PHA-Exch> IMF/TB disputre: The authors respond....

[Claudio Schuftan]

>From David Woodward:


IMF spokesperson William Murray responded:

http://www.lshtm.ac.uk/ecohost/projects/mortality-fsu.htm <
http://www.lshtm.ac.uk/ecohost/projects/mortality-fsu.htm>


Prof. David Stuckler countered to the points the IMF makes in turn:
excerpts

                 "We will be dealing with the flaws in the study via
contacts with the authors and the journal that published initially their
work. Let me just note that there are clear flaws in their econometrics, and
there are a numerous counterfactuals that they ignore or skirt. We will be
dealing with those in the proper forum. However, I acknowledge we have
significant questions about their claims".

We would welcome any opportunity to work with the IMF. As we noted in our
press release, we think the IMF has 'good intentions'. If our data show that
the IMF programs are having an unintended consequence of weakening
tuberculosis control, we would hope that, since the IMF claims to fight
poverty and promote development, they would not simply dismiss these
findings (as they have long done through constant denial of case-study and
NGO evidence on this topic). Rather we would hope they would work with us,
as experts in public health, to find ways to achieve their macroeconomic
goals without unnecessarily sacrificing people's lives.

No doubt there has been a lot of "IMF bashing" lately. The IMF seems to be
taking it on the chin from all sides. Questions of credibility, legitimacy,
a shrinking budget and a lesser willingness of many nations to be 'helped'
by the IMF all seem to have put the IMF in crisis-management mode. Recent
books by Stiglitz, Soros and even Jeffrey Sachs have been lambasting the
Fund's record in human rights and international development.

So why not see these findings as a real opportunity to boost the Fund's
global reputation instead of continuing to write-off what some very well
respected doctors, like Jim Kim and Paul Farmer, and medical NGOs, like Med
Sans Frontiere, have been saying for years.

As per flaws in our study, we followed best practices in econometrics and
epidemiologic methods. We used the same methods that the IMF does to
evaluate the economic impacts of its reform programs. Also, note that our
study was peer reviewed by six economists and statisticians. If we had not
taken into account the basic criticisms that the IMF raises below, our study
on such a controversial and often politicized topic would have never passed
peer review for publication at a flagship journal like PLoSMed.

We were disappointed to see the IMF respond to our study just like the
so-called "IMF bashers." In the New York Times, William Murray called our
article "phony science" .



       "Anyone can try finding a rationale for anything. This study is an
example of that".

The IMF is basically suggesting that we conducted some sort of 'fishing
experiment'. That's what we disparagingly call it in epidemiology when
researchers correlate a lot of variables, find some significant
relationships (1 out of 20 will correlate by chance alone), then make up a
theory and write up the paper about the finding as if that's what the
researchers had thought of all along.

None of this applies to our study. Our analysis was carefully thought out
and designed to test a basic theory: IMF lending is connected with
aggressive anti-inflation targets (see any of the latest IMF headlines to
back this up). These often in practice are thought to lead reductions in
government spending. In practice, health spending is one of the first things
to go, as summarized in the Center for Global Development report, Do IMF
programs constrain health spending in poor countries?,

Reductions in critical health services and resources, such as doctors,
hospitals and clinics, are thought to have weakened the fight against
tuberculosis in transition and resource-deprived economies.


       Murrayy continues: "As you well know, a central principle of the
IMF's economic policy advice is that public spending on critical social
needs -- healthcare and education -- is among the most productive and
responsible expenditures by a country. For instance, efforts by governments
and development agencies to attack tuberculosis in sub-Saharan Africa are
fully supported by the IMF. These academics imply otherwise".

No one wants to say that health spending is not a priority. But true
commitment can only be judged by the decision to spend money. The IMF puts
aggressive anti-inflation targets before all other policy goals. In practice
this results in cuts to government spending, and doctors have warned that
this leads to reduced health spending.

Until we see hard evidence that IMF programs have secured or improved health
or health spending, there is no support for the IMF's claim.

We also point out in the article that we applaud the IMF's direct support
for HIV/AIDS control, but worry that when it comes attached to
conditionalities that it might be doing more harm than good. Why? First, the
money from the IMF for steering the fight against HIV/AIDS could displace
local funds. That creates even greater dependency on the IMF in lending
countries. Second, the negative indirect effects of their economic programs
on health spending could far outweigh the benefits they claim credit for (as
our study suggests).

       "Our extensive published analysis is clear evidence that we are very
sensitive to the important role of healthcare and personal well being. We
also have contacts and relations with international bodies who are expert in
the area of healthcare and disease prevention and control. This doesn't seem
to register with the authors.       Broadly speaking, where you have a Fund
program you have an increase in health spending. Not the opposite".

Again, to our knowledge, there is no evidence to support this claim.

       "The most obvious counterfactual is their claims on the timing of the
increase in tuberculosis mortality rates. These rates are matched to the
point at which IMF funding was introduced".

Our analysis was set up to isolate the relationship of IMF programs to
tuberculosis control. We considered the possibility that the IMF was an
innocent bystander or trying to help financially ailing countries, and so
our results were simply 'guilt by association.' If this were the case, the
tuberculosis rises would occur prior to the IMF's arrival on the scene. We
found, all things being equal, just the opposite. Our models found that
tuberculosis rises linked to the IMF occurred at the point of or within a
few years after the countries entered into a lending program with the IMF.

In other words, we looked at countries to see which came first, tuberculosis
rises or IMF loans. We found tuberculosis rates were falling or steady
before the IMF programs began and rose during the IMF programs. When
countries left the IMF program, tuberculosis rates fell by close to the same
amount as they had risen once they started. Our paper makes these points.

        "Tuberculosis is a horrible disease that evolves over time, so
presumably the increase in mortality rates must be linked to something that
happened much earlier. Was there not a significant and well-documented
increase in tuberculosis cases in the Soviet Union in the late 1980s?"

 The tuberculosis trends simply do not support this claim. Tuberculosis
incidence, and the calculated annual risk of infection, was going down for
the 50 years prior to the study period. Even latent infections (or existing
infections that just weren't active) would have been lower prior to the
IMF's arrival.

In our Supporting Information Table 6, we show that in only two cases,
Georgia and Uzbekistan in 1993, were tuberculosis rates rising in countries
that were not on IMF programs. That means tuberculosis rates were falling
more than 99% of the time before these countries became involved with the
IMF's reform programs. In both of these countries, tuberculosis rates
increased after initiating an IMF program and either dropped or stayed the
same after leaving the IMF program."

       "Weren't prison populations in the Soviet Union well documented as
unfortunate carriers of the disease? Also, communist countries were where
health spending was inefficient and expensive but subsidized".

The IMF correctly notes that prison populations were important carriers of
the disease. We have another paper in press on this topic. We never claimed
that the IMF was the only determinant of rising tuberculosis rates, but that
exposure to their programs helped explain some puzzling differences across
countries.

However, it is worth asking: if tuberculosis rates were declining prior to
the early 90s, that means prison rates were not breeding grounds for
tuberculosis (granted, Soviet prisons were not very pleasant). What led to
the overcrowding of prisons and inadequate access to healthcare? One answer
might be the cuts to government spending. In many countries, government
support for penal institutions is an important source of funds needed for
prison and prison health infrastructure. But that remains a topic for future
research.

The economic shocks did not come until after the Soviet break-up, when the
countries started implementing radical market reforms -- the very ones
pushed by the IMF (mass privatization, liberalization and stabilization).

       "If the IMF had not stepped in to help the post-communist countries,
the declines in health spending would likely have been more pronounced and
disease generally more severe".

We found exactly the opposite: had the IMF not stepped in, all factors
pointed to tuberculosis continuing to decline. We compared IMF loans to
lending from other sources. Borrowing from other foreign banks had the
opposite effect as the IMF, and had a positive or neutral relationship to
public health infrastructure and government spending -- evidence in line
with our theory.

We saw that the tuberculosis rises in our models occurred during the IMF
programs, and that before- and after-the IMF programs tuberculosis rates
were falling.

As we noted in the NYT article, when you have one correlation, you raise an
eyebrow, but when you have more than 20 correlations pointing in the same
direction, you start building a case for causality.
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