94. ETHICS AND IDEOLOGY IN THE CONTEXT OF HEALTH

94. ETHICS AND IDEOLOGY IN THE CONTEXT OF HEALTH

CLAUDIO SCHUFTAN, MD
schuftan@gmail.com

What drives health professionals in their daily work? Why did they choose health and not another field? Presumably it is the appeal of working, either locally or globally, to alleviate the suffering caused by (preventable) ill-health. This article explores the political awareness of health professionals, the political implications of their daily activities and suggests an enhanced role for them in the battle against preventable ill-health worldwide. The starting point for this article is the motivating principles behind these professionals as individuals.

[The topic of the above title has vividly interested the author for many years. It is fascinating to him that the issues at stake have not changed for the last 25 years. As proof of this –and on purpose– references dug-up and quoted are only those published before 1985. Considerable material was available already then, but the difficulty was to find a unifying thread through the swamps and jungles of the raw data. The end result has been the (re)construction of a scenario that has been stubborn to change and that looks into most of the burning questions of then and now on the issues pertaining to the title of this contribution].

1. Health professionals active in the international arena, and health institutions, seem to be compelled by quite different motivations in the battle against preventable ill-health, malnutrition and surplus deaths. There seem to be three discernible approaches:

The amoral approach:
2. Although it can be assumed that most health professionals are attracted to health because of its relevance to people and societies, some of them stop their concerns just here; having become involved in health as a career, they often think that that is (and will be) their contribution to society as concerned human beings, as if health care per-se, or doing one’s job efficiently in a technical sense, were a magic tool of change. I call this motivation the amoral approach to health, although it really falls under the scope of an ethics of achievement. Because of its narrow scope, this approach has little to offer to the resolution of preventable ill-health in the world. So, at what point is concern with health care per-se really socially useful?
[Of course, we could also conceive of two other approaches, an immoral approach to preventable ill-health –those cases in which someone in the health profession does not care at all about the issue of preventable ill-health in the world and in its surrounding environment –and a situational approach in which standards are made up, as convenient, for each circumstance depending on ‘where the wind blows from’].

The moral imperative:
3. This drive is based on the judeo-christian-muslim (and other religions’) ethics that calls for compassion, charity, virtuousness and righteousness. This imperative of moral responsibility is at the forefront of many voluntary agencies working in health. In this category, we can find at least two types of individuals or institutions:

• Those who object to the capitalist system’s injustices and feel that their duty is to do something about preventable ill-health which they perceive only as one of the injustices, assuming that others will attack the system in other fronts. (We can also call individuals in this group ‘moral objectors’ or ‘progressive humanists’).

• Those who, embracing the capitalist system as desirable, but as out of control, cannot morally tolerate the extreme poverty and preventable ill-health the system generates and feel compelled to do something about preventable ill-health to mend this important shortcoming of the system. We can also call these individuals ‘humanitarians’, or more pejoratively, ‘moralists’, since they have made these issues a matter of personal conscience, but lack a visible further rationalization.

4. This sense of responsibility as a motivation found in many colleagues, does not seem to be sufficient either to see necessary changes occur: it leads to a dead end. It may solve the conscience problems of the person who devotes her/his time and effort to do ‘something’ to solve the problems at hand; however, it seems to have little effect on the real problems of the poor and vulnerable to more aggressively engage in preventing diseases –mostly the diseases of poverty. This is why groups in this category so often go on repeating weary slogans and pushing traditional health interventions that solve nothing much in the long run. In short, these positions lack political perspective. A genuine concern for the poor, even as part of a holistic approach, does not seem to be enough if it is not channelled in a political way.

5. The concept of being-socially-responsible-in-health is nothing but a euphemism for what really should be political responsibility, i.e., do we really have a choice not to take political sides? Rights, after all, are at the intersection of ethics and force (or correlation of forces).2 A political commitment is important, precisely because governments function as political entities.3 Moral causes have usually made progress only when powerful interests saw their advance as having ‘something in it’ for them.4 In such cases, moral imperatives were used politically.

6. A moralist’s attitude often comes from a religious imperative; if this religious imperative pushes people to act politically, they would tend to be more in the right track. But, if it pushes them to act ‘religiously’, by turning the other cheek, they are most probably doomed to fail in affecting the scourge of preventable ill-health in the long run.
[While the world’s religions condemn avarice as a deplorable vice, the world’s economists exalt it as a cardinal virtue. (To an economist, it is greed, not love that makes the world go round). Unlike priests, economists know that avarice is useful in understanding some of the major issues in today’s economy. Avarice is the opposite of the weather. Everyone talks about the weather, but no one does anything about it. No one talks about avarice, but everyone does a great deal about it, and that is why economists believe that greed makes the world go round (J. Gipson).

The political (ideological) imperative:
7. An emotional commitment is loose and romantic; an ideological commitment is more militant. People or institutions that fall under the latter category strongly feel that the capitalist system is wrong, that it generates and maintains preventable ill-health and they set out to fight its injustices, either by reforming it deeply or by trying to replace it with a more human-oriented system, more responsive to the already internationally sanctioned health rights of all people (‘So foul a sky clears not without a storm’, Shakespeare’s King John). People who take this latter position also depart from a moral imperative, but they have gone further. So at the root of the ideological problem there is a moral problem.5

8, Are individuals who take such a political position, on a more realistic track? It is clear that they look more into the ultimate (social) determinants of preventable ill-health which are to be found in poverty and in the different parameters of social injustice. Therefore, they would seem to be on the right track, or at least asking the right questions. (Of course, one could also conceive a political imperative from the right, neoconservative, pro-capitalist ranks, but this tendency is rare; it can be found in some people who work for or represent transnational pharmaceutical houses).

How is our ethos formed?
9. Social values and duties are implanted into and become imprinted in us early in life during our families (especially in our pre-school age) and later (in our school-age and in our teens); they are also acquired through our education and our social environment. All of the above are largely determined by our social class extraction. Some of the moral issues so acquired have universal validity; for many of us they are within the judeo-christian-muslim ethics; its general principles are not necessarily class-bound and are mostly expressed in a non-ideological way (although some of them most definitely are both class-bound and ideologically expressed).

How is our ideology formed?
10. Ideological values and duties are imprinted by the family, through education and by the social environment too (especially during adolescence). Therefore, most of the time, the ideology tends to be pro status quo (almost by definition, since the survival of that ideology would be otherwise at stake). Moderateness has a clear connection to the prevailing ideology and is the way in which the pursuit of material improvement and the non-material value-system are held together.6 Ideology is definitely not universally shared and is definitely bound more closely to our social class extraction.

11. Health workers are, additionally. influenced by the experiences they have had in the different political systems in which they have been trained and have been operating.7 Cultural and ideological bias is, therefore, unavoidable. Many colleagues tend to think of themselves as apolitical: but there simply is no such thing. Despite the fact that the spectrum of choices is a continuum, in the last instance, one either condescends to the system or one objects to it –totally or partially. Any of these are political stances.

12. Objection to the system is always the result of a conscious, voluntary effort to break with all or some aspects of the prevailing ideology. Going along with the prevailing ideology is less frequently a conscious, voluntary step; it is more often an unconscious ride-along attitude.

13. Ideology has several meanings.8 Ideology as a ‘content-of-thinking’ and as an ‘intellectual pattern’ reflects the involuntary elements of ideology which we all have and probably keep for life; it’s part of our indelible (class) heritage. It is ideology that channels our social behaviour in predictable directions. On the other hand, ‘ideology-as-an-integrated-politico-social-programme’ is the result of a voluntary internationalization of the values of a given society, be it real or utopic. This has a key influence in our stance towards health in general.

Liberals and radicals: a typology

Liberals
14. In the West, objectors to the capitalist system have often been divided into two main groups, pejoratively named liberals and radicals. Liberals are basically objectors that look publicly neutral but are morally anti-establishment. Although liberals are considered opposition forces, they often only accommodate capitalist logic: they think that changes within the system are called for. Probably because of this, numerous internal ideological inconsistencies can be found in their reasoning. They believe the world to be profoundly other than it should be, and have faith in the power of human reason to change it. Basically, they are scientific optimists and their theory and aims for a new order are often vague and inconsistent.

15. There are also those liberals who feel impotent to change the system, although they disagree with it. They tend to be rather cautious in the implementation of actions that will amend the prevailing system. They tend to work in the prevailing system’s bureaucracy (national or international), in academic or in think-tank institutes and are often skilled at using their organizations to further their interests. They often even sit in many of the establishment’s decision-making bodies.

16. Liberals often go along with the ‘content-of-thinking’ of their class of origin. which is mostly middle-class. They are outspoken in public, although often eminently declarative and formal; they openly denounce the evils of poverty and preventable ill-health and are, nevertheless often involved in token health interventions; or, they keep inventing new ‘more comprehensive’, or ‘multi-sectoral’ approaches to old problems as if these would change the major contradictions and the distribution of power within the system that is causing the problems to begin with. Liberals, for sure, coined the concept of ‘health planning’, so widely abused as the most rational panacea to solve preventable ill-health in the world, only to find out that little has changed for the poor majorities in the world; if anything at all, gaps have widened.

17. Liberals are often manipulated and used by ruling elites and their pressure groups and they are perceived as no real threat to the system of conservative politicians; they are, therefore, let alone to protest as much as they want following the logic that dissidents are to be incorporated or tolerated, as long as so doing reduces levels of conflict and increases the system’s macro-efficiency.9

18. The liberal approach embraces what it calls an ideology in terms of what really is a reformist social program. Therefore, this liberal imperative misses the real political perspective. It ultimately also lacks the political clout to change the system as it affects preventable ill-health and unnecessary deaths.

Radicals
19. Radicals or ‘leftists’ are probably more affected than liberals by the use of this pejorative labeling. They are thought of broadly as temperamental activists ready to destroy the free enterprise system. Most of the time, this simplistic view is not accurate. Radicals are generally characterized by a more idealistic commitment to pursue the solutions to the final and most important determinants of poverty and preventable ill-health. They definitely question the principles of social justice of the capitalist system and of the prevailing ideology: they strive for a better, more rational politico-social programme; they aim at generating social commitment in health, because they use an ideological approach in these efforts, there tends to be more internal consistency and more comprehensiveness in their approach to the problems of preventable ill-health.

20. Radicals tend to be action-oriented and verbal, constantly pointing-out contradictions in the system that leads to preventable ill-health and premature deaths. They spend a lot of time denouncing the inequalities and injustices they see and, within their ideological framework, they make an effort to propose possible solutions to solve the major contradictions; they use every opportunity they have to share these concerns with their peers, sometimes with decision-makers and, as much as possible, with members of the community that are suffering the problems themselves. They often work for the same bureaucracies that liberals do and academe is also one of their preferred refuges. They tend to be skeptical about traditional top-to-bottom health intervention programmes, although as the liberals, they often participate as actors in some of them. But more often they use these projects r programs as a vehicle for organizing the beneficiaries at the base to let them start solving their own problems, and to help them gain some additional power to do so. Ultimately, they feel an urge to contribute to the liberation of poor people from social oppression and exploitation.

21. Furthermore, they pursue those changes that they believe have a real potential for solving preventable ill-health. If the changes called for could be accepted and implemented by the prevailing system, the system itself would not necessarily become the target of radicals. But since the necessary changes cut deep into the basic structure of society, they are in conflict with the capitalist system and its basic principle –profit maximization.

22. Radicals prefer to by-pass traditional government bureaucracies and work at the grass roots as a port of entry, organizing the people around their problems. An important intervention for radicals, at that level, has to do with the task of making poor people aware of their problems in a political context and then organizing them accordingly. It is expected that people will channel their felt needs towards activities of self-help (if problems can be solved locally), or towards an organized fight for outside inputs (and changes), be they governmental or not, if outside action is needed.

23. Often, both liberals and radicals transcend the domains of pure or applied science, digging deeply into the underlying politico-economic issues, i.e., the social determinants of health. Nevertheless, the conclusions drawn, the actions proposed and seen-through and the channels utilized by the two groups are different in kind. This should come as no surprise, since even ‘objective’ analysis and diagnosis techniques are ideologically biased. One sees what one wants to see –and one finds what one wants to find. Even thinking about preventable ill-health in social and economic terms does not automatically assure commitment to something significant being done about it.

24. Of course, some health professionals fall in in-between categories, between liberals and radicals. After all, each of us arranges her/his universe and her/his role in it as well as s/he can. People in this limbo are either in a slow transition to either category, or are permanently in-between. The latter, for sure, have a heavier burden to carry, since one can presume they have to confront more everyday contradictions within themselves.

How relevant is our work?
25. A lot of semantic diplomacy bridges ideological differences in every-day contacts between health professionals. In trying to solve the problem of preventable ill-health, intra-professional responsibility should not be neglected. This means pooling together the genuine and honest predisposition to action of health professionals, ethically or politically motivated, if they are to fulfil their potential role as change agents. The latter has to begin through a process of critical analysis of professional affairs and goals (including their inherent contradictions). This very process should, hopefully, show to what extent overall activities in the field of health can be channeled to achieve a real, final impact in ameliorating preventable ill-health anywhere, in a reasonable time frame. Basically, health professionals should be searching for a new ethos, a professional, and at the same time, political ethos.

26. Of course, there are those who argue: ‘Why don’t you forget about those dilettante, upper-middle class health professionals and focus your efforts more on helping to change poor people (the blue collar workers, the peasants, or the unemployed) directly since they will ultimately be the ones called upon to bring about lasting social changes anyway?’ The answer to this question can be ambivalent too, neither of both activities being probably exclusive: it is mostly a question of what percentage of effort to devote to each of them.

27. In the long run, there will have to be moral changes on the part of those who enjoy the luxuries of affluence. The question is, will these lead to ideological changes in some?10 We have already passed the era when we asked health researchers to become more applied and participatory researchers; now we are asking them to become more socially conscious and more committed as real change-agents, leaving behind a lot of epidemiological preciosity. Depoliticized public health is not a discipline in the real service of man (Franz Fannon).

Political naivete?
28. Many moralists think that politics is ‘dirty’ or not a ‘virtuous’ activity. That is probably why they insist in quixotic actions against the injustices of the prevalent social system –which they also, more often than not, condemn– without realizing that in the end they are being instrumental to its maintenance. They assume decision makers are rational, righteous and pious and will bend in front of hard scientific evidence or react to outrageous injustice, Liberals, on the other hand, pay lip-service to needed changes, even applauding radicals’ interventions. But they lack, perhaps as much as the moralists, the political education or what is needed to work out ways to overcome preventable ill-health in capitalist societies. The fight against preventable ill-health and malnutrition is eminently a political and not a technical struggle. Technology is hardly the adequate point of departure to achieve the deep structural changes needed to end preventable ill-health and avoidable deaths; the right political approach is the better point of departure. Health professionals are rarely trained in the social sciences and, therefore, use social theory implicitly rather than explicitly.11 This is where the challenge lies in searching for the missing ideological link.

29. The average applied social scientist probably does not spend much time either in screening or purposely studying the basic theoretical elements of the ideology of the capitalist system to better understand how the system s/he lives-in works. Radicals will probably more often go through this exercise to better adjust their strategies and tactics.

Social consciousness
30. Does all this mean that radical health professionals or researchers have a higher level of social consciousness than their non-radical peers? What is clear is that once a certain level of political consciousness is attained (is there a threshold?…) an action-oriented attitude usually follows. At that point, there is a convergence of ideology and action which makes the difference between taking an observer’s as opposed to a protagonist’s role. Knowing about injustices does not move us. Becoming conscious about them generates a creative anger that calls for involvement in corrective actions. The latter can only happen within the framework of an ideology consciously acquired.

31. Political forces are fought with political actions, not with morals, or with technological fixes. This does not mean that strong ethical principles cannot be used as a political weapon, but this usually fails, mainly for ideological reasons. It is because of ideological and political naivete that health professionals who have occasionally jumped into the political arena in the West have so often failed.

Are we afraid of speaking-up in political terms?
32. Many health professionals feel that their positions in academe, government or international or private organizations might be jeopardized if they ‘come out of the closet’ with more radical positions. These professionals take a survivor’s attitude. The result of such a position is more palliative interventions that do not do much to curb preventable ill-health and malnutrition. There are certain actions that can be advocated in any system that will have a lasting effect and will really combat preventable ill-health and malnutrition. We seldom see agencies or concerned health professionals primarily pushing those actions, because they are mostly non-health, at least at the outset. If we could at least begin giving priority to some of these interventions, i.e., employment generation and income redistribution measures, we would be contributing more to solving the health problems of the deprived sectors of the population than by devising sophisticated health interventions.

33. Health professionals have to stop thinking that they cannot contribute much to the selection and implementation of non-health interventions, because they are outside their immediate field of expertise. These professionals are champions in denouncing transgressions to the exact sciences, but they are not half as active, and much less effective, in denouncing transgressions to the social sciences.

Health problems in the poor countries
34. What do internationally funded health programs in the poor countries really contribute to? How responsible are health professionals working in those projects for their failure or success? Who do they see benefiting from these programs? How do they see these programs’ impact in the long run? A good number of these programs only scratch the surface of the local problems and, therefore, contribute to the status quo in these countries. We must be aware, though. that most poor countries’ governments would not accept foreign aid programs at all if otherwise. Every donor brings its own ideas of the best health development strategy with it and its programs will reflect that ideology. The influx of foreign experts tends to a mystification of the planning process and a reinforcement of people’s feelings of inadequacy about their own capabilities.13

35. Professionals working in these projects should take part of the blame for failures They should fight for changes in direction if programs are not bringing about the anticipated and expected results Here, a new role becomes more evident: the health professional as a denouncer of non-realistic goals or methods of achieving them, especially because there are still some interventions that will partly contribute to improving preventable ill-health in a given population even within the constraints of the prevailing system. It is true that these colleagues, in most cases, did not participate in the program’s design, but it should never be too late to change directions. Therefore, for these Third World workers everything said about speaking up in political terms is doubly important, be they ethically or ideologically motivated.

A new direction: Some possible conclusions

Yes, but what can I do?
36. For those accustomed to solving problems and putting them aside, grasping a problem as intractable as worldwide preventable ill-health and malnutrition guarantees frustration. The flaw in our thinking is that the solution to the preventable ill-health problem is not in nature, but in ourselves. in our approach to the fundamental social relationships among men.14 Preventable ill-health should not be attacked because this brings mankind utility, but because it is morally necessary (Emmanuel Kant). What we need to fight for is equity not utility.

37. It seems that full devotion to science is not enough, we need to use science to follow our conscience. We need to think about ourselves as political human beings working as technicians in health remembering that global change does not begin at the global level, but starts with individuals.15 Many health professionals have initially been motivated to simply transfer knowledge to the people; the need is now to start focusing more on the social determinants of the problems of mass poverty and preventable ill-health.16 They need to act as humanists before acting as health professionals. An important requirement for this is to seek knowledge about the real world and not only about the world we would like to see.17 One cannot build on wishful thinking. It is precisely a misunderstanding of reality (or a partial understanding) that often reinforces the amoral position of some health professionals. Or, some of them may not really want to understand; they have, all too often and for all the wrong reasons, already made up their minds about one reality. The social reality is not like a laboratory; many variables in it are unknown and unforeseen and when we look at them it is often in the wrong way, searching for the statistical ‘whats’ instead of analysing the human ‘whys’.18

Health a vehicle?
38. Health seems to be as good (or bad) an entry point as any other (nutrition, employment, education, energy, natural resources, the environment, etc) to get involved in questions of equity in our societies. Since the hurdles in the road to equity are structural in nature, criticizing them from any angle, initially, should lead us invariably to the core of the social structural problems. Health can lead to global considerations if not made a ‘single-issue’ goal. Advocates of such a limited approach to health often look at constraints from a quite narrow perspective –a fact that seldom leads to more equity. There are too many substitutes for in-depth political action in ‘single-issue-politics’ that lead nowhere. The worst is that many people do not see this difference and a lot of political motivation and sometimes talent in scientists, health professionals or lay people is lost, because of a pseudo-ideological approach to global issues. Single-issue politics suffers from a lack of global vision of society and, in particular, a lack of will to make systematic historical changes.19

39. Mention has to be made here that there has recently been a call for a new ethic as the paradigm to replace the present Western ethic of constant growth.20 This new, ‘desirable’ ethic has been called the ‘ethic of accommodation’. It calls for simpler patterns of living, more in balance with nature. One might agree with such an approach only in what pertains to the finite availability of natural resources in our planet but, in what relates to social and economic relationships between men in our world, this new ethic seems to be a typical example of a partial interpretation of reality and choice of priorities that condones social status-quo.

40. What is needed is more dedication to work directly with the poor so they themselves can tackle the social and political causes of their poverty, ill-health and malnutrition. This calls for health professionals to go, as much as possible, back to field work and out of their offices or labs. Only there, can the strengths needed for a change in direction and perspective be found. Knowledge and scientific power created in institutions away from the people are returning to the people and affecting them. The gap between those who have social power over thinking –an important form of capital– and those who have not, has reached dimensions no less formidable than the gap in access to economic assets.21

Establishing the needed links
41. Health professionals need to learn from the people, as well as from their perceptions of the problems. They need to establish links with local mass movements and participate in their consciousness raising. This latter process may fail, because it is possible that the socioeconomic contradictions present locally are not sharp enough to give priority to political action over, say, technological action that could immediately, but superficially benefit poor people and marginalized groups of society for which there may still be room in the system. The choice is, essentially, between leading poor people towards social changes with an external consciousness, and raising mass consciousness and their capability to make the changes themselves. It is important to demonstrate to them that it is in their power not only to change social reality, but the physical reality that surrounds them as well.22

The bottom line
42. Strictly speaking, health professionals can go to the field as researchers or in charge of certain interventions. But in reality, researchers should always participate and intervene as well, even at the cost of altering some of the parameters they are interested in studying. They should enter into a dialogue with the group studied which should direct the research towards the problems that are relevant to the group. It is probably because of this that quick in-and-out research creates more frustration than motivation, both in researchers and in the community.

43. In any event, the desirable standard role of the health professionals in the field would be one of a monitor that does not allow programmatic interventions to proceed unchanged if they are culturally or politically neutral or biased against the interests of the beneficiaries.

44. This leads us to the concept of accountability; to whom should the health professionals in the field be accountable-to for their work, besides themselves? Traditionally, they have been accountable to their peers and to funding agencies, Too often they have neglected their accountability to a third group, namely, the public at large or, more specifically, the beneficiaries.24 In the case of research, we seldom see researchers communicating their findings directly to the people being served or studied, in an understandable language. Here, then, is another urgent area for improvement.

45. This brings us back full circle to the question: what can I do? All that has been said here just stresses the fact that the battle against preventable ill-health, malnutrition and avoidable deaths can be won, if health professionals play their roles to their ultimate consequences.

References:

1 The following definitions, found in Webster’s New Collegiate Dictionary. G. and C. Merriam, Springfield, MA, 1949. will help clarify the concepts used in the text:

Ethos: The distinguishing character or tone of a social of other group.

Ethics: Science of moral duty, principles and practice or action.

Moral: Establishing principals of right or wrong.

Morality: Instils moral lesson; virtue.

Ideology: a) Content of thinking of an individual or class; b) Intellectual pattern of any culture or movement; c) Integrated assertions, theories and aims constituting a politico-social programme,

2 J. Ki-Zerbo, Pour une stratégie globale de la culture et de la communication, IFDA Dossier 14, December, 1979. p 12.

3 B. Winikoff, Political commitment and health policy, in B. Winikoff, ed, Health and National Policy, MIT Press, Cambridge, MA, 1978.

4 R.H. Green, Gale warnings: fragments of charts and guides for navigators, Development Dialogue, No,1, 1980.

5 Winikoff. op cit, Ref. 3

6 G. Gunatilleke, Sri Lanka national dialogue on development, IFDA Dossier 14, December 1979, p.4.

7 Winikoff. op cit. Ref. 3.

8 Op cit. Ref 1.

9 Green, op cit. Ref. 4.

10 Winikoff, op cit, Ref 3.

11 H. Bantje, Constraint mechanisms and social theory in health education’, mimeo, BRALUP, University of Dar Es Salaam, Tanzania (presented at the XI International Congress of the IUNS, Rio de Janeiro, August 1978).

12 C. Schuftan, The challenge of feeding the people: Chile under Allende and Tanzania under Nyerere, Social Science and Medicine, Vol.13C, No. 2, June 1979, p.97.

13 F. Moore-Lappé and A. Beccar-Varela, Mozambique and Tanzania: Asking the Big Questions, IFDP, San Francisco, CA, 1980.

14 Adapted from J. Omo-Fadaka, Water planning and management – an alternative view, IFDA Dossier 7; May, 1979.

15 L. Brown, The Twenty-Ninth Day, World-Watch Institute, 1978.

16 A. Rahman, Science for social revolution, IFDA Dossier 4, February, 1979.

17 J. Sigurdson, Better analytical tools and social intelligence, The Lund Letter on Science, Technology and Basic Human Needs, Letter No.6, July, 1978.

18 R. Critchfield, The village the world as it really is…it’s changing, Agenda, USAID, Vol.2, No.8, October, 1979.

19 J. Echeverria, Sovereignty of needs, reversal of unjust enrichment, IFDA Dossier 15, January, 1980, p 94.

20 Brown, op cit. Ref 15.

21 Rahman. op cit. Ref 16.

22 Ibid

23 Bantje. op cit, Ref. 11.

24 C. Klemeyer and W. Bertrand, Misapplied cross-cultural research, in British Sociological Association, Health and Formal Organizations, Prodist, London, 1977, p 217.

Claudio Schuftan, Ho Chi Minh City.