New Bottle, Old Wine? Implications of the World Bank's Systematic Diagnostic Reports for the Rise of Noncommunicable Diseases in the Organization of Eastern Caribbean States.

Since its foundation in 1944, the International Bank for Reconstruction and Development, soon renamed the World Bank (hereafter, "the Bank"), has shifted its initial goal of reconstructing post-World War II Europe to promoting economic development and alleviating poverty in Africa, Asia, Latin America, and the Caribbean. Bank assistance is provided through loans awarded to countries that agree to policy changes that the Bank deems necessary to achieve its stated goals. Bank policies-dubbed Structural Adjustment Programs (SAPs) and, over time, superseded by Poverty Reduction Strategy Papers-have been criticized for not only failing to ameliorate underdevelopment and poverty, but for exacerbating both. The most recent Bank approach to development and poverty alleviation, the Systematic Diagnostic Reports (SDR), attempts to address these criticisms. We appraise the SDR for six Organization of Eastern Caribbean States (OECS). All share daunting economic and social challenges, including an ongoing epidemic of noncommunicable diseases (NCDs). We argue that, contrary to the Bank's claims, these challenges will continue under, and may even be exacerbated by, the policies the Report demands, and we elaborate on their implications for NCDs in the OECS and for social and health equity in the region.

Since its establishment in 1944 during the Bretton Woods Conference, the International Bank for Reconstruction and Development, soon renamed the World Bank (hereafter, “the Bank”), has shifted its initial goal of reconstructing post-World War II Europe to promoting development and alleviating poverty in Africa, Asia, Latin America, and the Caribbean. Bank assistance in these regions is provided through loans awarded to countries that agree to economic and social policy changes that the Bank deems necessary to achieve its stated goals. Bank policies—first dubbed Structural Adjustment Programs (SAPs) and, over time, superseded by Poverty Reduction Strategy Papers—have been criticized for not only failing to ameliorate underdevelopment and poverty, but for exacerbating both.[2-4] The most recent Bank approach to development and poverty alleviation, the Systematic Diagnostic Reports (SDR), attempts to address these criticisms.

Drawing from critical theories of development[5,6] and health,[7,8] we perform a historically informed analysis of Bank policies in the Organization of Eastern Caribbean States (OECS). Our goal is to show that, contrary to the Bank's claims, SDR (hereafter, “Reports”) for this region will reproduce the problems they purport to address. To achieve our goal, we appraise publicly available Bank documents, focusing on the specific Report for six OECS countries, because the differences among these countries notwithstanding, they all share daunting economic and social challenges, including an ongoing epidemic of noncommunicable diseases (NCDs), relevant to our analysis. In addition to providing a much-needed appraisal of the Report—as far as we are aware, the first that specifically delves into their social and health implications for the region—our work contributes to the scarce body of research on the OECS and to understanding the implications of the geopolitical architecture of the world order born in Bretton Woods for social and health equity more generally.

After describing the methods and theoretical traditions that inform our work, we introduce the economic, social, and health landscape of OECS nations, subsequently appraising how evolving relations between OECS nations and their colonial masters actively promoted their underdevelopment, with a brief hiatus after decolonization. This background should help contextualize the Bank's development policies in general and in the OECS. As we shall argue, the joint effect of the historical context and past OECS Bank policies has led to the rise of NCDs in the region, which is likely to continue, or even be exacerbated by, the Bank's most recent recommendations articulated in the OECS Report.

Theoretical and Methodological Considerations

Classical theories of development propose that national poverty, that is, underdevelopment, is due to countries’ failure to “modernize”—that is, to develop technologically, to attract foreign investment, and to implement policies that allow countries to compete in the global economy. In contrast, critical theories of development posit that underdevelopment is not the result of a failure to modernize but rather of successfully modernizing under coercion—coercion imposed by countries in positions of power in the global economy.[5,6,10] All too often, policies that coerce “underdeveloped” countries into “modernizing” fail to meet the needs of local populations, even if they succeed in meeting the demands of a global institutional architecture within which the World Bank and the International Monetary Fund play a critical role.

In the OECS, underdevelopment has historically resulted from the power imbalance between these island states and their former colonial masters. As our analysis will show, the power imbalance and relational dynamics between colonial masters and colonized subjects has persisted despite “decolonization.” A similar focus on power imbalances characterizes critical theories of health, which assume that health inequities—that is, avoidable differences in health among social groups—reflect these imbalances.[1,8] Health promotion efforts like the Bank's prevail in societies where power imbalances are concealed under the appearance of political equality and often fail to meet their ostensible goals precisely because they neglect these imbalances. In turn, critical approaches to policy analysis assume that their goal is to reveal how political power is exercised in the policy process, often using language to legitimize the process, to continue business as usual rather than promote social change. These theoretical traditions jointly inform our work.

To provide a historical context to our investigation, we reviewed the historical literature of OECS countries available from the York University Library catalog (Omni digital search interface) through December 31, 2021. We used the search terms “Eastern Caribbean,” “Antigua and Barbuda,” “Saint Kitts and Nevis,” “Saint Vincent and the Grenadines,” “Dominica,” “Grenada,” “colonialism,” “organization of eastern Caribbean states,” “small island states,” “development,” “underdevelopment,” and “World Bank,” and we selected books that provided detailed accounts of the history of the OECS and the Eastern Caribbean region. As previously mentioned, literature on the OECS is very limited, so our search retrieved only six books. The focus of our policy analysis were Bank documents, selected directly from the Bank's online document database with the filer option “OECS countries.” While we recognize OECS members’ unique histories and social and economic challenges, we note that given their limited resources and small populations, they rely on pooling as a policy strategy: For instance, as we elaborate later, they share a currency, a common market, and a public health agency. This policy approach has also led to shared data production, including academic analyzes of regional data. Indeed, the Bank's Report focuses on the OECS as a historical, social, economic, and cultural unity rather than on each island state, thus our choice of analytic approach and data. In addition to the Report, we selected key documents—for instance, the Poverty Reduction Strategy Papers and the Economic Policies for transition in the OECS—as they represent major long-term policy initiatives championed by the Bank. Over the course of the investigation, the authors met to discuss and structure the analysis. The first author wrote the first draft, which was thoroughly revised by the second author. Both authors participated in subsequent rounds of revision and discussion to reach the final version.

Background

The OECS and their Discontents

The OECS is an association of island countries that strives to promote economic cooperation and social solidarity in the Eastern Caribbean. Member states share a common currency and judiciary system and collaborate on development initiatives regarding trade, environmental sustainability, education, and health. They also share development challenges common among low-income countries, even as they are classified as middle income : high levels of public debt,[14,15] stagnation of service-based economies that are heavily reliant on tourism, vulnerability to economic downturns in high-income countries where tourists originate,[16,17] and low levels of skilled labor that makes them unattractive to foreign investors.[13,15] In addition to their economic woes, OECS countries experience chronic social and health problems: Citizens struggle to afford adequate housing, education, and health services, and NCDs—cancer, cardiovascular disease, and type 2 diabetes—are on the rise, impacting quality of life, burdening health systems, and accounting for six of 10 deaths.[15,18]

That an epidemic of NCDs exists in OECS countries is not surprising: NCDs are common in low- and middle-income countries, with widening wealth gaps and vast segments of the population living in poverty. As was well established more than 200 years ago, poverty breeds disease[20,21] and in the modern world is generally indicated by “plump poverty”: NCDs related to the metabolic syndrome, a constellation of conditions including cardiovascular disease, high blood pressure, and type 2 diabetes, often although not always associated with overweight, in addition to the usual underweight historically indicating poverty.[22,23] It is also well established that income predicts health behaviors, in turn shaped by the material conditions under which people live, work and age—that is, the social determinants of health. Therefore, any attempt to manage the health crisis in the OECS must also involve improving their economies.

Unfortunately, and since the so-called “discovery of America,” systematic resource extraction by the islands’ colonial masters, followed by decades of neglect as colonial powers turned to more profitable horizons, created a perfect storm for chronic underdevelopment. While some progress was made when the island colonies achieved formal political independence and became sovereign countries, the rise of U.S.-led global capitalism forced them to reach out to international financial institutions to manage their economic challenges. It is to an analysis of this colonial and postcolonial history that we now turn.

Colonial Rule and the Development of Underdevelopment

The underdevelopment of OECS countries was a direct consequence of their colonial status within the British empire. During the scramble for territories in the “New World,” the tiny islands in the Caribbean archipelago were only useful as fuel, fresh water, and food resupply stations for Spanish, English, and French armadas entering and leaving the region. It was not until sugar became a major cash crop in the 1600s that European countries dispatched well-resourced settlers to transform the islands into commercial outposts. Like their Latin American neighbors, the then-island colonies would be stripped of their resources—critically, the wealth of their sugar plantations—to enrich an empire hundreds of miles away. With soil and climate ideal for sugarcane cultivation and a seemingly inexhaustible labor force of thousands of imported African slaves, colonists soon forged the islands into profitable territories for sugar production. By the late 1600s, most of the islands that would later become the OECS were under British rule, with a colonial structure almost entirely built around the sugar economy.

Colonial rule denied the islands political, economic, and civil freedoms, blocking the development of sovereign systems of trade, education, and health and resulting in cash-strapped societies with inadequate institutions. Colonists only invested in structures benefiting plantations, reaping huge profits mostly shipped to Europe, and made no effort to support local industry or provide social services. Workers, especially slaves, were denied education, as plantation owners felt that an educated workforce was more likely than an uneducated one to rise up against an inhumane system. These practices jointly resulted in the “development of underdevelopment”.[21,30]

As the British empire grew, its interests shifted away from the small island colonies to larger colonies in Asia and Africa. When more profitable sugar industries developed in other parts of the world and the Eastern Caribbean colonies were no longer useful, “the metropolis abandoned them to their own devices [and] existing economic, political, and social structures of these regions prohibited autonomous generation of economic development”, p. 28. By the time the empire abolished slavery, the islands’ sugar industry had virtually collapsed, and the island colonies fell into ruin. Cash-strapped governments whose policies were subject to approval from the “mother country” were unable to support local industry or engage in meaningful trade, not only with neighboring French and Dutch colonies and independent South American countries, but even within British island colonies. Since the abolition of slavery around the 1830s and through World War II, the colonies—now rebaptized British West Indies—were denied resources, material or human, and even freedom to develop their own. In 1937, a Royal Commission was dispatched to assess the state of the island colonies. British officials touring the islands witnessed decrepit buildings, dilapidated plantations, and a labor force barely scraping a living. The visit resulted in the Moyne Commission, which detailed widespread poverty and malnutrition, inadequate sanitation leading to dysentery and malaria, lack of medical facilities, and low life expectancy.[17,26,29]

The post-emancipation period was both the result, and the continuation of, a centuries-old process of underdevelopment. The lack of infrastructure investment during the sugar plantation years had left the colonies without adequate buildings, transportation networks, or social services. Decades of slavery produced a traumatized population with little choice over its destiny. Hesitant to continue working on the very plantations that had so brutally dehumanized them, many freed slaves opted to occupy small plots of lands on which they could build precarious dwellings and cultivate small agricultural plots. The process began a culture of small, independent farms whose owners relied on traditional knowledge and produced just enough to feed themselves or sell their limited surplus in local markets.

The post-World War II decline of the British Empire paved the way for decolonization. Britain no longer had the military or political power to enforce her will on colonies that were demanding political independence, which the smaller Eastern Caribbean islands gained by the early 1980s. They then joined the international trade group of recently decolonized nations, the African Caribbean Pacific, that negotiated trade agreements with the European Union. These agreements, known as the Lomé Accords, allowed African and Caribbean countries preferential access to development aid and European markets, affording them for the first time a modicum of socioeconomic growth, which we elaborate on in the next section,

Development at Last in the Era of “Green Gold”

The early decolonization period was arguably the most successful period of development for the region. For most OECS countries, the path to decolonization was relatively peaceful, with a gradual transition to constitutional governments that promptly set out to organize their own affairs. This was no small task, as the islands still maintained vestiges of plantation society: Most citizens lacked special skills, and agriculture continued to be the primary industry and employer of the local labor force.[16,32] Because sugar cane had long ceased to be a profitable cash crop, farmers turned to coffee, cocoa, and bananas. Bananas were in particularly high demand in Europe, the tropical climate of the islands was perfect for their growth, and the infrastructure of sugar plantations could easily be repurposed for banana cultivation. By the mid-1980s, bananas had become the chief industry for most OECS countries and employed marketers, accountants, seaport workers, and farmers.

The importance of the industry cannot be overstated: As much as 70% of the workforce was involved in the production and shipping of bananas.[16,17] Banana revenues, together with development aid from the European Union, allowed OECS governments to invest in transportation, communications, and social services,[27,33] such that more OECS citizens finally had access to education beyond elementary school[13,17,26] and to considerably better living conditions that improved population health. Improvements to the water supply led to lower rates of infectious diseases, and although a specialized health care force remained scarce, as more nurses and doctors were trained, more services were offered. Because so many people were involved in agriculture, locally grown rice, sweet potatoes, maize, plantains, yams, and a wide variety of tropical fruits and locally raised livestock were readily available at affordable prices. These developments lowered rates of malnutrition and increased life expectancy. By the late 1980s, a sizable middle class of teachers, nurses, and tradesmen had developed, all of whom benefited from membership in thriving unions. Banana exports continued to drive the economy, alongside an emerging tourist industry. While still considered “developing” states, by 1990, OECS countries had relatively less poverty than countries in Asia and Africa and considerably less social inequality than Latin American and Caribbean countries.

These infrastructural and social—especially health—improvements were anything but “natural”: They resulted from the shift from colonial rule to political independence that gave OECS island countries control over their resources, an essential determinant of development. No longer peripheral outposts supporting the wealth of colonial masters, the island countries were able to engage in “inward-directed growth” and dedicate it to improve the living conditions of the citizenry. However, and despite the protection afforded by trade agreements with the European Union, reliance on a single cash crop put the island countries at the mercy of global capitalist markets, especially as hurricanes or pests could wipe out banana crops in hours. To make matters worse, monocrop farming deteriorated the quality of agricultural land. This vulnerability was exacerbated by the absence of diversified industry such that disruptions in the banana trade could affect the entire economy. And a disruption was fast approaching, driven by a globalizing system whose political economic architecture relied on international financial institutions like the Bank and whose toolkit consisted of “free trade,” “development assistance,” and public policy “reforms.” Although ostensibly designed to bring millions in former colonies out of poverty, since partnering with the Bank, the economies of OECS countries have steadily and consistently contracted.

Findings and Analysis

Enter Development World Bank-Style and Structural Adjustment Programs

As mentioned earlier, the initial goal of the Bank was to assist with the reconstruction of devastated, post-World War II Europe. By the 1960s, the Bank's focus had shifted to infrastructure development in member countries in Asia, Africa, and Latin America, and by the 1970s, it had shifted again to eradicating poverty in these regions, p. 200. Bank policies, informed by modernization theory, consisted of a cocktail of “free trade,” private-sector expansion, and reduction of social spending. Dubbed SAPs, the cocktail was supposed to be the perfect strategy for economic growth. Bank assistance came in the form of loans awarded to governments prepared to implement SAPs policies. As it turns out, SAPs did little more than widen wealth gaps, increase poverty, and worsen social and health outcomes throughout Asia, Africa, and Latin America.[1,39-41]

Through the 1980s, the Bank had had little involvement in the OECS. Most development aid, including loans for sewage and transportation projects, came from the European Union, which made these independent from international institutions such as the Bank.[17,31] However, the early 1990s found the OECS with their most important industry threatened, as the European Union was pressured by the United States to end trade agreements with the African Caribbean Pacific group. U.S.-owned banana companies claimed that these agreements violated “free market” rules established under the General Agreement on Tariffs and Trade (GATT) and threatened legal action. OECS governments were extremely concerned, as banana production was crucial to their economies. Excluded from negotiations between the United States and European Union and lacking global power in the international arena to advocate for themselves, OECS government had little option but to embrace Bank loans.

In 1994, the Bank responded to OECS countries’ request for development assistance with several conditions—aligned with the Bank's vision for a new health policy laid out in its seminal 1993 report “Investing in Health” —that essentially encouraged state competition alongside the reduction of state responsibility for social services, couched in the language of “diversity”. Firstly, the OECS countries were to reconfigure their banana industries to compete with other banana-producing nations, on the grounds that “free markets”—advantageous to powerful countries that after centuries of protectionism had “kicked away the ladder” —would be equally good for “developing” nations seeking their way out of poverty. Secondly, it recommended that OECS countries shift to service-based industries, such as tourism, to enjoy the “comparative advantage” of their tropical climate and natural resources, attractive to tourists from wealthy countries. Finally, it urged OECS governments to reduce tariff protections, alleging that they discouraged foreign investors.

The Bank's conviction notwithstanding, its recommendations were not only useless, they significantly, and predictably, harmed the tiny island countries. With a combined surface area of 2806 square kilometers, they could not compete with Costa Rica, with a surface of 51 100 square kilometers or Honduras, with a surface of 112 492 square kilometers. Even if they embraced banana production, they would never match the productive capacity of vast farms in those countries. Also, the OECS model of banana production was one of small farms with traditional agricultural practices[31,33]: basic technologies and greater reliance on human labor. Of note, this model—“inefficient,” according to modernization theory—was a boon for local laborers, who, as a crucial force in the production process, were paid very good wages by landowners who depended on them to run their estates, so the exploitation common on U.S.-owned estates elsewhere in the Caribbean was unheard of in the OECS. Finally, because most OECS banana growers were small, independent cooperatives lacking capital for technological upgrades, they could not afford expensive machinery and chemical fertilizers.

Shifting to a service industry would be no solution, either. Tourism was too dependent on increasingly common economic downturns in wealthier countries. Competition with larger tourist destinations would also require OECS governments to invest in sophisticated amenities—resorts comparable to U.S.-owned resort chains such as the Hilton Hotels —and in advanced transportation networks, far less useful to local populations than social services and infrastructure. The foreign-owned nature of these amenities deprived locals from the autonomy they enjoyed as small banana producers. Furthermore, only St. Lucia and Antigua and Barbuda had airports large enough to accept huge jet airplanes. Finally, reducing tariffs, a Bank's favorite, did not help to develop local industries, but rather contributed to their demise.

Be that as it may, in 1994, the Bank's conditions were presented as a report by Bank experts to OECS leaders at a meeting of the Caribbean Group for Cooperation in Economic Development. Yet even as the United States was increasingly pressuring the European Union to end protected markets—which the European Union did by 1997—and vis-à-vis the imminent demise of the banana industry, in order to secure Bank assistance, OECS countries finally “liberated” their economies, shifting to service industries and shrinking the public sector. Importantly, adopting the Bank's policies fundamentally changed the role of the state : From investing in local markets, supporting local business, and providing for social needs, governments turned to courting foreign investment through low tariffs, promotion of tourism, fewer public sector jobs, overall lower wages, and impoverished public schools and health services, precisely when household incomes were collapsing with the decline of the banana industry. In sum, the advent of SAPs resulted in a major transfer of political and economic power from the masses to the very few. No longer imposed by a colonial master, underdevelopment returned to the OECS with a vengeance, courtesy of a global capitalist “free trade” system.

The World Bank Strikes Again With Poverty Reduction Strategy Papers

In the 2000s, and upon the collapse of the banana industry, it became clear that tourism, now the main industry in most OECS nations, was failing to generate comparable revenue. Most of the small number of hotels in operation, foreign owned, transferred their profits abroad. Most OECS nationals, lacking the sophisticated training required for hospitality services, were pushed into low-wage jobs. Unemployment and emigration soared, and public borrowing to face increasing energy costs depleted public coffers, such that even before the Great Recession of 2007–2009, OECS countries were struggling with high public debt and shrinking economies. Confronted with this conjuncture, OECS governments negotiated new loan agreements with the Bank, contingent upon their agreeing to a Poverty Reduction Strategy Papers (hereafter, “Papers”) framework. The Papers were the Bank's attempt to rebrand its policies to align with the ideological demands of the current era—they were a more “inclusive” and “collaborative” approach to development. Confronting increasing criticism from advocacy groups, nongovernment organizations, and researchers, the Bank was due for a facelift, so rebranding would kill two birds with one stone: It would restore its reputation as a nurturing institution, whose policies were implemented by “partners” themselves—local experts, administrators, and government officials—even as they continued, as functional equivalents of the SAPs of yore, to support capital accumulation.[2,49,50]

Astutely, the Papers acknowledged that OECS countries could not compete with subsidized products from rich countries and that the collapse of the banana industry had harmed the population, including their health. Nevertheless, as in SAPs, the Papers prioritized economic “liberalization” through reduced trade barriers; promoted an investor-friendly business climate of lower, “competitive” wages ; and encouraged private-sector development through credit support, even as they discouraged credit for the public sector, attributing OECS financial woes to excessive public spending. Upon the Bank's recommendations, Dominica, St. Vincent & the Grenadines, and Grenada attracted call center operations, St. Lucia rebranded itself as a high-end visitor destination, Antigua and Barbuda began to promote wedding and honeymoon vacation packages, and Dominica launched a program that offered citizenship in return for foreign investment. The revamped development approach merely reproduced previous Bank strategies and goals, only this time legitimizing, through “partnerships,” a global system that trapped victims into age-old and unequal, albeit “voluntary,” terms of trade.

New Bottle, Old Wine, and the Systematic Diagnostic Reports

By 2016, and despite a 15-year domination under the Papers framework policies, OECS countries still faced the problems of previous decades. The tourism industry still underperformed, unemployment had increased, and emigration continued. New problems, related to global warming, compounded older ones. Rising ocean temperatures increasingly led to hurricanes, threatening coastal regions and low-lying islands such as Antigua and incurring millions of dollars in damage.[54,55] Yet despite lackluster results from previous policies, OECS countries continued to seek development support from the Bank, which had by then abandoned the Papers approach and was now inviting “partners” to co-produce country-specific Systematic Country Diagnostic Reports (hereafter, “Reports”).

The OECS Report, published in 2018, analyzes development challenges in OECS nations and identifies new “strategic priorities” to guide development. Produced by a task force that combines the expertize of Bank analysts with the know-how of local leaders in the public and private sectors, it emphasizes means-tested support systems and, notably, “sustainable” development. And yet, sustainable in Bank-speak appears to mean rehashing the same policies of further integration with global capitalist markets that led to underdevelopment in the first place. The Report also encourages “openness”—open borders to ease the flow of people and resources in and out of the islands —and a “blue economy,” capitalizing on the islands’ wealth in marine resources, breathtaking landscapes, and benign weather to promote the tourist industry.

The Report persuasively engages with the Sustainable Development Goals and appears especially sympathetic to global warming challenges, offering compelling evidence for the economic implications of said challenges in the form of precise quantitative data, such as the estimated $35.1 million (all dollar amounts in U.S. Dollars) damage caused by 2017 Hurricane Maria. To fully prepare for these crises, the Report advises the development of data systems and response protocols for disaster relief and strategies to rebuild the private sector—for instance, comprehensive insurance packages for businesses. It further proposes “new insurance products and optimized policies” to protect infrastructure, public services, and fiscal balance, p. 104. Combining aggressive insurance tools and data systems, the Report claims, will position countries to rebuild efficiently at reduced costs.

One major strategic priority in the Report is “regional integration”. As we noted earlier, OECS countries already have a good track record of regional integration: The OECS monetary union is one of the oldest inter-regional currency unions in the world, and island states are part of the Caribbean Common Market and the Caribbean Public Health Agency. After lauding OECS regional integration, the Report asserts that integrating even further with “the rest of the world can help to realize scale economies”. It goes on to suggest that an OECS regional tourist brand could enhance integration, help the islands compete with other tourism destinations, and prove effective for pooling savings to support reconstruction efforts following natural disasters. Yet like SAPs and Papers, the Report simultaneously emphasizes fiscal “reform”—that is, shrinking the public sector—only this time acknowledging the volatility of tourism and the threat posed by global warming, while portraying Bank-style reform as the best way to address the challenges produced by the same Bank policies that caused the vulnerability of the island states.

In sum, the Report amounts to little more than an environmentally-friendly—in Bank parlance, “sustainable,” “collaborative,” and “inclusive”—version of the SAPs and Papers of yore, albeit with a “local” face that benefits from the collaboration of a managerial class of public- and private-sector leaders and ensures that the more privileged classes within the island states will themselves perform the ideological and material work of the global capitalist system that underdeveloped their countries. Calls to open markets—which virtually always come along with significant corporate protectionism —to purchase foreign technology, and to protect the public good through commercial, for-profit insurance strengthen even more the monopolies that today dominate global markets. Even the call to create a skilled labor force is bound to backfire, as skilled workers from poor countries tend to emigrate to wealthier ones in search of better opportunities, a phenomenon that the Report itself acknowledges, noting that “the proportion of OECS nationals abroad rose from 35.9% in 1990 to 54.9% in 2017”.

Perhaps the most notable aspect of the Report is its rewriting of history. When describing former trade agreements between OECS nations and the European Union, it refers to them as a relic of the “colonial era”—a “European trade preference regime” —supported by “an enslaved and indentured workforce”, pp. 13 and 38. By associating the Lomé accords with colonialism, authoritarianism, and exploitation, the authors deliberately depict preferential trade in a very negative light, so readers who are unaware of the historical context will reasonably conclude that the Lomé accords must have been far worse than the coercive, pro-corporate, and inequitable global “free trade” system that replaced it. By insinuating that the latter is the epitome of freedom, the Report fails to acknowledge the trade treaties that produced the greatest economic growth for OECS countries, and the privileges of countries that destroyed these treaties, while duplicitously promoting preferential systems of trade such as NAFTA.

Private Troubles, Public Issues, and the Dialectic Between Development Bank-Style and Health

The Bank's strategy for development has not benefited the OECS nor the health of their citizens. On the contrary, it has worsened the economic challenges of the region, reduced the gains of the earlier period of decolonization, and exacerbated socioeconomic and health inequalities. As late as the 1980s, NCDs were virtually unheard of in the OECS. The economic, social, environmental, and behavioral factors that contributed to them were largely nonexistent, and active lifestyles were built into the structure of everyday life and work. During the colonial period, one notable effect of Britain's neglect was the prevalence of squatting. Emancipated slaves did not own their own land, and while many of them acquired small plots from ruined sugar estates, many of them simply squatted on whatever available land they could find. Policing of squatters was irregular at best. Widespread squatting eventually led to villages and towns lacking proper road networks. The inhabitants of those villages, often lacking resources to purchase and maintain cars, relied on walking for transportation. With much of the labor force involved in agricultural work, there were very few urban areas. OECS citizens were spread out in rural areas with plenty of access to green, open spaces. Many OECS citizens played sports such as cricket or soccer, activities requiring minimal equipment on easy-to-maintain public savannahs. Most jobs in agriculture were physically demanding, so much so that even before the banana industry's demise, some OECS residents opted for professional jobs to avoid the intense physical labor of the farms.

Concerning nutrition, during the heyday of the banana industry and even when bananas were the main crop, OECS farmers grew a wide range of tropical fruits and vegetables that formed the basis of their meals. Traditional meals in most of the islands consisted of seasoned meats and fresh vegetables. Restaurants were scarce, and meals were consumed mostly at home. Processed foods were rare and expensive. Barely available in villages, especially in the rural areas, high tariffs and transportation costs made them unattractive or at least inaccessible. The fast food industry had not yet taken hold, and restaurants were mostly reserved for the elites.

All this changed with the demise of the banana industry. The shift from an agriculture-based to a service-based economy led to rapid urbanization. Tourist amenities and hotels concentrated in special districts, which prompted workers to move away from rural areas to urban centers. Call centers and other service-based industries, set up in urban cores lacking the green space of rural towns and villages, pulled even more workers to larger towns and cities, further increasing urbanization, while service industry jobs increased sedentary lifestyles. New urban areas lacked public spaces, whereas most recreation facilities now require fees and thus are mostly used by tourists. With poorly developed public transit systems, most urban workers have been forced to purchase cars to move around, straining their already meager incomes and limiting their opportunities to walk. Dependence on cars, congested housing, and limited open spaces and public recreation facilities have all contributed to the sedentary lifestyles now all too common in OECS towns.

By the 1990s, looser tariffs and import taxes, another recommendation of the Bank, made it easier to import American foods, and media campaigns by the U.S. food industry made food chains household names, so demand for their products grew. Low-priced processed crackers, biscuits, cereals, and sugary drinks outcompeted fresh produce. Meanwhile, the loss of food sovereignty and the shift from agriculture to a service industry contributed to the overall deterioration of nutrition in OECS countries. Fewer farmers also meant less fresh produce, thereby driving up costs. Moreover, the need to cater to tourists prompted major changes in eating habits, as businesses pushed for North American-style foods to attract visitors, leading the island nations to welcome, willingly or not, U.S. fast food chains such as Kentucky Fried Chicken. By the mid 2000s, the diets of many OECS citizens closely resembled those of U.S. citizens. This was not simply a matter of choice. The change in the socioeconomic structures of OECS countries made unhealthy food far more readily available and affordable than unprocessed foods, which became simply out of reach for most OECS citizens.

The adoption of Bank policies occurred alongside a noticeable rise in NCDs. In 2012, the World Bank released a report titled “The Growing Burden of Noncommunicable Diseases in the Eastern Caribbean,” The report described an epidemiological outlook where NCDs—cardiovascular disease, malignant neoplasms, and diabetes—now accounted for 75 to 85% of deaths in all OECS countries. This rise has become a burden to the already under-resourced health systems in OECS countries. The islands jointly spend on health services less than the 8% of gross domestic product recommended as a minimum by the World Health Organization. With scarce resources, the burden of paying for NCD health care costs is passed to private citizens. While out-of-pocket spending varies between OECS countries—for instance, citizens of St. Vincent and the Grenadines spent on diabetes treatment an annual average of $322, whereas those of Antigua and Barbuda spent an annual average of $769—this out-of-pocket spending is significant considering the low average salaries in the region.

Beyond the direct costs of treatments, NCDs result in significant loss of earnings to individual and communities. Time spent in hospitals and clinics and in recovery results in time not working. Using St. Lucia as an example, the Bank has reported that the average Saint Lucian diagnosed with an NCD loses roughly $241 on work absenteeism. The authors further note that time spent on domestic care is a significant burden on community members who assume responsibility for taking caring of family members affected by illness. With much of the cost of NCDs passed on to individuals, inequities in access are apparent in all island nations. In St. Lucia, the Bank notes that while the poor spend less on NCD health care costs, those expenditures account for a significant amount of their yearly incomes. As public services deteriorate and the wealthier can afford private options, a two-tier system is created where the poor rely on under-resourced public health systems while better-off citizens can access private—and often better—health services, within the OECS and abroad.

While the Bank is transparent about existing health inequities, it does not address the underlying socioeconomic structures which contributed to them. Instead, its 2012 report encourages a focus on nutrition education and intentional encouragement of physical activity in schools and adult learning centers. The Bank insists that the most impactful approach is to promote healthy lifestyles, yet offers no information on how to address the barriers that make those lifestyles inaccessible to the poor, nor acknowledges the socioeconomic factors that created such barriers. In sum, Bank-style policy “reforms,” as they have transformed the political and economic landscape in the OECS, have played a key role in the changes that today drive the epidemic of NCDs. While the most recent incarnation of Bank development policy for the region, the OECS Report, acknowledges the importance of the social determinants of health and no longer recommends, as in past reports, promoting healthy lifestyles to address the challenge of NCDs, it nonetheless continues to endorse economic “solutions” that, as we have argued, can only exacerbate the challenge.

Discussion and Policy Implications

The best way to counteract the rise of NCDs in the OECS is to supersede the current global trade system. Unequal systems of trade will never benefit OECS countries or countries similarly constrained by them. Rather, they will make it impossible for low- and even middle-income countries to protect and develop national markets, precisely what Great Britain or the United States themselves did en route to becoming empires. It is critical to transform the character of the state so that it will support a strong, local food industry; well-paying jobs; high-quality education; and an equitable distribution of the social determinants of health generally.

OECS countries will also be better served by joining the struggle for equitable, international, and regional trade agreements and partnerships. One such partnership is the Bolivarian Alliance for the Peoples of our America (ALBA), first promoted by Hugo Chavez (then president of Venezuela) and Fidel Castro (then president of Cuba) as an alternative to the coercive, “free trade” models advanced by the corporate classes in the Americas. Central to ALBA's ethos is prioritizing human needs over capital accumulation. Member states engage in cooperative trade relations, allowing smaller countries to share resources and support. It was not until joining ALBA that Antigua and Barbuda, St. Vincent and the Grenadines, and Dominica could access much needed oil for their energy sectors, as Venezuela agreed to supply them with oil at reduced prices to enable them to overcome their energy challenges. OECS partner countries responded by exporting agricultural produce to the larger countries, offering an example of a system of trade that does not rely on exploiting the weak. Indeed, OECS countries should heed the Bank's advice on regional integration, yet with institutions such as ALBA, informed by principles of solidarity rather than by the zero-sum game ideology that glamorizes “competitiveness.”

As an institution that provides financial assistance to poor countries, the Bank is a powerful actor in the development arena—in its own words, part of “a unique global partnership […] working for sustainable solutions that reduce poverty and build shared prosperity in developing countries”. Yet after close to three decades, Bank policies have mostly impaired the development of the OECS. While the language of their multiple policy reports may occasionally align with the Bank's stated mission of “reduce[ing] poverty and build[ing] shared prosperity in developing countries,” in practice, these policies function as an extension of global capitalist interests that rely on coercive and inequitable, even if legal, systems of trade. As noted more than 30 years ago, Bank policies are “bound up with the reproduction of mass poverty,” because even if they recognize “poverty in the third world,” they do not confront the “class structures and global capitalist interests” that lead to poverty, and as such can only reproduce, rather than challenge, the “basic structure of imperialist underdevelopment”, p. 471. Similarly, as we have shown, the continuing repackaging and rebranding of similar policies in the OECS are part of the Bank's public relations and operational structures. While formally not “colonial,” rebranded policies achieve outcomes similar to those of former colonial masters. Economic harms are only one side of the Bank coin. The other side are the health outcomes, which the Bank itself has described as a matter of grave concern. But because the Bank does not address the political economy of health, it can only recommend short-lived, quick fixes: nutrition and exercise workshops. Continuing Bank involvement in the region is bound to guarantee the persistence of economic woes and the rise of NCDs.