This article is about the problems of malnutrition and disease in a rural area of an underdeveloped country, Tanzania. The particular way in which health problems were conceptualized during the colonial era, the structure of the medical services established, and the effects of health care on the health status and size of the rural population of Songea District in Tanzania are shown in the article to have been determined by the economic, social, and political requirements of German and British colonial rulers rather than by the health needs of the African population. Colonial economic policy emphasized the production of cash crops for export, whether by African peasant farmers or by European plantation owners. To provide workers for the plantations, a system of labor migration was instituted. Songea District became an area that supplied male workers to other parts of the country, with grave consequences to the health and nutrition of the women and children left behind. Domestic food production was neglected by Africans forced to migrate in search of cash to pay taxes and by those enganged in the cultivation of cash crops. Extensive malnutrition and persistent ill health related to poor diet are thus traced directly to capitalist underdevelopment of th Tanzanian economy and the structural distortions of a dependent relationship between Tanzania and the metropolitan power.

Current medical definitions of health and disease are inadequate for an understanding of public health problems. The narrowest attribute causa tion to agents of disease (e.g., germ theory); the widest (e.g., medical ecology) take into account some social factors like behavior and culture. All focus on the individual rather than the collectivity. The evidence reviewed in this article, drawn mainly from England during the industrial revolution and the rise of capi talism, suggests that changes in health status are related to class struggle and to the international division of labor. An historical approach is adopted to expalin how health and disease came to be defined medically and why politics and economics were rejected as irrelevant to medicine. The holistic perspective of Marxism, which permits analysis of the dynamic interaction of public health, social organization, and the mode of production, is offered as the basis for a socialist alternative.

Perhaps no part of the health system is as imperiled by neoliberal economic reforms as the public drug sector. The national bill for pharmaceuticals can claim one-third of a developing country's annual health budget. This article describes the essential drugs program created by WHO in the 1980s to protect financially reduced ministries of health from the high prices charged by multinational pharmaceutical companies. It describes the backlash from the World Bank and UNICEF, which launched the Bamako Initiative and other community financing schemes and revolving drug plans in which individuals, families or community groups buy drugs above the wholesale purchase price; clinics use the proceeds to maintain drug supplies and subsidize other health services. When this plan failed, the Bank proposed outright privatization of drug purchase and supply, returning power to the multinational suppliers. The article ends with a consideration of patents and the new intellectual property rights as they pertain to pharmaceutical production in Africa.

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