Smita Srinivas is an assistant (for now, I think) professor at the Graduate School of Architecture, Planning and Preservation at Columbia. My topic today is her wonderful book, which I believe was her dissertation project, Market Menagerie.
The motivating question for the book concerns how nations like India, which have flourished economically by moving into new health services and pharmaceutical markets, can move some of that growth into greater health access among impoverished local residents. The research is meticulous, and the subject matter is important to social welfare and social justice. By the end, Srinivas manages to connect the market and institutional themes to urban and regional planning in ways that help enlighten a new approach that guides health and development away from the silos of western planning.
The first chapters of the manuscript start the reader off by helping us understand development as occurring within the complex interplay between markets, states, and institutions. This backdrop then enables a discussion about the evolution of health systems from local health services delivery systems to one in which the nation-state becomes an important player, but only along selected dimensions. The chapters covering the period from 1950 to 1970 discuss federal social policy evolution after independence; the subsequent chapters on the 1970s through the 1980s highlight the private industrial contributions to modernizing medicine within the country. Subsequent to these changes, political upheaval in India allowed for the re-emergence of nonmarket institutions, such as unions, in trying to capture more of the benefits of economic growth for a broader based of Indians.
The late 1980s saw a shift towards globalization. Srinivas refers to this time period as the “second market” environment, where India’s pharma industries began to respond to trade liberalism and regulatory harmonization by entering into global markets. That shift meant an expansion of industrial capacity into markets intended almost exclusively for export.. As Srinivas notes in a key chapter relating the history surrounding vaccines, the result was “health for some” as vaccine manufacturers in India lost out to other producers in the global market, and Indian venture capital found ready markets for other innovations, largely focused on exports that yielded greater returns even as Indian children went without vaccination.
The third market environment for India is one where the industries become both adaptable and flexible in responding to developing niche markets, and where the state has played a tremendous role in providing opportunities for innovation via learning and research.
The final chapters of the book place the ideas in a global, comparative context. I disagree a bit with Srinivas’ read of Polyani in these chapters, but that is a minor point. The latter chapters bridge policy across global, national, and community scales of health services in multiple contexts. I will use the chapter “Health Technologies in Comparative Global Perspective” in my graduate classes in Urban Social Policy and Planning. There are some problems with cohesion in this chapter, but it contains so many interesting and useful points that I think its problems come down to simply having a lot of ideas. I wish more books had this problem.
In particular, there is a comment that made me run out of my office to share it with my colleagues:
An analyst of today’ s mixed economies has no excuse for minimizing the state’s roles by pointing to past errors of centralized socialism. (p. 183)
The final chapter contains another nice contribution, one that I will likely assign in my planning theory class, on cities as mediating sites for health, health access, and health services, and the role of practical utopians in trying to forge a theory of healthy development within international cities.