). Amerindian mortality led the colonialists to introduce increasing numbers of Afiican slaves to the continent (Williams, 1964; Beckles, 1990), changing the ethnic and cultural demography of the Americas.

As regards the Caribbean specifically, Hispaniola was the site of the first American epidemic in 1493 - probabiy swine influenza. Other diseases followed so that West Indian populations were in decline even before smallpox was recorded in the Caribbean in 1518 (Kiple, 1996). Smallpox was to remain as a major killer of Amerindians and slaves, particularly before the introduction of inoculation for smallpox in the 1760s in Europe, and later in the colonies (Porter, 1996; Sheridan, 1985). Different strains of malaria were brought fiom both Europe and Afirica. The falciparum strain killed many Amerindians but Afiicans had a degree of immunity through the development of a sickle trait in red blood cells as a result of long exposure in Afica (Sheridan, 1975).

Yellow fever emanated fiom Afiica and slave ships probably brought its principal vector, the aedes aegypti mosquito (Sheridan, 1985). In 1647, an epidemic in Barbados spread throughout the Caribbean and American coastal cities. In 1793-6, yellow fever killed 80 thousand men fiom the British Army in the West Indies. It accounted for a substantial proportion of the 40 thousand French who died in their abortive attempt to regain St. Domingue fiom the slaves (Kiple, 1996). Yellow fever remains one of the important infectious diseases in the Caribbean and the aedes aegypti is also responsible for spreading dengue fever which periodically breaks out, occasionally causing death, particularly in its haemorrhagic form. Hookworm, yaws and leprosy, which had previously disappeared from Europe, came to the Caribbean on slave ships (Kiple, 1996). Yaws, while usually not fstal, brought disfiguring morbidity during slavery (Sheridan, 1985).

By the nineteenth century the Caribbean was thoroughly established as a peripheral area of Europe. The triangular trade created a hybrid disease environment in the Caribbean consisting of diseases fiom the Americas, Europe and Mica. Tuberculosis was brought &om Europe, and killed many Amerindians and A.Erican slaves. It is estimated that death rates from tuberculosis reached 1 in 100 in the Caribbean in the early part of the 19th century. Slaves suffered mostly from scrofula, the glandular form of tuberculosis. Before the 19th century, cholera was confined to India, but appeared outside India from 1817. By 1831, at the height of the imperial exploitation of India, cholera reached England, and only two years later it arrived in the Caribbean. There were six other global pandemics fiom cholera before 1961 (Kiple, 19%; Lewis, 1997). Thus colonialism led to the spread of disease across the expanse of the European world-economy.

While the notable characteristic just outlined was the spread of disease between areas of the world-economy, in later periods this diffusion of disease would persist but be supplemented by increasing inequality and the concentration of diseases of poverty in the periphery. To understand the development of this inequality we must shift our attention to epidemiology and demography in the core economies of the Old World.

3. The development of global inequalities in health

3.1 Disease environments in the "Old World": the case of Britain

Has Europe not always celebrated Columbus' voyage as the greatest event in history 'since the creation'? (Braudel, 1984: 387)

Eric Williams (1 964) showed how slavery contributed to the development of capitalism in Britain. This section explores the health consequences of this development. The encounter of Columbus with the New World brought immense economic benefits to Europe, which helped

An exception is smallpox, which was eventually eliminated world-wide in 1980, partly as a result of a concerted campaign by the World Health Organisation. populations to expand and people to survive longer, while eventually introducing different health problems associated with industrialisation.

The earliest bonus to Britain was probably the potato, introduced from America in the sixteenth century by Walter Raleigh. It became a staple of working class diets, was the predominant influence on the growth of population in Ireland, and also affected population growth in England from about 1750 (Gray, 1993; Pelling and Harrison, 1995).

The early period of Spanish and Portuguese colonisation was dedicated to the pillage and then the mining of precious resources - gold and silver. Capitalists throughout Western Europe profited by providing the initial capital and outlets for Spanish and Portuguese products. An inflow of silver from America in 1560 enabled the protection of the value of Britain's currency, sterling; the resulting stability was a major factor behind industrial expansion (Braudel, 1984). Increased quantities of bullion led to a fall in interest rates, encouraging investment in productive sectors (Wallerstein, 1974). The gold and silver of the New World enabled Europe to live beyond its means, to invest beyond its savings. (Braudel, quoted in Wallastein, 1974: 128)

The expanded money supply engendered a long-term rise in grain prices. This was initially damaging for consumers (real wages lagged behind until around 1600 in England) but beneficial for producers, who were able to ride out periodic and seasonal falls in production while investing in expanded and new forms of production. Productivity was improved fiorn the eighteenth century by new techniques such as crop rotation, stock-breeding and improved drainage and fertilisers (Gray, 1993). Between 1650 and 1750, agricultural production rose faster than population; Jones (in Braudel, 1984: 558) argues that this gave the economy the boost it needed to begin the industrial revolution. The abundance of food led to high demand for labour to get the harvests in, and to a rise in real wages as grain prices fell, both developments improving overall standards of living, which in turn encouraged a rise in the birth rate (Gray, 1993; Lane, 1978; McKeown, 1976).

The development of slavery in the Americas was used to provide cheap raw materials to the European market, enabling capitalists to pay wages and provide affordable goods to the emerging proletariat which improved their health. It thus helped develop social solidarity at home. Williams (1964) shows that in many cases owners of plantations and captains of British industry or banking were the same people, the profits from sugar or slave trading being ploughed back directly into their British concerns. Sugar was a vital ingredient in the preservation of many foods, extending their availability in periods of fresh food scarcity such as the winter months (Braudel, 1984; Mine 1986; Webster, 1995). Because many raw meterials and foods were imported, agriculture in Britain was able to diversifi with increasing devotion of land to livestock rearing, bringing meat and dairy products and thus increased protein into the diet of many, improving strength and endurance. Manure from livestock improved the productivity of arable land (Braudel, 1984; Lane, 1978).

The colonies were also vital in providing markets for British goods. While in Europe British goods were subject to stiff competition, in the colonies, Britain was able to exert force to ensure that British products were bought, literally fighting off competitors by military means. Trade was assured by the might of the navy: rapid improvements in British sea transport technology enabled the speedy delivery of goods. The amounts contributed by trade with the colonies were by no means negligible: India alone contributed about E2 million every year fiom 1750 to 1800, compared with total investments in the British economy of £6 million in 1750 and £1 9 million in 1800 (Braudel, 1984).

In the sixteenth and seventeenth centuries, the British population increased very slowly. From 1700, it began its inexorable and ever more rapid climb. Standing at around 5,835,000 in 1700, it had reached 6,665,000 by 1760, the date when many scholars agree the industrial revolution began. Around 1740, births began to exceed deaths on a consistent basis. After that population growth accelerated to reach almost 18 million by 1850. Population doubled again between 1850 and 1900 (Braudel, 1984; Lane, 1978; McKeown, 1976). It is notable that industrial success and rapid population growth coincided with the period of British hegemony within the world-economy, fiom around 1815 to 1914.

Thus, as Eric Williams (1 964) argues, colonial control over Caribbean economies based on slavery facilitated the early preindustrial stages of a capitalist world-economy. With growing disparities in standards of living arising fiom different forms of labour exploitation, health conditions between the "core" and the "periphery" began to diverge. Health improvements in the core were made possible by the joint multiplier effects of investment of profits fiom the colonies and the existence of a wage economy in a context of rising real incomes, along with the direct health benefits of the raw materials produced in the colonies. 3.2 Relationships between public health systems under coioniaiism

State concern for people's welfare in Britain emerged in the nineteenth century against a background of severe social and health problems associated with rapid industrialisation and urban overcrowding (Engels, 1969). The situation was ripe for the rapid increase of epidemics; cholera, tuberculosis, scarlet fever, bronchitis, influenza, measles and pneumonia spread rapidly (Ashton and Seymour, 1988; Lewis, 1997; Szreter, 1995). Cox (1 987) notes that in Britain, as in a number of other European countries, state welfare provisions emerged during the period when imperial power was at its height. He sees welfare and imperialism as interlinked, and coins the term "the welfatenationalist state" to denote this. He follows Marxist thinking in arguing that welfare provisions sought to satisfy the needs of the population to prevent uprising against the capitalist system. Connected to this was imperialism, which combated the tendency for the rate of profit to fall by acquiring new markets and investment opportunities. Wealth obtained through exploitation of the periphery enabled the development of an extensive health and welfare system. Nationalist public propaganda stressed the glory of the empire and urged citizens towards self- sacrifice in the interest of Great Britain. Wallerstein (1 991b) argues that raising living standards in the core expands the market for goods which enables the concentration of high valuaadded production there. On the other hand, imperialism supplies cheap labour assured by more repressive political structures (Chussodovsky, 1981).

The nineteenth century saw the development of partnerships between social reformers and doctors in Britah weifhrbm and science began to walk hand-in-hand. In 1842, the Poor Law Commissioner, Edwin Chadwick, published the Report on the Sanitary Conditions of the Labouring Population of Great Britain, containing a series of "sanitaryn maps demonstrating a strong correlation between the level of economic prosperity of a district and its mortality rate. In 1849, Dr. John Snow proved that contaminated water supply was responsible for the spread of cholera in London. The work of Chadwick and Snow influenced the establishment of state support for various forms of environmental and social engineering, including the public provision of Medical Officers of Health, sanitary inspectors, and of water and sewerage systems. Even earlier in the century the government set up Boards of Health and began to regulate conditions in factories and parish workhouses (Ashton and Seymour, 1988; Rawson and Grigg, 1988). By 191 1, Lloyd George's National Insurance Act provided compulsory insurance for low paid workers in regard to General Practitioners' services and a tixed fee for each person on the GP's register. A major concern was to involve medicine in the fight against poverty which was thought to hold back British progress: Lloyd George made the connection between welhre and imperialism by remarking that a C3 population would not do for an A1 empire (Lewis, 1997). State legislative and substantive provisions for public health expanded throughout the first three- quarters of the twentieth century, exemplified most forcefully in the National Health Service.

Between the world wars, the Great Depression brought a hll in living standards and a rise in unemployment across the world. In Britain, a General Strike in 1926 protested at the harshness of living conditions and led John Maynard Keynes to recommend an increase in public expenditure to stimulate aggregate demand and thus raise overall prosperity while absorbing unemployed labour (i.e. protecting profit margins at the top of the commodity chain). The colonies suffered fiom the recession as a result of their dependency on trade with the West. For a long time social discontent had been brewing, fuelled by the perception that discriminatory, racist forms of government were operating in the colonies. Colonists throughout the British Empire were entitled to better forms of health and other forms of welfare provision than the population at large. Significant numbers of people had travelled to Europe as students or workers and had been struck both by its relative affluence and by social inequalities. Some had fought in the First World War and seen that working class Europeans were also exploited, but that their own position was compounded by racism. Some, like George Padmore and C.L.R James of Trinidad, were to combine socialism with the development of solidarity against colonialism and racism (Martin, 1984).

Labour militancy and racial consciousness spread to the colonies and resulted in widespread social protests, rioting and strikes. In Trinidad in 1933, there was a small demonstration by unemployed workers, followed by a larger demonstration of 400-500 unemployed the following year, accompanied by strikes on sugar plantations. These led to the appointment of a committee of enquiry. From 1935 strikes spread across the British colonies in the Caribbean: St. Kitts, followed by St. Vincent, then St. Lucia (1935), Barbados, then Trinidad (1937), Jamaica, then Guyana (1 938) (Hart, 1993; Lewis, 1993). In 1938 the British government launched a West India Royal Commission to investigate social conditions, which came to be known as the Moyne Commission (Cmd 6 174, 1940 and Cmd 6607, 1945). Memoranda were submitted to the Commission by a wide range of individuals and organisations, including associations of local nurses and social workers. While the majority of these petitioned for improved pay and conditions of service, there were some recommendations concerning improvements in health and welfare service provision and regulation to protect the public (Memorandum 893 to the West India Royal Commission by the Trinidad and Tobago Coterie of Social Workers). In 1938, Arthur Lewis of St. Lucia wrote a book, Labour in the West Indies: The Birth of a Workers Movement, published by the Fabian Society, which was highly critical of colonial policy and laid out recommendations for economic policy, industrial legislation, taxation and redistribution. Notabty, it recommended that Britain should offer improved preferential prices on West Indies sugar, atad give loans and grants "to build and equip hospitals and clinics, to drain swamps and supply drugs for a concerted attack on malaria, yaws, venereal diseases, children's diseases, and other ailments of the people" (Lewis, 1993: 368).

The general burden of the Moyne Commission report was to emphasize the need fa considerable extensions in the public social services provided by the governments of the West indies, and to state the case fapreparing a gend scheme fathe social reconsbructim of the communities concerned (Simey, 1947: 26)

The report recommended that a West Indies Welfare Fund be established to provide expenditure on social services and development, to be financed by an annual grant fiom the British Treasury of El million a year for a period of twenty years. The grants were to be devoted to the financing of schemes to improve education, health services, housing, slum clearance, social welike facilities, land settlement and the creation of labour departments. Thus the principle of welfarism as a solution to social protest was to be extended to the colonies. However, the hial recommendations of the Commission were merged into a wide scheme applying to the whole colonial empire, whereby sums of £5 million for general purposes and £500,000 for research were made available. It became the duty of the Comptroller of the West Indies Welfare Fund to propose schemes for grant aid in collaboration with West Indies governments. This cumbersome procedure led to an implementation of new health and wekeschemes which was so slow that it resulted in heightened strident West Indian calls for political independence (Simey, 1947). It was clear then that the extension of health and welfare provision to the colonies had been undertaken only grudgingly, and with such huge inertia that it came to disbursement of only a very small amount of funds. The differential treatment of the home country and the colonies by Britain with regard to health and welfare provision persisted. By 1945, it was apparent that welfkism should be extended at home, and that its extension to the colonies was therefore increasingly unaffordable. Furthermore, it had done little to stifle the call fiom colonial subjects for political independence. Granting political independence to the colonies served to shift welfare costs onto the newly independent postcolonial states while conserving resources for welfare provision at home. 4. Recent developments In the world-eystem: implkations for Caribbean health in the po8tcolonial em

In colonial times Caribbean people were systematically excluded, as we haw seen, fiom forms of health and welfare provision granted to the colonialists. The locally based ruling class was "the core in the peripheryn, far more loyal to the core than to local people, sharing core values and where possible, lifestyles, and rewarded by preferential treatment by the colonial country. Adherents of the plantation model of Cariibean society argue that such social structures and loyalties persist to the present day (Levitt and Best, 1993). The entrepreneurial class is concentrated in international trade and is highly influenced by metropolitan values and culture. They produce only a small component of any commodity chain, tending to engage in tminal activities of resource extraction at the me end of the spectrum and distrihtion and ha1assembly of imports at the other. (I..evitt and Best, 1995: 406)

Vertical linkages with the core are strong, while linkages within and between Caribbean countries are weak (Nursc and Sandiford, 1995: 128).

During slavery, the Western medical model was imported as doctors fiom England and Scotland came to serve the plantations (Sheridan, 1985). They provided health care for the planters and in cases of more severe illness for the slaves. The association of Western medicine with privilege has arguably had a lasting effect on the forms of health care and health-seeking behaviour in the Cariibean today.

Caribbean countries have continued to play a peripheral role in the world-economy. Their incorporation at an early stage bas had certain economic benefits through high levels of trade and preferential access to markets. Thus the Caribbean is not as poor as some areas which were incorporated later into the global economy. However, economic development has been of a highly dependent form, highly subject to the vagaries of the world market, and with Caribbean people reaping a hction of the profits of their own labour. Markets for primary products such as sugar and bananas have been subject to keen competition as core countries have diversified their sources of supply. Prices obtained by primary producers have been unstable and declined in real terms (Nurse and Sandiford, 1995). Tourism and other service industries have not broken the mould as they rely heavily on foreign investment and inputs. The Caribbean continues to supply cheap labour (e.g. hotel workers) and the raw material (sun, sea and sand).

The implications for health and health care in the region include the following. Cariigovernments bave attempted to build western style health care and welfivc systems but have been stymied by lack of resources. They have tried to concentrate resources on the poorest while the lack of equipment and adequately paid staff has made the system a last resort for many people.

By the time most Caribbean colonies achieved independence in the 1960s and 1970s, a biomedical service centred around hospital provision was the norm in the West. This was accepted as the appropriate model, as nationalist governments became involved in a perpetual struggle to "catch up with" the West (Sack, 1992). Only very rarely was this norm challenged and alternatives arising fiom other systems of knowledge proposed. The result is a system inadequately focussed on primary care and prevention (Allen, 1999).

Metropolitan trends in management and organisation of health (e.g. the shift away fiom direct provision towards regulation and "health promotion") continue to be promoted by the concentration of higher education and training institutions in core countries.

The position of the Caribbean in the world-economy is such that it has a high level of access to important markets in Europe and North Amaica. Economic growth has on the whole been positive, and has created health benefits. For example, in the 1960%nutritional deficiencies and infectious diseases accounted for 20 to 50 per cent of deaths in the Commonwealth Caribbean. By the late 1980s, these accounted for 2 to 7 per cent of deaths (Sinha, 1995).

Cariibean countries generally have middle range per capita incomes but in many countries this is accompanied by high levels of economic inequality. This is associated with unusual health patterns. Unemployment and poverty have generally risen since the recession and structunrl adjustment policies of the 1980s. Infectious diseases associated with poverty have since staged a resurgence and been compounded by HIV, which is four times as prevalent as in the rest of the Americas and second only to Sub-Saharan Africa. At the same time chronic non-communicable diseases (CNCD) have reached extremely high levels, and are the leading causes of death.

A number of historical factors associated with the position of the Caribbean within the world- system may help explain the high prevalence of CNCD. These include the high carbohydrate diets established during slavery and the taste for sweetened food. As Mintz (1 986) showed, sugar became a staple of British diets across the whole population in the nineteenth century; tastes and food preparation practices were shaped by what was happening in the metropole as well as by the local availability of sugar. The emulation of Western diets persists to this day in the high consumption of fsst food Sinha (1 995) shows that the proportion of calories available in the Cariibean accounted for by imports hes risen between 1975 and 1990, and that countries with higher per capita caloric availability also have significantly higher mortality due to diabetes. Often imported foods are processed, packaged and high in artificial chemicals and are nutritionally poor when compared with locally grown hits and vegetables. The dependency of Canibean countries on imports to meet basic needs may thus be associated with rates of non-communicable disease. This is not to deny the role of genetic &ctmin contributing to the high prevalence of CNCD, but to offer additional explanations. These explanations are explored in more depth in Allen (1998).

Young (1 995) argues that colonial discourse gained much of its power through apjxaling to the desires and aspirations of the colonised. Levitt and Best (1993) maintain that plantation economies tend to be associated with preferences for products fiom the core and semi- peripheay. In an era when advertising and brand fetishism have reached new heights of sophistication, Caribbean people have faced growing inequality in access to high valueadded products. Stress-related health problems, including violence and substance abuse, may be associated with this "desiring complex" of the capitalist world-economy. Moreover there is increasing evidence that young people in the Caribbean are placing themselves at risk of HIVI AIDS by having sex with people who could enhance their access to "brand names".

Conclusion

Eric Williams forcefully argued that slave exploitation was at the root of the British Industrial Revolution and imperial success. Britain also derived enormous health benefits fiom its colonies, including the Caribbean. The world-systems approach provides a coherent explanation of long-standing health inequalities between Britain and the Caribbean. It offers a Mework for understanding the relationship between colonial history and changes in the disease environment as well as in public health policy.

Since decolonisation, the economic and political ties between Britain and the Caribbean have weakened, and thus health interdependencies between them have diminished. However, colonisation had the long-term effect of establishing the Caribbean as a peripheral region of the world-economy, highly dependent on trade and foreign investment and culturally disposed to consumption of sophisticated products fiom core countries. The result has been the coexistence of high rates of chronic non-communicable "diseases of modernisation", infectious "diseases of poverty" and social problems such as drug abuse and violence. In that the Caribbean was incoprated into the periphery of the capitalist world-economy earlier than many regions, the Caribbean may provide important pointers to the future of health in "developingncountries.

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