The New York Times reported yesterday on a new study concluding that receipt of loans from the International Monetary Fund is associated with increased tuberculosis cases. The bottom line, from the Editors’ Summary (posted below the article):
“[T]hese results challenge the proposition that the forms of economic development promoted by the IMF necessarily improve public health”
Here is the Times article:
Rise in TB Is Linked to Loans From I.M.F.
By Nicholas Bakalar
The rapid rise in tuberculosis cases in Eastern Europe and the former Soviet Union is strongly associated with the receipt of loans from the International Monetary Fund, a new study has found.
Critics of the fund have suggested that its financial requirements lead governments to reduce spending on health care to qualify for loans. This, the authors say, helps explain the connection.
The fund strongly disputes the finding, saying the former communist countries would be much worse off without the loans.
“Tuberculosis is a disease that takes time to develop,” said William Murray, a spokesman for the fund, “so presumably the increase in mortality rates must be linked to something that happened earlier than I.M.F. funding. This is just phony science.”
The researchers studied health records in 21 countries and found that obtaining an I.M.F. loan was associated with a 13.9 percent increase in new cases of tuberculosis each year, a 13.3 percent increase in the number of people living with the disease and a 16.6 percent increase in the number of tuberculosis deaths.
The study, being published online Tuesday in the journal PLoS Medicine, statistically controlled for numerous other factors that affect tuberculosis rates, including the prevalence of AIDS, inflation rates, urbanization, unemployment rates, the age of the population and improved surveillance.
The lead author, David Stuckler, a research associate at Cambridge University, defended the study against the fund’s criticisms, noting that the researchers considered whether increased mortality might have led to more loans rather than the other way around.
Instead, they found that the increase in tuberculosis mortality followed the lending; each 1 percent increase in credit was associated with a 0.9 percent increase in mortality. And when a country left an I.M.F. loan program, mortality rates dropped by an average of 31 percent.
“When you have one correlation, you raise an eyebrow,” Mr. Stuckler said. “But when you have more than 20 correlations pointing in the same direction, you start building a strong case for causality.”
The study can be read here. Here is the Editors’ Summary for the article:
Tuberculosis—a contagious, bacterial infection—has killed large numbers of people throughout human history. Over the last century improvements in public health began to reduce the incidence (the number of new cases in the population in a given time), prevalence (the number of infected people), and mortality rate (number of people dying each year) of tuberculosis in several countries. Many authorities thought that tuberculosis had become a disease of the past. It has become increasingly clear, however, that regions impacted by health and economic changes since the 1980s have continued to face a high and sometimes increasing burden of tuberculosis. In order to boost funding and resources for combating the global tuberculosis problem, the United Nations has set a target of halting and reversing increases in global tuberculosis incidence by 2015 as one of its Millennium Development Goals. Yet one region of the world—Eastern Europe and the former Soviet Union—is not on track to achieve this goal.
Why Was This Study Done?
To achieve these targets, the World Health Organization (WHO) and tuberculosis physicians’ groups promote the expansion of detection and treatment efforts against tuberculosis. But these efforts depend on the maintenance of good health infrastructure to fund and support health-care workers, clinics, and hospitals. In countries with significant financial limitations, the development and maintenance of these health system resources are often dependent upon international donations and financial lending. The International Monetary Fund (IMF) is a major source of capital for resource-deprived countries, but it is unclear whether its economic reform programs have positive or negative effects on health and health infrastructures in recipient countries. There are indications, for example, that recipient countries sometimes reduce their public-health spending to meet the economic targets set by the IMF as conditions for its loans. In this study, the researchers examine the relationship between participating in IMF lending programs of varying sizes and durations by 21 post-communist Central and Eastern European and former Soviet Union countries and changes in tuberculosis incidence, prevalence, and mortality in these countries during the past two decades.
What Did the Researchers Do and Find?
To examine how participation in IMF lending programs affected tuberculosis control in these countries, the researchers developed a series of statistical models that take into account other variables (for example, directly observed therapy programs, HIV rates, military conflict, and urbanization) that might have affected tuberculosis control. Participation in an IMF program, they report, was associated with increases in tuberculosis incidence, prevalence, and mortality rate of about 15%, which corresponds to hundreds of thousands of new cases and deaths in this region. Each additional year of participation increased tuberculosis mortality rates by 4.1%; increases in the size of the IMF loan also corresponded to greater tuberculosis mortality rates. Conversely, when countries left IMF programs, tuberculosis mortality rates dropped by roughly one-third. The authors’ further statistical tests indicated that IMF lending was not a positive response to worsened tuberculosis control but precipitated this adverse outcome and that lending from non-IMF sources of funding was associated with decreases in tuberculosis mortality rates. Consistent with these results, IMF (but not non-IMF) programs were associated with reductions in government expenditures, tuberculosis program coverage, and the number of doctors per capita in each country. These findings associated with mortality were also found when analyzing tuberculosis incidence and prevalence data.
What Do These Findings Mean?
These findings indicate that IMF economic programs are associated with significantly worsened tuberculosis control in post-communist Central and Eastern European and former Soviet Union countries, independent of other political, health, and economic changes in these countries. Further research is needed to discover exactly which aspects of the IMF programs were associated with the adverse effects on tuberculosis control reported here and to see whether IMF loans have similar effects on tuberculosis control in other countries or on other non–tuberculosis-related health outcomes. For now, these results challenge the proposition that the forms of economic development promoted by the IMF necessarily improve public health. In particular, they put the onus on the IMF to critically evaluate the direct and indirect effects of its economic programs on public health.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050143.
- This study is further discussed in a PLoS Medicine Perspective by Murray and King
- The US National Institute of Allergy and Infectious Diseases provides information on all aspects of tuberculosis, including a brief history of the disease
- The US Centers for Disease Control and Prevention provide several fact sheets and other information resources about tuberculosis
- The World Health Organization provides information (in several languages) on efforts to reduce the global burden of tuberculosis, including information on the Stop TB Strategy and the 2008 report on global tuberculosis control—surveillance, planning, financing
- Detailed information about the International Monetary Fund is available on its Web site
- An article that asks “Does the IMF constrain health spending in poor countries?” (with a link to a response from the IMF) is provided by the Center for Global Development
July 23rd, 2008