TY - JOUR
AU - Morefield,, Heidi
AB - In the aftermath of the 1970s, the United States’ foreign assistance program posed a particular challenge to free-market policymakers. For Peter McPherson, senior consultant to the presidential campaign of then-Governor Ronald Reagan in the spring of 1980, the question of how to optimize aid would be crucial to rethinking U.S. bilateralism. In a report envisioning “A Cheaper and More Effective Foreign Aid Program,” he argued that “the U.S. foreign aid program should be changed to emphasize self-help and technology transfer rather than resource transfer. Studies have shown a higher ‘rate of return’ for ‘investments’ in the self-help/technology transfer programs.” The change in emphasis, McPherson continued, would be consistent with the emerging ideology of Reaganism, although the presidential hopeful should still be “sensitive to the fact that U.S. business provides most of the goods included in resource transfers.”1 In the field of international health, critics of the rise of neoliberalism and structural adjustment programs in the Reagan/Thatcher 1980s look back toward the mid-to-late 1970s—the Carter years—as a high water mark for investment in developing country health systems, especially following the rise of the New International Economic Order (NIEO) at the United Nations and the World Health Organization’s (WHO) 1978 Declaration of Alma Ata in support of primary health care.2 At the time, a widespread commitment to broad-based basic health care systems was seen by many in the developing world as a welcome antidote to the disease-specific eradication campaigns that had characterized colonial and early post-colonial public health efforts.3 But the emerging ideology of Reaganism—as described in documents like McPherson’s memo—led the broad-based horizontal, primary health care approaches of the late 1970s to give way once again to a set of narrow, disease-specific interventions known as selective primary health care, which comprised programs aimed at growth monitoring, oral rehydration therapy, breastfeeding, and immunization (GOBI).4 If the history of international development is largely concerned with the history of multilateral bodies like the World Health Organization, this account has merit. It also tallies with anthropologist Salmaan Keshavjee’s account of “how neoliberalism infiltrated global health,” wherein he ties the rise and implementation of free-market thinking in health systems to the World Bank and the network of non-governmental organizations that proliferated in the international health sector in the 1980s after the elections of Ronald Reagan and Margaret Thatcher.5 But multilateral agencies have only represented a small fraction of U.S. foreign assistance obligations. Bilateral flows of aid have historically made up the bulk of U.S. development assistance (between seventy and ninety percent), most of which, since 1961, has been channeled through the United States Agency for International Development (USAID).6 Focusing exclusively on multilateral agencies also misses a key point: the logics of cost-containment that McPherson recommended to Reagan in 1980 were nothing new. They described rather plainly the situation already on the ground at USAID in the Carter era. The timing and nature of the turn towards neoliberal policies in international health programming look significantly different from the perspective of U.S. bilateral aid. Well before the election of Ronald Reagan, as policymakers sought to control costs in the United States foreign aid program and shift balance of payments back towards the United States economy in the 1970s, they invited the privatization of international health projects. As Daniel Sargent has shown, the balance of payments problems led to a fundamental shift within what he calls the Pax Americana, wherein the United States became the primary consumer, rather than producer and distributer, of global resources.7 This led to reductions in multilateral aid spending, as Patrick Sharma has shown with the World Bank.8 While standard critiques of neoliberalism in global health plot the intentional infiltration of this new ideology via the machinations of the Mont Pèlerin Society (which led to the adoption of market-based policy by the World Bank in the early 1980s and the Bamako Initiative of 1987), the commercialization of international health was well underway within U.S. foreign aid, for more pragmatic and less ideological reasons, from the early 1970s.9 This was particularly evident in the U.S. foreign aid program’s engagement with the bilateral transfer of health technology. Using the political history of USAID through cycles of boom and bust as a vehicle to study competing models of international healthcare as a form of soft power, this article seeks to uncover not only the roots of neoliberal practices but also how free-market thinking in development assistance has shifted over time. Historian Angus Burgin likewise has shown how neoliberalism more broadly, and even the thinking of the Mont Pèlerin Society, has shifted significantly since the Great Depression. Their ideas were not stable, which complicates scholars like Keshavjee’s ability to trace a direct lineage from Mont Pèlerin to Bamako.10 This paper focuses on pharmaceuticals in particular, especially vaccines and antibiotics, as emblematic technologies of international health—though they were not the only form. In practice, exporting “health” internationally often meant exporting small-scale health technologies, which were logistically easier to deploy and scale up than major investments in health systems or medical education. The power of these technologies as heuristics lay in their appeal to both sides of the “self-help” debate in foreign aid, as both commodities and embodiments of technical knowledge. In his report to Governor Reagan, McPherson characterized resource transfers (the mass transfer of commodities, or as the old saying goes, “giving a man a fish”) as wasteful “doles” associated with primary health care approaches and technology transfers (the transfer of technologies that allow for the production of those commodities, or, “teaching a man to fish”) as a means of “self-help” associated with cost-efficient, vertical approaches. Yet this characterization belies a more complex situation in practice, wherein such distinctions were much fuzzier. In a similar challenge to common perceptions of “neoliberal” international development programs, anthropologist James Ferguson has explored how, in the twenty-first century, cash transfers to the poor—characterized much like the commodity transfer programs of the 1970s—proliferated under supposedly neoliberal regimes.11 Health technologies like pharmaceuticals were simultaneously commodities and technologies and are therefore an ideal conduit for understanding the complexity of the situation. Indeed, McPherson did note two caveats to his advice: the Public Law 480 food aid program, which involved the mass transfer of U.S. agricultural commodities to developing nations, should continue, while technology transfer programs should avoid technologies which would “undercut American business,” presumably by threatening market-share or the patent regime. Health technologies were not value neutral.12 They were essential resources for development—health systems, family planning programs, and disease eradication campaigns depended on their availability. David Engerman has noted the importance of such technical and material resources in fueling “Development Politics” during the Cold War and immediate postcolonial period.13 Using health technology transfer at USAID as a case study also provides a concrete example of what Daniel Sargent calls the reversal of the “material dynamics” of the U.S. world order—that is, the shift from outflows of resources from the United States in the 1960s to a concern predominantly for inflows of capital and other resources in the 1970s.14 At the same time, a study of pharmaceuticals and other health technologies in development projects demonstrates how the networks of development politics both extended to and were limited by corporations in capitalist donor countries like the United States.15 The United States’ embrace of the private sector in foreign assistance was nevertheless bounded in important ways. Policymakers in both the global North and global South, on the political right and left, coalesced around the concept of “appropriate technology” in the late 1970s and early 1980s, even if what the different groups meant by the term varied starkly. Appropriate technology was typically defined as that which was suitable to the social, economic, environmental, and cultural conditions of the space in which it would be applied, though this was interpreted very differently by different actors. The concept can be traced back to economist Ernst Schumacher’s 1973 work Small is Beautiful: A Study of Economics as if People Mattered, and informed key planks of the World Health Organization’s 1978 Alma Ata Declaration, which specified the provision of essential drugs.16 By explicitly casting certain technological interventions to be “appropriate” for transfer, while tacitly barring others as inappropriate, policymakers and pharmaceutical manufacturers alike worked to limit pharmaceutical distribution in foreign aid programs that might be disadvantageous to U.S. industry.17 Tracing the history of bilateral health technology assistance programs at USAID therefore shows the competing visions of technology transfer at play. Early commodity transfer projects were preoccupied with building brick and mortar facilities like manufacturing plants. This approach roughly mapped onto what James C. Scott has termed “high modernism,” a form of development concerned with large-scale, high capital modernization projects that was typical of the 1960s.18 After the 1973 oil shocks, international health policies directed at technology transfer became a way to economize in an era of fiscal austerity. Yet in a move reminiscent of what sociologist Jess Gilbert has termed “low modernism,” the provision of technical assistance through small-scale technologies like pharmaceuticals followed the more basic logics of President Truman’s Point Four program, which aimed to help developing countries develop their own scientific and technological capacity.19 In the 1970s, motivating commercial sector engagement in foreign aid was one way of stop-gapping the decline in government funding, and “market development” was the major incentive for U.S. pharmaceutical firms. The over-riding concern was, as McPherson’s memo to Governor Reagan put it, return on investment. The profits from the sale of pharmaceuticals abroad, representing forty percent of sales for U.S. pharmaceutical firms by 1976, had to return home to help the United States economy’s balance-of-payments woes.20 However, technology transfer proved a sticking point for the industry, which was—and remains—very protective of its patents. Although this article tells a story centered on policymakers in the United States, the impact of their decisions reached development programs across the globe. The history of USAID has been strangely piecemeal to date: there is still no authoritative volume on the Agency’s history. Using USAID project archives, interviews with former staff, and the personal paper collections of its leaders, this paper attends to the institutional culture, personal connections, and practical realities of an agency whose operations are typically abstracted. What might seem to be minor quibbles between United States bureaucrats had outsized impacts on the international health projects that made their way from Washington out into the rest of the world. “An American Factory with No Americans” USAID was established on November 3, 1961 through an Executive Order of President John F. Kennedy. The Agency replaced the International Cooperation Administration.21 Whereas the International Cooperation Administration was an outgrowth of the Marshall Plan focused mainly on short-term economic development projects, Kennedy’s vision for USAID was broader. The new aid program was to explicitly focus on long-term development, including sectors like international health. Even so, programmatic operations initially looked similar (down to the report cover sheets, see Figure 1). Acting on the dominant modernization theory of development, the Agency mostly focused on large capital projects throughout the 1960s.22 If “development” was a linear progression, the theory was that these major technological achievements would enable the country in question to skip steps in the development trajectory and save time in the modernization process. In the Agency’s initial approach to international health, this model translated into programs concerned primarily with the mass distribution of medical commodities in vertical, disease-specific eradication campaigns and the construction of pharmaceutical manufacturing plants. As USAID planned its approach to international health some influential advisors, such as Dr. Walsh McDermott, a public health specialist at the Cornell University Medical College, framed medicine itself as a technology. McDermott was well known for studies of tuberculosis and the reach of biomedical technologies in Navajo reservations, which members of his team referred to as “a Third World country within the United States.”23 McDermott often equated the impact of “modern medicine” with the impact of interventions like pharmaceuticals. Although he did recognize the importance of social, environmental, and sanitary conditions for health, McDermott was a technologist. He believed strongly in the power of modern medicine, science, and technology to overcome environmental conditions, including among the Navajo. McDermott therefore believed, particularly early in his career, that medical technology had already reached a sufficiently high threshold to help most of the world’s poor; the problem was with the logistics of delivery.24 Figure 1: View largeDownload slide Left: International Cooperation Administration, “Plant Requirements for Manufacture of Pharmaceutical Products” (1961). Right: USAID, “Plant Requirements for Manufacture of Antibiotics” (1962). The logo and branding of the two agencies was identical in the early years. Both items held in the USAID Development Experience Clearinghouse. Figure 1: View largeDownload slide Left: International Cooperation Administration, “Plant Requirements for Manufacture of Pharmaceutical Products” (1961). Right: USAID, “Plant Requirements for Manufacture of Antibiotics” (1962). The logo and branding of the two agencies was identical in the early years. Both items held in the USAID Development Experience Clearinghouse. In one of the founding documents of USAID, a report titled “Research and Development in the New Development Assistance Program,” the Development Assistance Panel of the President’s Science Advisory Committee, chaired by McDermott, strongly emphasized this point: “One technology, Medicine, is both a technology and a service. While little can be done to simplify the technology per se, much could be done by adaptations of the systems for its delivery.”25 Pharmaceuticals were invoked in the report as a key example. Quoting from McDermott’s 1960 article in the journal Science, the report argued that “with today’s drugs it is possible to place in the hands of a barefoot nonliterate villager more real power to affect the outcome of a child critically-ill, with, let us say, meningitis or pneumonia or tuberculosis than could have been exerted by the most highly trained urban physician of twenty-five years ago.”26 Research and development for international health should therefore not be “focused on developing simple medications for they could hardly be simpler than they are now,” but instead on adapting delivery systems. Early USAID health programs reflected this perspective, with a focus on vertical distribution campaigns and pharmaceutical manufacturing efforts. Malaria eradication was one such vertical distribution program. While the spraying of the insecticide DDT was the principal strategy for curbing the transmission of malaria, distribution of anti-malarial drugs was an important adjuvant method, particularly during the “attack phase” of eradication programs and in the “consolidation phase” when remaining cases were identified.27 These were typically paid for by USAID. In the 1965 plan for a USAID-funded malaria eradication program in Honduras, for example, project organizers estimated that 50,000 homes would be sprayed with DDT, 146,000 people would receive “Mass Drug Treatment” (for confirmed cases of malaria) and a further 244,000 people would receive “Presumptive Drug Treatment” (treatment with anti-malarial drugs before the results of the blood smears had been returned).28 In a USAID-funded eradication program in El Salvador, mass drug treatment was the primary “method of attack” in the coastal zone “problem areas,” with 290,000 people slated to receive anti-malarial medication every fourteen days for the duration of the 1966–1968 project.29 In the reports of USAID-funded malaria eradication programs, the anti-malarial drugs were typically black-boxed—unidentified by name, the specific technology of the drug did not matter so long as it worked for the stated purpose.30 When drug names were mentioned, it was usually to indicate that due to drug resistance one anti-malarial drug had been substituted for another, as with the substitution of any other good or commodity. USAID financed the construction of pharmaceutical manufacturing plants in the developing world as a means of delivering pharmaceuticals to local markets, though the extent of technology transfer was closely circumscribed by U.S. pharmaceutical firms, which maintained close control over training and patents. As part of its broader commitment to large-scale capital projects, the Agency commissioned two guidance papers on building such facilities, one on “Plant Requirements for the Manufacture of Pharmaceutical Products” in 1961 and a follow-up in 1962 on “Plant Requirements for the Manufacture of Antibiotics” (Figure 1).31 The actual construction of the plants was often done with financing from the “Cooley Fund” within the Agency, which was the reserve of local currency revenue from the sale of Public Law 480 agricultural products in the host country, named for Representative Harold Cooley (D-NC) who sponsored the amendment that set up the loan program.32 Most Cooley funds were available in India, Pakistan, Turkey, and the Philippines, as these countries had some of the largest P.L. 480 programs. When the United States government sold agricultural goods on the local market, a portion of the revenue in Indian rupees or Turkish lira went into the Cooley Fund.33 Financing for large-scale construction of manufacturing plants did not go to developing country governments. They were loans primarily to private U.S. commercial enterprises to enable them to establish subsidiary firms in developing countries. A means of direct intervention in the market, locally produced pharmaceuticals would then be sold on the local markets, where they were less expensive than imported alternatives and could be purchased by the local population and government. For example, in an attractive brochure full of photos of gleaming new constructions, titled “Pakistan’s Economic Development and United States Assistance,” USAID asserted that the Cooley Fund expanded the contributions of private industry to economic development, and had “directly benefited the average citizen by its contribution to the rapid expansion of Pakistan’s own pharmaceutical manufacturing industry.”34 It went on to list nine different U.S. pharmaceutical manufacturers (including Johnson & Johnson, Merck, Sharpe, and Dohme, Parke, Davis & Co., Wyeth, Abbott, and Pfizer) who took out Cooley loans through USAID and built subsidiaries in Pakistan, mostly in Karachi, between 1959 and 1966. The situation was similar in Turkey. A 1965 issue of the USAID/Turkey publication Participant Journal, celebrated the “many stories of Turkish factories situated along the ‘Cooley Highway.’” The factories produced goods for the domestic market and potentially for export and were expected to contribute significantly to Turkey’s industrial development. “The products range from sewing machines to Jeeps—from truck tires to pharmaceuticals—from corn products to rolled steel,” the article read. “American participation has permitted Turkey to shorten radically the normal time needed to develop such an industrial resource of trained men and operating plants. The ‘Cooley Highway’ leads to economic development.”35 Here, pharmaceuticals are one of a number of commodities being produced by Turkish subsidiaries of U.S. firms along the “Cooley highway”—an apt (though perhaps unintentional) metaphor for modernization theory. With a large photo of the new Pfizer pharmaceutical factory in Ortaköy, Turkey on the cover, the publication goes on to profile the training and public education initiatives Pfizer had undertaken in the region. According to one Turkish report from 1964, 114 million Turkish lira had been disbursed through Cooley loans in the country by the end of 1962, with a further 162 million Turkish lira in the Cooley Loan Fund Account.36 For the five firms providing information to the Turkish government, the Cooley loans made up an average of twenty-nine percent of the subsidiary’s total capital, which enabled some to “become well established,” and others to “meet current financial difficulties.”37 It was a significant financial boost that made the subsidiaries financially viable. The Cooley program was conceived of as a “win-win,” in that U.S. parent companies profited from the sales of their goods manufactured and sold overseas by the subsidiary firms, while the local economies of developing countries benefited from the employment of their citizens and the sale of relatively inexpensive, locally-manufactured goods in their markets. In the case of pharmaceuticals, these goods carried the added significance of being vital commodities for the establishment of modern medical and public health infrastructure. For example, the subject of the article, referred to as “An American Factory with no Americans,” was itself a Turkish stock company with 100 percent of its shares owned by the Pfizer parent company in the United States. It was built with a seven-million Turkish lira Cooley loan from USAID in 1961, and staffed, with the exception of the Australian General Manager, entirely by Turkish technicians and managers.38 This was consistent with the Cooley program, which was never intended to provide complete transfer of technology (U.S. parent companies owned the means of production, the intellectual property, and the operational plans). Rather, the focus of the program was to use U.S. capital to stimulate the local production and circulation of commodities for economic development and, in return, to contribute to the bottom line of U.S. corporations. Figure 2: View largeDownload slide “Down the ‘Cooley Highway.’” USAID, “Progress Partnership,” Participant Journal 4, no. 18 (April 1965). USAID Development Experience Clearinghouse. Figure 2: View largeDownload slide “Down the ‘Cooley Highway.’” USAID, “Progress Partnership,” Participant Journal 4, no. 18 (April 1965). USAID Development Experience Clearinghouse. In this early period of health programming in U.S. foreign aid, the form of bilateral technology transfer was heavily controlled by the U.S. government. While there was a role for private industry as the driver of expanded manufacturing capacity in some countries under the Cooley Fund, the administration of the loans for large-capital projects and the management of disease-specific campaigns like malaria eradication were always carried out by USAID headquarters and field staff. Pharmaceuticals moved as medical commodities, mass distributed and manufactured. The United States government, through subsidies for local production and the direct administration of certain eradication-centered drugs, was, to put a more inclusive spin on the old saying, “giving the people some fish.” This was all to change in the late 1960s and early 1970s. The 1968 Tet offensive in Vietnam, in which the United States military sustained heavy casualties, and the increasing current of critique against modernization-driven development meant Congress lost much of its public support for foreign aid—USAID’s budget was cut nearly twenty-six percent in inflation-adjusted dollars between fiscal years 1968 and 1969.39 Put another way, the Agency’s budget went from about one percent of the overall U.S. government budget, to 0.72 percent.40 The 1973 oil shocks, on top of the already enormous costs of the Vietnam War, then created a fiscal crisis within the United States which led to even more severe cutbacks in the foreign aid budget—a further fifteen percent reduction in constant dollars, or 0.63 percent of the overall budget.41 The new, constricted global economic regime meant that capital was moving in new ways—local production in developing countries declined as U.S. firms shuttered subsidiaries that no longer benefitted from government financing and kept profits at home, while the “Third World” became dependent on goods shipped from overseas. Reimbursable Development and New Directions As the United States foreign aid apparatus adjusted to its new, more restricted financial reality, the large-scale, high-tech construction projects of the 1960s, President Kennedy’s “Development Decade,” came grinding to a halt. The scale of development projects shrank along with the budget, and a new focus on community development and appropriate technology pervaded the Agency. In December 1973 President Nixon signed the “New Directions” policy into being as Public Law 93-189, an amendment to the 1961 Foreign Assistance Act. New Directions is often remembered by policymakers for its emphasis on the provision of resources to meet the basic human needs of the poorest citizens of beneficiary countries, and very much in line with the spirit of the New International Economic Order and Robert McNamara’s basic human needs approach at the World Bank.42 However, its practical significance lay more in the changes it brought to the project management structure of USAID programs. The legislation itself stressed the role of U.S. technical expertise, and stated plainly that “U.S. cooperation in development should be carried out to the maximum extent possible through the private sector.”43 Although private industry had played a role in foreign aid, to some degree, since President Truman’s Point Four program, this renewed commitment to private sector involvement addressed critiques, including from attorneys with the AID Office of the General Counsel Bruce E. Clubb and Verne W. Vance, Jr., that throughout the history of U.S. foreign aid “the administrators repeatedly have responded with little more than lip service and the most limited stimulation of private U.S. investment resources.”44 The increased contracting out to “private and voluntary” organizations for project management, an antecedent category to the now-common “non-governmental organizations” which elided for- and non-profit outfits, offered a way that the Agency could expand development activities, particularly the supply of resources, without vastly increasing its staff or logistical operations. On March 11, 1977, Judith W. Gilmore of USAID’s Office of Private and Voluntary Cooperation wrote a report entitled “AID’s ‘New Directions’ with Private and Voluntary Organizations,” which recommended that USAID relinquish tight controls over private and voluntary contracting organizations in favor of allowing them independence, creativity, and flexibility with programming.45 Gilmore’s report led to the creation of new types of grants to private entities and substantially increased funding for them. One of these new grant types, “matching grants,” allowed private organizations near complete autonomy over programming, and were centrally funded through USAID headquarters rather than through a specific mission or bureau. Private and voluntary organizations could also take advantage of the Reimbursable Development Program Overseas Freight plan, wherein USAID would pay the cost of shipping privately-supplied commodities to developing country beneficiaries. Medical Assistance Programs International, a Christian relief organization, is a good example: according to the proposed Matching Grant they were slated to receive in the 1980 fiscal year budget, they had shipped $156 million worth of drugs and medical supplies to over 350 institutions in eighty-four countries.46 While they supplied the drugs and medical equipment, USAID paid for the freight costs. Although President Carter had attempted to restore some of USAID’s budget in 1976—raising it to a level approximately equivalent to what it had been in 1968 in inflation-adjusted dollars—Congress continued to seek further cutbacks.47 A logic of cost-containment permeated USAID. The context of how this played out at the Agency is important to understand how and why the theoretical undergirding of U.S. bilateral health programs shifted. As budgets shrank, the role of private industry in development grew. The structural changes that resulted within the Agency set the groundwork for the reconsideration of medical commodity distribution programs as more cost-efficient technology transfer and sales programs. This creeping economic logic was expressed at all levels of USAID, from strategic planning documents and programmatic changes down to the personal correspondence of its staff. To overcome these challenges, the Agency instituted policies designed to find “efficiencies” in aid operations. One program in particular, the Reimbursable Development Program, was used to bolster the role of private industry in development as it allowed developing countries to buy commodities directly from private suppliers through the United States Government’s General Services Administration. This change was significant in that it allowed for the supply of pharmaceuticals by private companies for USAID development projects—a mechanism that would be used extensively in 1980s bilateral drug programs. The Cooley Funds provided financing to U.S. firms to build subsidiaries in certain countries, which apart from building manufacturing capacity and generating local training and employment also supplied local markets with relatively inexpensive goods. Profits flowed to the U.S. parent companies. Departing from this model of U.S. government intervention into developing country manufacturing markets, the Reimbursable Development Program was configured to more directly bolster the United States economy. It abandoned not only the intermediary step of local subsidiaries (all profits flowed directly to U.S. contractors) but also the pretense that it was intended to do anything other than sell the goods and services of U.S. private enterprises. The Reimbursable Development Program started in 1963, when the United States government approved a deal in which the United States Geological Survey would conduct a mineral resource survey for the government of Saudi Arabia. The Saudi government was, in essence, reimbursing the U.S. government for “technical assistance”—buying its expertise. Intended to allow “friendly” countries, international organizations, and non-governmental organizations to purchase goods and services from or through the United States government, the program eked out a marginal existence for over a decade. It dragged along until, spurred by the oil shocks, President Ford signed the new Section 661 of the Foreign Assistance Act into law in December 1974. This gave the President a budget “1) to facilitate open and fair access to natural resources of interest to the U.S.; 2) to stimulate reimbursable aid programs consistent with Part I of the Act.”48 As the program started to flourish in this new context, USAID hired a coordinator specifically for the Reimbursable Development Program in 1976, and, “with an eye on the rising petro-dollar balances, the objective of the RDP shifted from responding to requests for technical services to maximizing the sales of both U.S. goods and technical services”—a focus that was maintained under the Carter administration. While the program was originally designed to give access to U.S. government services and technical expertise, under Section 661 sales were opened up to private industry suppliers within the United States who worked on the General Services Administration schedule, the United States government’s list of vendors for procurement.49 As such, the Reimbursable Development Program allowed U.S. private industry to sell, en masse, to the developing world through the Foreign Assistance Act. As with P.L. 480 agricultural assistance, a major object of this form of “aid” was not only to help the developing world, but also to assist the United States economy. With the Reimbursable Development Program and new forms of grants and contracts for private and voluntary organizations under the New Directions policy, private industry gained ways to sell commodities in transactions brokered by the United States government. Moreover, while reimbursements through USAID for the Reimbursable Development Program were tracked closely (as of FY 1977, they amounted to $178.9 million), the larger General Services Administration program was not required to track or report sales to developing countries through their procurement schedule.50 This suited the U.S. pharmaceutical industry. It gave them a large degree of freedom in expanding their sales abroad without government intermediaries or interference. On May 9, 1977, President Carter addressed the 30th World Health Assembly in Geneva. He commended Director-General Halfdan Mahler’s work and reaffirmed the U.S. government’s interest in promoting public health abroad. Ill-health and infectious disease, he stated, were threats not only to local economic development, but, because of increased travel between nations, to the United States and to political and social stability around the world. “I will strive personally to find ways in which our government and the private sector can better cooperate with other nations on health, population, and nutritional needs,” President Carter told the Assembly.51 Soon after, the White House commissioned a report, “New Directions in International Health Cooperation,” which aimed to provide a comprehensive summary of U.S. international health efforts. The United States government’s efforts had been, according to lead author and Special Assistant to the President for Health Issues Dr. Peter G. Bourne, “piecemeal and uncoordinated” to that point, with “no effective overall U.S. international health policy.”52 Bourne framed health as a major human right and situated the international health mission in the broader context of the United States’ commitment to securing human rights at home and abroad. Referencing the success of the worldwide smallpox eradication program, the report urged that the solution lay in developing self-sufficiency through science and technology transfer, through partnerships with the U.S. private sector—metaphorically teaching the people to fish, in this case through the purchase of U.S. technology and expertise.53 As President Carter promised in his remarks to the World Health Assembly, a significant portion of the report is dedicated to the role of the private sector and commercial involvement in international health. Even in 1978, the report notes that “commercial activities constitute the majority of all U.S. international health activities” particularly for “so-called ‘graduate’ countries” who have high enough per capita income to afford to purchase U.S. goods and technical services but “inadequate” health services.54 It emphasized how an approach in which host country governments purchased aid from the United States was favorable for the U.S. government and private industry alike—first, it allowed the health industry to recuperate its research and development costs while allowing developing countries access to the newest technologies; second, the U.S. government needed to “ration its support” as its efforts alone could never be “enough.” 55 It made the case for considering international health a matter not just of foreign assistance, but of U.S. international economic policy. Health sector manufacturing contributed a positive trade balance of $1.44 billion in 1976, and made up a significant portion of U.S. industrial technology transfer. However, which health technologies could be transferred, and which technologies were of an “appropriate” level of technology, remained matters of significant debate.56 In July 1978, the Subcommittee on Domestic and International Scientific Planning, Analysis, and Coordination of the Committee on Science and Technology of the United States House of Representatives convened hearings on appropriate technology and its role in U.S. bilateral foreign assistance. Based on the opening statement of Congressman James H. Scheuer (D-NY), who chaired the subcommittee, the impetus for the conference seemed to be the increased skepticism of many policymakers and development experts towards the large-scale capital-intensive projects built in the name of modernization theory. He attributed this to a “complex of concerns” arising from, among other events, the environmental movements of the 1960s and early 1970s, the oil shocks in 1973, and “disenchantment with many of the massive welfare programs of the 1960s (as embodied in the Great Society).”57 The hearing called witnesses from academia, such as development economist Dr. Gustav Ranis of Yale University, non-profit foundations, and other government departments, including USAID. Dr. Ranis presented a prepared statement, “Appropriate Technology: Obstacles and Opportunities,” which defined appropriate technology as the “optimum choice” of technology that will lead to the “maximization of societal objectives given the society’s capabilities.”58 Total optimization required, in theory at least, perfect knowledge of the market, which Ranis conceded was perhaps not appropriate in the case of information protected by patent rights, as in the pharmaceutical industry. Ranis suggested that, to restore perfect competition as much as possible, international patent legislation be revisited to “ensure that patents are actually used (and technology transferred) rather than serve as a way of controlling markets and inhibiting the flow of information.”59 In the discussion that followed his address, he clarified that although “core technologies” were unlikely to be adapted to developing country needs due to patent restrictions, appropriate technology could be adapted for “related operations” such as packaging pharmaceuticals—something already done, to some extent, by developing country subsidiaries of multinational corporations.60 This answer seems to have satisfied the Subcommittee, as patent rights were not raised again throughout the three-day hearings. The subsequent silence on patents, when the goal of meeting basic human needs would arguably be undercut by the exclusion of “core technologies” such as pharmaceuticals in the appropriate technology mandate, could also be read as part of a larger deference to, and increasing dependence on, private industry in bilateral foreign aid. As critical nodes in the network of resource distribution, pharmaceutical manufacturers were both purveyors of goods and, through the legislation designed to protect their industry in the United States, adjudicators of the technological knowledge and goods that made their way into development programming. And though this primacy was challenged by member nations of the New International Economic Order at venues like the August 1979 United Nations Conference on Science and Technology for Development, held in Vienna, developing countries were not successful in securing the types of “high-technology” transfer guarantees from the U.S. that they saw as essential for development. The U.S. delegation, which had consulted with pharmaceutical manufacturers ahead of the conference, reiterated the importance of patents to research and development and argued that many pharmaceuticals were not appropriate technologies for transfer.61 The unwillingness to budge on technology transfer led to the widespread perception of the conference as a failure.62 “More with Less” In December of 1979, the Christmas cards that USAID Administrator Douglas Bennet received from his employees captured the resigned humor with which the Agency faced its latest blow. Congress had still not passed the appropriations bill for foreign aid for the 1980 fiscal year that had begun on October 1, 1979, which meant that USAID faced increased budget cuts on top of the ten percent slash the Senate Foreign Relations Committee had already made to their request.63 This substantially increased pressure on an Agency already stretched thin. Bennet, a career bureaucrat with a PhD in history from Harvard, had been appointed just six months prior. One staffer sent a poem—addressed “To Fearless Leader” and entitled “The Ballad of Herrick’s Goal,” it began: Fear not oh brown skin babies! No need to feel distress. USAID’s a comin’ And we’ll do “More with Less.”64 Six additional rhyming stanzas, rife with casual racism, dig at a plan for budget and staffing reductions at the Agency, written by Budget Office Director Allison Herrick, before the staffer signs off with “Merry Christmas.” Another, by the name of Wasielewski, wrote simply: “Sorry about the budget. Carry on bravely!” on the inside of a card which depicted a large eagle (Congress) with a man (Bennet) in a cage (USAID).65 Bennet himself reacted with similar humor. On December 10th, he sent a poem to John T. McEvoy, the Staff Director of the Senate Budget Committee (a position Bennet had also once held), again poking fun at the “More with Less” mantra that had come to symbolize the Herrick plan: Lacking Little and Nothing, We have to confess, Suggests your committee Must be quite a mess. But this is a case We’re prepared to address We’ll compromise and Push forward with Less.* P.S. *I refer to Dr. Morer Less, the noted fiscal economist.66 Herrick’s plan for budget and staffing reductions meant that USAID would come to rely much more heavily on the private and voluntary sector—not only for the supply of commodities, but also for project management. This move towards the widespread contracting out of foreign aid projects is significant in that the tide of non-governmental organizations that rose in this period have been characterized as a conduit for neoliberal ideology within international health.67 Yet a close study of how and why these organizations gained such a strong foothold in foreign aid shows that their rise was due more to the demands of the budget than to a commitment to ideology. By the time the budget failed, Allison Herrick had already become a divisive figure at USAID. Trained in anthropology at Yale, she began a career at the USAID Africa Bureau in 1968. She moved to the Latin America Bureau in 1972 before a “reduction in force” three years later landed her, down-graded from her previous post, in the Budget Office of the Bureau for Policy and Program Coordination. Believing her gender to have been a factor in the decision, she appealed to the Office of Personnel Management and, with the help of a lawyer, had her grade and pay level eventually restored. She stayed in the Budget Office, however, and became its head in 1978. Her plan to reduce staff and budgets further, when she herself had fought hard against similar cuts just a few years before, caused a stir in an Agency commonly thought of at the time as an “Old Boys’ Club.”68 Figure 3: View largeDownload slide “The Ballad of Herrick’s Goal.” December 1979. Photograph of item held by Wesleyan University, Special Collections & Archives, Middletown, Connecticut. Figure 3: View largeDownload slide “The Ballad of Herrick’s Goal.” December 1979. Photograph of item held by Wesleyan University, Special Collections & Archives, Middletown, Connecticut. The budget failure came at a time of increasing demands on foreign aid and decreasing staff and funding levels. Overall, USAID’s budget was cut thirteen percent in fiscal year 1980, or by over 1.5 billion inflation-adjusted dollars.69 These increased budgetary constraints were due in part to additional scrutiny by Congress, factions of which, in the midst of the Iranian hostage crisis and following the misappropriation of funds in Vietnam, feared that aid money would somehow end up in the hands of the Iranians.70 Shortly thereafter, the Iranian Revolution had sparked a second oil crisis, and the United States government as a whole was facing balance-of-payments problems. Figure 4: View largeDownload slide “Sorry about the Budget.” December 1979. Card front (left) and inside (right). Photograph of item held by Wesleyan University, Special Collections & Archives, Middletown, Connecticut. Figure 4: View largeDownload slide “Sorry about the Budget.” December 1979. Card front (left) and inside (right). Photograph of item held by Wesleyan University, Special Collections & Archives, Middletown, Connecticut. The Herrick Plan, meanwhile, known at USAID for its “more with less” ethos that staffers so lamented over Christmas 1979, meant that Administrator Bennet faced not only budgetary pressure from Congress but that he was also politically hobbled by an Agency restructuring within the Department of State, which oversaw it. On January 31, 1979, former Administrator Jack Gilligan had resigned under pressure from Secretary of State Cyrus Vance over a proposed reorganization of the Agency and due to their disagreements over “political” rather than development aid.71 Gilligan believed firmly in reducing headquarters staff in favor of putting more personnel in the field, and had also ruffled feathers among his staff when he was quoted as saying that the problem with USAID was that too many of its employees were “overage, overgrade, and over here.”72 Administrator Bennet was not appointed until June, which left the Agency without a leader for several months.73 In the interim, the reorganization that Gilligan had sought with the support of Senator Hubert Humphrey came to fruition, even if the effects were not what either had anticipated. In September, President Carter officially established the International Development Cooperation Agency (IDCA) with Executive Order 12163—“Administration of foreign assistance and related functions.”74 Senator Humphrey’s original vision for the IDCA was that it would be an umbrella and coordination organization for the disparate forms of foreign assistance that resided under many different U.S. government departments—the Public Law 480 food aid under the Department of Agriculture, the multilateral development banks under the Department of the Treasury, security and political assistance under the Department of State, USAID, the Peace Corps, and others. This sparked a political turf war. By the time the IDCA was established the larger and more powerful departments had pulled out and the IDCA, headed by lawyer Thomas Ehrlich, was left to oversee just USAID and the Overseas Private Investment Corporation. This effectively meant that, unlike his predecessors who had reported directly to the Secretary of State, Administrator Bennet had an additional layer of bureaucracy he had to contend with in order to make decisions. Alexander Shakow, the Assistant Administrator for Policy Planning and Coordination at the time, recalled in an oral history interview with former USAID Africa Bureau colleague W. Haven North, that “poor Doug Bennet, having come in as Administrator of AID, and normally with responsibilities to the Secretary of State directly, and very often the White House, found himself with another layer. Tom Ehrlich brought in a dozen very bright people and their job was to try to ride herd over AID.” Shakow described the situation as “a constant struggle … he wanted the kind of freedom that previous AID Directors had had, and yet he was caught.” And though Bennet ultimately won most of the battles, “it was so enervating to have to go through all that, over and over and over again.” The IDCA had what Shakow saw as their own “crazy schemes” which meant that “in practice it turned out that it was only a duplicate of AID, essentially, without the resources and getting in the way of the really competent people.”75 Facing increasing development goals and a reduced budget, Herrick, whose job it was to find a way to balance the priorities of the USAID Administrator, the USAID Missions, and the Department of State within the funds available, authored the “Draft Plan for Expansion of the AID Program with Stable or Reduced Staff Ceiling” in consultation with Ehrlich, Bennet, and Shakow.76 One major point of contention was that Ehrlich and the IDCA wanted to change funding allocations to be per country rather than per Mission (AID’s term for its regional field offices), which riled the overseas personnel. They also wanted to cull Missions that were not cost-efficient to run, which were often in smaller African countries—a proposal that horrified the State Department because for many ambassadors to these nations the AID program was one of their few bargaining chips.77 The debate over where to cut costs cut to the heart of the development enterprise—was their purpose to deliver aid where it was most cost efficient, or where it was needed most? Herrick thus came under fire from her colleagues both in headquarters and overseas. Among AID staff, her plan was referred to colloquially as “More with Less,” the “Herrick Debate,” or—emphasizing Ehrlich’s involvement—the “Herr-lich Plan.”78 Bennet and Ehrlich were planning for a ten percent staff reduction by 1985. In a memo to Ehrlich on October 11, 1979 Bennet emphasized the need to “enhance the use of intermediaries, particularly [private and voluntary organizations] and universities under Title XII, and expand cooperation with Peace Corps” to help compensate for the reductions.79 This led to the increased reliance on private contractors to oversee project management and to draft reports.80 The outsourcing brought in organizations such as Management Sciences for Health, the Johns Hopkins School of Public Health, the Program for Appropriate Technology in Health, and a network of independent consultants, who would go on to have an instrumental influence on how policy priorities were translated into programmatic goals for bilateral health assistance schemes and expressed in national and international development fora. To extend the metaphor still further, in this period USAID began paying people and organizations to teach Other people to fish. Just one year later, Ehrlich took the direction of foreign aid funds to U.S. private companies a step further by augmenting the Reimbursable Development Program and putting it directly under the IDCA. To address their balance of payments problems, the United States needed to reverse the flow of capital back to its own economy.81 The “Third World Trade Plan” announced in the Washington Post on July 3, 1980, took over from and expanded the Reimbursable Development Program.82 With a budget of $4 million in the 1981 fiscal year, the Trade and Development Program, as it came to be known, was “designed to help private companies in the United States break into Third World markets” and boost the export of U.S. technology.83 The program’s budget was “expected to expand rapidly over the coming years.” However, key to this program was the fact that developing countries were expected to commission and pay for the projects (to be carried out by U.S. private industry) “out of their own resources,” which would limit the beneficiaries of the program to those countries who could afford to pay.84 While there are precedents for making recipient nations buy their own resources before the RDP program—Gisela Mateos and Edna Suarez-Diaz have pointed out that under the Atoms for Peace program Mexico had to procure their own radioisotopes for research—RDP and the Trade and Development Program made these arrangements commonplace for basic forms of foreign aid.85 The programs to sell U.S. commercial goods and services abroad effectively divorced USAID from the direct purchase of pharmaceuticals for international health programs, a phenomenon that would have a lasting impact. An internal USAID Program Guidance Paper on “Pharmaceuticals in Health Assistance” published in 1985, states that “Except for certain centrally-funded family planning pharmaceuticals, AID does not buy drugs directly but funds and monitors their procurement under host country contracting systems … GSA procurement has been the most important of these mechanisms.”86 The Guidance Paper identified seventy-five different USAID health projects with pharmaceutical components in 1983. Only twenty-one of these seventy-five projects received funding from USAID to purchase drugs, which was done by a procurement agent through the U.S. private sector, though the funds spent—$14 million in just those twenty-one projects in 1983—was a way to give capital back to U.S. industry through the Foreign Assistance Act while also allowing them to maintain control over patents, technology transfer, and commodity distribution.87 Of the remaining projects, those in countries that could pay for U.S. pharmaceuticals had a ready vehicle for their purchase and were expected to foot the bill, while those that could not—particularly those under structural adjustment programs imposed by the International Monetary Fund in the 1980s—were left to pass the costs onto patients or to go without aid entirely.88 Although these impacts on international health programs of the 1980s are frequently attributed to the new, neoliberal world order, the commercialization of international health began well before. Peter McPherson went on to replace Douglas Bennet as Administrator of USAID after Ronald Reagan’s inauguration in 1981.89 Although the Carter and Reagan administrations could hardly be considered more divergent, and McPherson had positioned his foreign aid approach in the memo to Governor Reagan as a major “shift in emphasis,” there was little difference in how USAID projects were approached under his tenure relative to Bennet’s. Tracing the bilateral circulation of health technologies like pharmaceuticals, these continuities become visible. The privatization of commodity supplies and technical assistance in U.S. foreign aid in the 1970s meant that neoliberal economics played a significant role in international health well before the 1978 Alma Ata Declaration and structural adjustment. A focus on bilateralism draws attention to the importance of bureaucratic practice within donor agencies. Turning inward to study these power dynamics—the individuals striving and struggling within the bureaucracy—reveals the extent to which practice often diverges from stated intent. Bureaucratic stagnation meant that when financial pressures arose it was often more efficient to re-purpose old structures, like the Reimbursable Development Program, to act as stop-gaps than to reconsider broader policy objectives. It also shows how the thinking of even relatively minor U.S. policymakers within USAID has historically been of disproportionate significance relative to more visible and well-known international health actors at multilateral organizations. USAID health programs shifted from the mass distribution and manufacture of pharmaceuticals in the 1960s under the Cooley plan to the much more circumscribed, private-sector controlled sales program of the 1970s. Although these structural and programmatic changes within the Agency—the budget and staffing reductions, the turn towards private contractors and suppliers, and the commodification of aid through the Reimbursable Development Program—were in line with the neoliberal policy imperatives of the Reagan era, they were not coordinated as part of an over-arching ideological policy shift. Rather, they grew autochthonously from the challenges that USAID faced amid the decline of the foreign aid budget. Informed by the logics attendant in the United States’ embrace of the free market after World War II, these policy shifts were variously the result of individual initiatives, as in the case of the Agency restructuring; efforts by the senior staff to cope with unforeseen budget shortfalls, as with the outsourcing to NGOs and contractors; and broader schemes by the Ford and Carter administrations to resolve America’s balance of payments problems by increasing the sale of U.S. goods overseas, as with the Reimbursable Development Program. To trace how health technologies have moved and continue to move in international health programs today is to highlight a network of actors, institutions, and corporations who determine their course. Using technologies like pharmaceuticals as an example further shows how technical and material resources caught in the crosshairs of development politics function on multiple registers simultaneously—reverse-engineerable embodiments of technical knowledge, subject to patent regimes and industrial protection, they are also brought to markets and consumed as medical commodities. USAID health programs are a productive venue to examine competing models of aid, as they pose a challenge to the dipoles of commodity-transfer/technology-transfer, appropriate-/high-technology, and local/global used both by historical actors and analysts. Mapping these divergent values shows how a broad approach to governance, like neoliberalism, can be mobilized by the circulation of an object, like a pharmaceutical. Arguments over how to optimize U.S. foreign aid are therefore telling. The debates lay bare not only the models of international health at play, but the structures of power and governance behind them. To focus on bilateral aid agencies such as USAID may seem to be provincial and Americanist in a moment at which global histories are increasingly called for. But to focus only on multilateral histories of international health and development runs the risk of inadvertently giving a partial view from Geneva. We gain a fuller picture in considering bilateral programs and the ways in which they both aligned with and diverged from multilateral imperatives. Histories of aid through USAID help provide a sense of the pragmatic realities through which the seeming ideological shifts of neoliberalism took root, even in administrations (such as Carter’s) which may have seemed antithetical to it. Bilateral aid programs—somewhere between the local and the global—are therefore a valuable space for further research exploring how and why science, technology, and ideology move. Acknowledgments I would like to thank Jeremy Greene for his mentorship and support with this project. Thanks also to Randall Packard, Angus Burgin, Graham Mooney, and Jean-Paul Gaudilière, who read and commented on earlier drafts. Footnotes 1 Report, “A Cheaper and More Effective Foreign Aid Program,” M. Peter McPherson to Governor Ronald Reagan, April 28, 1980, box 11, folder 6, Douglas Bennet Papers, Special Collections & Archives, Wesleyan University, Middletown, CT, USA (hereafter Bennet Papers). McPherson worked for the Washington, DC firm Vorys, Sater, Seymour and Pease. 2 Socrates Litsios, “The Long and Difficult Road to Alma-Ata: A Personal Reflection,” International Journal of Health Services 32, no. 4 (2002): 709–32; Marcos Cueto, “The Origins of Primary Health Care and Selective Primary Health Care,” American Journal of Public Health 94, no. 11 (2004): 1864–74; Theodore M. Brown, Marcos Cueto, and Elizabeth Fee, “The World Health Organization and the Transition from ‘International’ to ‘Global’ Public Health,” American Journal of Public Health 96, no. 1 (2006): 62–72. 3 Randall Packard, A History of Global Health: Interventions into the Lives of Other Peoples (Baltimore, MD, 2016). 4 Cueto, “Origins of Primary Health Care,” 1871; Julia Walsh and Kenneth Warren, “Selective Primary Health Care: An Interim Strategy for Disease Control in Developing Countries,” New England Journal of Medicine 308 (1979): 967–74. 5 Salmaan Keshavjee, Blind Spot: How Neoliberalism Infiltrated Global Health (Berkeley, CA, 2014), 95–96, 103, 106. 6 On the balance of bilateral vs. multilateral aid spending in the United States, see Report, “Trends in U.S. and International Financial Support … ,” Lee Milton Howard, box 3, folder 3.13, Lee Milton Howard Collection, The Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions (hereafter Howard Papers); Report, “A Profile of U.S. Development Cooperation in Health Sectors,” Lee Milton Howard, July 1981, box 3 folder 3.58, Howard Papers; The World Bank, International Development Association Resource Mobilization, “Aid architecture,” accessed February 19, 2019, http://documents.worldbank.org/curated/en/745221468313781790/Aid-architecture-an-overview-of-the-main-trends-in-official-development-assistance-flows; Homi Kharas, “Rethinking the Role of Multilaterals in the Global Aid Architecture,” The 2010 Brookings Blum Roundtable Policy Briefs, accessed February 19, 2019, https://www.brookings.edu/wp-content/uploads/2016/07/09_development_aid_kharas2-2.pdf. 7 Daniel Sargent, “Pax Americana: Sketches for an Undiplomatic History,” Diplomatic History 42, no. 3 (2018): 357–76. 8 Patrick Sharma, “The United States, the World Bank, and the Challenges of International Development in the 1970s,” Diplomatic History 37, no. 3 (2013): 572–604. 9 Keshavjee, Blind Spot, 85–99. 10 Angus Burgin, The Great Persuasion: Reinventing Free Markets since the Depression (Cambridge, MA, 2012). 11 James Ferguson, Give a Man a Fish: Reflections on the New Politics of Distribution (Durham, NC, 2015). 12 Arturo Escobar argues that, in modernization frameworks, technology was seen as value-neutral and unquestionably good. Arturo Escobar, Encountering Development: The Making and Unmaking of the Third World (Princeton, NJ, 1995), 36. 13 David Engerman, “Development Politics and the Cold War,” Diplomatic History 41, no. 1 (2017): 1–19. 14 Sargent, “Pax Americana,” 371. 15 Engerman, “Development Politics,” 5. 16 E. F. Schumacher, Small is Beautiful: A Study of Economics as if People Mattered (London, 1973); World Health Organization, “Declaration of Alma Ata,” International Conference on Primary Health Care, Alma Ata, USSR, September 6–12, 1978, accessed February 19, 2019, http://www.who.int/publications/almaata_declaration_en.pdf. 17 Essential drugs lists were determined by national governments in consultation with the WHO and were often based off of the WHO model list. Jeremy Greene has documented the controversy over defining drugs as “essential” in “Making Medicines Essential: The Emergent Centrality of Pharmaceuticals in Global Health,” Biosocieties 6, no. 1 (2011): 10–33. As this paper shows in a later section, U.S. policymakers and their advisors also pushed back on pharmaceuticals as “core” technologies that were not “appropriate” for technology transfer—though “peripheral” technologies, like pharmaceutical packaging machines, could have been. 18 On modernization theory, see Nils Gilman, Mandarins of the Future: Modernization Theory in Cold War America (Baltimore, MD, 2003). For a critique of this large-capital, “high modernism,” see James C. Scott, Seeing Like a State: How Certain Schemes to Improve the Human Condition Have Failed (New Haven, CT, 1998). For a response to Scott, which shows the undercurrent of a community development driven school of development theory which coexisted with (though was overshadowed by) modernization theory, see Daniel Immerwahr, Thinking Small: The United States and the Lure of Community Development (Cambridge, MA, 2015). 19 On Point Four, see Amanda Kay McVety, “Pursuing Progress: Point Four in Ethiopia,” Diplomatic History 32, no. 3 (2008): 371–403. The concept of “low modernism” is attributed to Jess Gilbert, Planning Democracy: Agrarian Intellectuals and the Intended New Deal (New Haven, CT, 2015). 20 White House, New Directions in International Health Cooperation: A Report to the President (Washington, DC, 1978), 133. 21 John F. Kennedy: “Executive Order 10973—Administration of Foreign Assistance and Related Functions,” November 3, 1961, The American Presidency Project (APP), accessed February 19, 2019, http://www.presidency.ucsb.edu/ws/?pid=58911. 22 Nick Cullather, The Hungry World: America’s Cold War Battle Against Poverty in Asia (Cambridge, MA, 2010), 75–77; David Ekbladh, The Great American Mission: Modernization and the Construction of an American World Order (Princeton, NJ, 2010), 154–67 and 191–97; Gilman, Mandarins of the Future, 155–202. 23 Kurt Deuschle quoted in David Jones, “The Health Care Experiments at Many Farms: The Navajo, tuberculosis, and the limits of modern medicine, 1952–1962,” Bulletin of the History of Medicine 76, no. 4 (2002): 749–90. 24 McDermott’s later writings concluded that there was a need to adapt modern medical technologies to better suit the developing world. 25 Report, “Research and Development in the New Development Assistance Program,” the Development Assistance Panel of the President’s Science Advisory Committee, April 30, 1961, box 13 folder 6, Walsh McDermott Papers, Weill-Cornell Medical Center Archives. 26 Ibid; Jones, “The Health Care Experiments at Many Farms.” 27 Paper, “The Worldwide Malaria Eradication Program,” Melvin E. Griffith, Deputy Chief, Malaria Eradication Branch, AID, Presented at the Plenary Symposium on International Programs, Entomological Society of America, New Orleans, 1965, USAID Development Experience Clearinghouse; Report, “Report and Recommendations of the ICA Expert Panel on Malaria,” August 1, 1960, USAID Development Experience Clearinghouse. For more on the failure of the global malaria eradication campaigns, see Randall Packard, The Making of a Tropical Disease: A Short History of Malaria (Baltimore, MD, 2007); Nancy Stepan, Eradication: Ridding the World of Diseases Forever? (Ithaca, NY, 2011). 28 Report, “Capital Assistance Paper: Honduras - Malaria Eradication,” 1965, USAID Development Experience Clearinghouse. 29 Report, “Capital Assistance Paper: El Salvador - Malaria Eradication,” 1966, USAID Development Experience Clearinghouse. 30 Report, “Capital Assistance Paper: Pakistan - Malaria Eradication,” 1964, USAID Development Experience Clearinghouse; Report, “Capital Assistance Paper: Paraguay - Malaria Eradication,” 1967, USAID Development Experience Clearinghouse; Report, “Capital Assistance Paper: Brazil - Second Malaria Eradication Project,” 1968, USAID Development Experience Clearinghouse. 31 Report, “Plant Requirements for the Manufacture of Pharmaceutical Products,” Technical Aids Branch, International Cooperation Administration, September 1961, Prepared by Penniman and Browne of Baltimore, MD, USAID Development Experience Clearinghouse; Report, “Plant Requirements for the Manufacture of Antibiotics,” Communications Resources Division, August 1962, Prepared by the United States Testing Company, Inc. of Hoboken, NJ, USAID Development Experience Clearinghouse. 32 “Cooley Fund Little Known Cash Bonanza,” Lodi News-Sentinel, January 6, 1964; Report, “Pakistan’s Economic Development and United States Assistance,” 1967, USAID Development Experience Clearinghouse; Report, “Progress Partnership,” Participant Journal 4, no. 18, April 1965, USAID Development Experience Clearinghouse. 33 Aid paid for with U.S.-owned local currency was thought to benefit the U.S. balance of payments. See Robert H. Deans, “Potential Effects of U.S. Commodity Grants to Other Countries,” American Journal of Agricultural Economics 50, no. 4 (1968): 1009–17. 34 USAID, “Pakistan’s Economic Development and United States Assistance,” 19. 35 USAID, “Progress Partnership,” 9. 36 Resat Aktan, “Economic Effects of the U.S. Agricultural Commodity Aid Program in Turkey,” The Turkish Yearbook of International Relations, Vol. V, 1964, accessed February 19, 2019, http://www.politics.ankara.edu.tr/dergi/tybook/5/economic_effects_of_the-us_agricultural_commodity_aid_program_in_turkey.pdf. 37 Ibid, 134. 38 Ibid, 22. 39 Ekbladh, Great American Mission, 226–27; USAID, “Foreign Aid Explorer: The official record of US foreign aid,” accessed February 19, 2019, https://explorer.usaid.gov/aid-trends.html. 40 For 1960s USAID budget figures in nominal dollars, see the USAID “Greenbook” U.S. Overseas Loans and Grants and Assistance from International Organizations: Obligations and Loan Authorizations, July 1, 1945–June 30, 1969, Special Report Prepared for the House Foreign Affairs Committee, April 24, 1970, USAID Development Experience Clearinghouse. For historic overall budget numbers, see “The Budget of the United States Government: Fiscal Year 1969,” (Washington, DC, 1968), accessed February 19, 2019, https://fraser.stlouisfed.org/title/54/item/19022/toc/380798. 41 Constant dollars are adjusted for inflation. Constant dollar figures available from https://explorer.usaid.gov/aid-trends.html, accessed July 20, 2017. For USAID budget figures, USAID, U.S. Overseas Loans and Grants and Assistance from International Organizations: Obligations and Loan Authorizations, July 1, 1945–June 30, 1974, 1975, USAID Development Experience Clearinghouse. For historic overall budget numbers, see “The Budget of the United States Government: Fiscal Year 1974” (Washington, DC, 1968), accessed February 19, 2019, https://fraser.stlouisfed.org/files/docs/publications/usbudget/bus_1974.pdf. 42 See, for example, Allison Butler Herrick, Oral History with W. Haven North, April 1, 1996, USAID Development Experience Clearinghouse. How Herrick remembers the New Directions policy is significant, in that she was responsible for ensuring projects complied with it in her role at the Budget Office. 43 United States Government, “Public Law 93-189, December 17, 1973,” Section 2. (2)(B)(b)(3). http://uscode.house.gov/statutes/pl/93/189.pdf. 44 Bruce E. Clubb and Verne W. Vance, Jr., “Incentives to Private U.S. Investment Abroad Under the Foreign Assistance Program,” The Yale Law Journal 72, no. 3 (1963): 475. 45 Report, “AID’s ‘New Directions’ with Private and Voluntary Organizations,” Judith W. Gilmore, March 11, 1977, USAID Development Experience Clearinghouse. 46 Report, “Congressional Presentation Fiscal Year 1980, Annex VIII: Selected Development Activities, Other Appropriation Accounts,” 1979, USAID Development Experience Clearinghouse. 47 USAID, “Foreign Aid Explorer: The official record of U.S. foreign aid,” accessed February 19, 2019, https://explorer.usaid.gov/aid-trends.html. 48 Report, “Draft Appraisal Report: The Reimbursable Development Program,” Operations Appraisal Staff, Bureau of Program and Policy Coordination, August 11, 1978, USAID Development Experience Clearinghouse. The “natural resources of interest” to the United States most likely refers to oil. 49 Ibid, 10. 50 Operations Appraisal Staff, “Draft Appraisal Report,” 30. 51 White House, New Directions in International Health Coordination, vi. 52 Ibid, iii. 53 Ibid, xxiii. 54 Ibid, 18–19. 55 Ibid, 19. 56 Ibid, 21. 57 U.S. House of Representatives, “Appropriate Technology: Hearings before the Subcommittee on Domestic and International Scientific Planning, Analysis, and Cooperation of the Committee on Science and Technology,” 95th Cong., 2nd Sess., July 25–27, 1978 (Washington, DC, 1978), 3. 58 Ibid, 55. 59 Ibid, 66. 60 Ibid, 77. 61 Developing World Industry and Technology, Inc., “Changes in the Terms and Conditions of Technology Transfer by the Pharmaceutical Industry to Newly Industrializing Nations over the past Decade,” July 1979, USAID Development Experience Clearinghouse. 62 John W. Forje, The Rape of Africa at Vienna: African Participation in the 1979 United Nations Conference on Science and Technology for Development (Lund, SE, 1979). 63 Karen DeYoung, “Carter Request for Foreign Aid Slashed by 10%,” Washington Post, May 2, 1979, A1.; Frank C. Ballance, “The Mugging of Foreign Aid,” Washington Post, March 18, 1980, A19. 64 Letter, “The Ballad of Herrick’s Goal,” from staffer to Administrator Douglas Bennet, December 1979, box 11, folder 3, Douglas Bennet Papers. See Figure 3. 65 Card, “Sorry about the Budget,” from J. Wasielewski to Administrator Douglas Bennet, December 1979, box 11, folder 3, Douglas Bennet Papers. See Figure 4. 66 Memo, Douglas J. Bennet, Jr. to Mr. John T. McEvoy, December 10, 1979, box 13, folder 1, Bennet Papers. 67 Keshavjee, Blind Spot, 106 68 Administrator Bennet himself, an alumnus of Wesleyan University and later its President, joked in a memo that USAID was effectively the Wesleyan alumni association. Wesleyan was an all-male college until 1970. Memo, Douglas Bennet to staff, box 13, folder 7, Bennet Papers. 69 USAID, Foreign Aid Explorer Dataset, 2017. 70 Frank C. Ballance, “The Mugging of Foreign Aid.” The Foreign Assistance Act of 1980 (PL 96-465, approved October 17, 1980) took scrutiny of USAID a step further and established the Office of the Inspector General. 71 By “political” or “security supporting” aid, Gilligan was referring to the massive outlays that countries like Israel and Egypt received (particularly following the 1978 Camp David Accords) relative to others which had a greater developmental need but which were less strategically important. Security Assistance was typically administered through the State Department. 72 Bill Peterson and David S. Broder, “Gilligan Resigns as Foreign Aid Chief,” Washington Post, February 1, 1979, A1. 73 “Bennet, State Dept. Official, to Head AID,” Washington Post, June 12, 1979, A14. 74 Executive Order 12163 - Administration of foreign assistance and related function, September 29, 1979, accessed February 20, 2019, http://www.archives.gov/federal-register/codification/executive-order/12163.html. 75 Alexander Shakow, oral history interview with W. Haven North, July 6, 1998, USAID Development Experience Clearinghouse. 76 Report, “Draft Plan for Expansion of the AID Program with Stable or Reduced Staff Ceiling,” Allison Herrick, July 25, 1979, USAID Development Experience Clearinghouse. 77 Shakow, oral history interview with W. Haven North, 29. 78 Herrick, Oral History Interview with W. Haven North; “The Ballad of Herrick’s Goal.” 79 Memo, “Implementation of AID Program Efficiencies and Personnel Reduction, FY 80-83,” Douglas Bennet to Tom Ehrlich, October 11, 1979, box 12, folder 7, Bennet Papers. 80 Memo, “Comments on the Draft Plan for Expansion of the A.I.D. Program with Stable or Reduced Staff Ceilings,” box 12, folder 4, Bennet Papers. 81 This was one of a broader set of policy changes across the US government aimed at attracting foreign capital. The major changes were increasing interest rates and lowering corporate taxes. 82 Caroline Atkinson, “Third World Trade Plan Is Established,” Washington Post, July 3, 1980, E3. 83 Ibid.; Report, “IDCA and its Director’s Office: Briefing Book,” 1980, USAID Development Experience Clearinghouse. 84 Atkinson, “Third World Trade Plan.” For more on how this policy impacted local economies and industries, see anthropologist Kristin Peterson’s work on drug markets in Nigeria. Kristin Peterson, Speculative Markets: Drug Circuits and Derivative Life in Nigeria (Durham, NC, 2014). 85 Gisela Mateos and Edna Suarez-Diaz, “Clouds, airplanes, trucks, and people: carrying radioisotopes to and across Mexico,” Dynamis 35, no. 2 (2015): 299. 86 Report, “Program Guidance Paper: Pharmaceuticals in Health Assistance,” July 1985, USAID Development Experience Clearinghouse. 87 Ibid, 12–13. 88 Ibid, 2. Selling basic medicines to the local population was a common way of funding primary health care systems in the 1980s. 89 Bennet went on to a career as head of National Public Radio and, later, President of Wesleyan University. © The Author(s) 2019. Published by Oxford University Press on behalf of the Society for Historians of American Foreign Relations. All rights reserved. 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TI - “More with Less”: Commerce, Technology, and International Health at USAID, 1961–1981*
JF - Diplomatic History
DO - 10.1093/dh/dhz024
DA - 2019-09-01
UR - https://www.deepdyve.com/lp/oxford-university-press/more-with-less-commerce-technology-and-international-health-at-usaid-b4nFibf0zO
SP - 618
VL - 43
IS - 4
DP - DeepDyve
ER -