The International Monetary Fund could be bad for your health. The organisation loans money to countries with financial problems, and in return requires governments to undertake "structural adjustment" policies aimed at improving their financial management.
These usually cut government spending to control inflation. Critics have long charged that this reduces spending on healthcare, so much so that some have called for the organisation to be renamed the "Infant Mortality Fund".
David Stuckler and colleagues at the University of Cambridge have now tested this by analyzing TB data in 21 countries in central and eastern Europe that were involved with the IMF for different amounts of time after 1989 and borrowed different amounts of money.
They found these were associated with 13% more TB cases, and 16% more deaths.
The countries started with TB death rates averaging six per 100,000 of the population. This rose to 12 per 100,000 by 2003 in countries with IMF loans, but sank in countries without them. In a detailed statistical analysis of the timing of the loans, the team found that this was not because countries with worsening TB simply attracted more IMF attention.
"We found TB rates were falling or steady before the IMF programmes began, and rose during the IMF programs," then fell again afterwards to almost the rate they had been before the IMF, says Stuckler.
The team also found that death rates rose almost 1% for each percent increase in the size of the loan, and by another 4% for each year of IMF involvement.
The effect was not associated with other lenders, such as the European Bank for Reconstruction and Development, which invests in Eastern Europe. Nor did it vary in step with other factors such as HIV, conflict, or the rate at which people were put in prison, where much TB transmission takes place the region.
The team found that IMF programmes were associated with less government spending, fewer doctors per person, and a cut of nearly half in the number of people with TB that received Directly Observed Therapy, or DOTS.
DOTS is the World Health Organisation's recommended method of managing TB, in which health personnel directly ensure that TB outpatients always take their medicine. The technique requires investment in public health staff.
"TB takes time [to cause death], so the increase in mortality rates must be linked to something that happened much earlier," objects IMF spokesman William Murray.
TB actually kills quickly when patients do not get drugs and medical supervision, says Stuckler, so death rates are likely an indicator of rapidly declining care, not of events years previously.
Murray also says that the increase in TB was related to the fall of the Soviet Union. But, if that was so, says Stuckler, the effect should have had similar timing and magnitude across the old Soviet block, instead of being linked closely to IMF involvement. In Slovenia, which got no IMF loan, he points out, TB didn't worsen at all.
Murray says the IMF advises countries to spend on healthcare. "No-one wants to say that health spending is not a priority," says Stuckler, "but, in practice, the IMF's aggressive anti-inflation policies cut government spending."
Journal reference: PLoS Medicine (DOI: 10.1371/journal.pmed.0050143)
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