How did the World Revolution of Westernization disrupt non Western societies?

Changes in Diet

Economic development is associated with Westernization of diet in non-Western countries. As a result, diabetes is now appearing in India and Africa. Some factors contributing to obesity and diabetes in the developed countries are listed below:

Eating out. Portions are large, and additional fats are added.

Not eating as a family; poorly balanced meals.

Television viewing during mealtime, which is inversely associated with consumption of products not typically advertised, such as fruits and vegetables.

High fructose corn syrup: The rise in type 2 diabetes closely parallels increased use of sweeteners, particularly high-fructose corn syrup.

Communism between East and West

Bolshevik communism in the USSR/Russia began as a project of Westernization. For Lenin and Trotsky Russia was ripe for Westernization; it was something that needed to happen not merely for the revolution to succeed but for it to be thinkable. In his typically imperious style Lenin decreed in 1918 that,

it is our task … not to spare dictatorial methods in order to hasten the copying of Westernism by barbarous Russia even more than did Peter [the Great], not shrinking from barbarous methods of struggle against barbarism. (Lenin, 1965: 340)

The Bolshevik's association of barbarism and slavery with the East was, in part, a reflection of their faithful reading of Marx, who expressed similar views. However, it also represented the continuation of the views of the Russian elite. The conviction that progress was Western and conservatism Eastern was mapped onto an existing imaginative geography of the West being modern, enlightened, and civilized and the East being the antithesis of all three. ‘Asianism’ (Aziatchina) represented everything that was old and rotten, everything that needed to be ripped out of both Russia and her colonies. Mixing images of political reaction, with those of decay and infestation, Trotsky looked forward to the development of a clean, new Western civilization. “The revolution” he wrote in 1923, “means the final break of the people with Asianism, with the 17th century, with holy Russia, with ikons and cockroaches … an assimilation of the whole people of civilisation.”

However, the ‘moral support’ for the Soviet state offered by some Western workers did not compensate for the brute fact that the revolution did not spread to the West. The Bolshevik project was premised on internationalism; more specifically, on revolution in the West. It was thought impossible for a communist state to survive in the midst of hostile capitalist powers. The absence of revolution, or even genuinely popular mass revolutionary movements, to materialize in the West, changed the nature of Soviet politics. It allowed Stalin to turn his back on the West and develop a form of nationalist socialism in which Russia was proclaimed to be the home of world revolution. “The whole world now admits,” Stalin declared in 1930, “that the centre of the revolutionary movement has shifted from Western Europe to Russia.” This attitude encouraged an almost phobic withdrawal from the West. In The Captive Mind (first published 1953), Czeslaw Milosz explained that,

The official order is to evince the greatest horror of the West. Everything is evil there: trains are late, stores are empty, no one has money, people are poorly dressed, the highly praised technology is worthless. If you hear the name of a Western writer, painter, or composer, you must scoff sarcastically, for to fight against ‘cosmopolitanism’ is one of the duties of a citizen. (Czeslaw Milosz, 1985: 43)

With the collapse of communism in the late 1980s and early 1990s, Russia and its former colonial possession sought once again to redefine themselves in relation to the West. The outcome of this process is still not clear. Contemporary Russian governments like to deploy both pro-Western and anti-Western rhetoric. The latter is, in part, a response to the ability of the West, notably the USA, to proclaim ideological victory in the global battle for ideas.

Development and Resistance

In terms of development geography, a significant component of resistance scholarship has documented resistance to development in its multiple forms, including colonialism, neocolonialism, imperialism, Westernization, modernization, and neoliberalism.

Colonialism as an early exercise in development before World War II produced its own forms of both overt and covert resistances by the colonized. Geography as a discipline played a key role in colonial expansion through its cartographic production and through the development of environmentally determinist accounts of people in colonized parts of the world. Human geography has begun to engage with the legacies of its colonial origins through engagement with key debates in postcolonial studies and through empirical treatments of historical resistance to colonialism and slavery, as well as explorations of the colonial present. These intellectual endeavors serve to question and expose geography’s past and present complicity with imperial relations of all kinds and constitute a crucial part of intellectual attempts to de-colonize geography as a discipline.

Development geography has also provided insights into the resistance movements and new social movements which have developed more recently in response to the failures of development, particularly in its modernizing and Westernizing guises. In this respect, the new social movement (NSM) school has been particularly influential. NSMs are broadly understood as a new kind of political activism which emerged in the 1970s and 1980s in response to changes in late capitalism and in which activists moved away from formal spheres of politics such as trade unions and political parties and began to organize around diverse axes of identity such as gender, sexuality, ethnicity, and so on. NSMs include women’s movements, indigenous movements, environmental groups, neighborhood lobbying organizations, human rights groups, and lesbian and gay movements. They are often perceived to be more spontaneous and participatory and less hierarchical than conventional political movements. The NSM approach has broadened our understanding of what constitutes resistance and how it is to be theorized.

Many recent resistance movements in both the First and the Third Worlds have developed in response to neoliberalism and the Washington Consensus, the set of economic policies promoted and designed by the World Trade Organization (WTO), the International Monetary Fund (IMF), and the World Bank. As debt-burdened nation-states have embraced (or been forced by the international financial institutions to embrace) forms of economic globalization such as trade liberalization, privatization, and cuts in public spending, they have become subject to political challenges from within. Such policies have had devastating social and environmental costs in many places, bringing inequality, exclusion, poverty, and environmental degradation and exacerbating the already precarious situation of small farmers, women, and indigenous people. Resistance to free market capitalism and the predatory forms of global governance to which Third-World nations are often subject takes many collective and individual forms including increased migration and crime but often also includes spectacular high-profile political action which attracts significant academic and media attention. Examples of this nature include the Zapatista uprising in Chiapas in Southern Mexico to protest the North American Free Trade Agreement (NAFTA) and other dimensions of neoliberalism, the mobilizations in Brazil by the Movimento Sem Terra (MST) to challenge the overwhelming concentration of agricultural land in the hands of a minority, the protests against water privatization in Cochabamba, Bolivia and movements to prevent the construction of World Bank sponsored and environmentally destructive dams along the Narmada River in India.

Resistance to neoliberalism also includes everyday forms of mobilization. Women across Latin America, resistant to the idea that they should be the shock absorbers under neoliberal economic policies, have developed a multiplicity of strategies to cope with falling real wages and declining social services. These strategies include running communal kitchens in order to feed their families, creating handicrafts or saving cooperatives, lobbying government agencies or nongovernmental organizations (NGOs) to secure drinking water or electricity in their communities, ending relationships with unproductive or violent partners, and pulling children out of school. Such place-based and community-oriented approaches to struggle and resistance have been extended by the work of J. K. Gibson Graham, whose work has shown how the sense of inevitability promoted by proponents of neoliberalism is fragmented by the everyday anticapitalist practices which are adopted by people negatively affected by neoliberalism. There are hundreds of examples in which ordinary and marginalized people have mobilized to defend lands, livelihoods, and environments under threat. All of these movements raise important questions about nationhood, citizenship, and belonging and often serve to undermine many of the Western and masculinist biases of the development process.

Up until recently, resistance to neoliberalism involved mainly extra-institutional forms of struggle, but is now increasingly involving governments of the South. The political landscape of Latin America has shifted considerably in the last few years as a result of the election of a number of Latin American governments who campaigned on anti-neoliberal tickets. The governments of Venezuela, Bolivia, Ecuador, and Nicaragua are all seeking to find alternatives to economic dependency and modify the forces of globalization through the nationalization of key natural resources such as oil and natural gas and through the creation of alternative trading blocs to the US-sponsored Free Trade Area of the Americas (FTAA) such as the Bolivarian Alternative for the Americas (ALBA). Venezuelan president, Hugo Chávez and Bolivia’s first indigenous president, Evo Morales have become important reference points and symbols of resistance for activists worldwide.

There is also significant and growing resistance to free-market capitalism in the First World which is frequently developed in solidarity with the Third World or as a protest about the effects of neoliberalism in the Third World. Meetings held by the international financial institutions are now almost always accompanied by protests and large amounts of money are spent on security to combat what some media commentators unhelpfully refer to as ‘antiglobalization’ activists. In recent years, there have been high-profile protests at a whole range of meetings, including the WTO meeting in Seattle in 1999, the IMF and World Bank meeting in Prague in 2000, the G20 meeting over the FTAA in Quebec City in 2001, the G8 summit in Genoa in 2001, the WTO meeting in Cancún in 2003, and the G8 summit in Scotland in 2005.

Resistance to the neoliberal economic model in the First World is also driven by alternative consumer practices through the boycott of goods which involve exploitative labor relations or environmentally destructive practices or through the consumption of ethically and sustainably produced products. The growing consumption of fair-trade coffee, tea, chocolate, and other products creates a form of mutually beneficial solidarity between Third-World producer and First-World consumer and produces tangible benefits in the lives of producers and their families.

Along with ‘antidevelopment’ and ‘beyond development’, postdevelopment is a radical reaction to the dilemmas of development policy and thinking. Postdevelopment combines these critiques with a Foucauldian methodology of discourse analysis and post-structuralism. These radical critiques typically problematize poverty, view development policies and paradigms as Westernization, and question modernism and science. They also object to development policy because it is inherently antidemocratic. Adherents of postdevelopment are not interested in alternative development approaches but rather in alternatives ‘to’ development. Antimanagerialism and dichotomic thinking are other common features of postdevelopment views. There is an affinity between the development agnosticism of neoliberalism and postdevelopment in that both critique the role of the state. Postdevelopment also parallels postmodernism, both in its acute intuitions and in being directionless in the end. Since most insights in postdevelopment sources are not specific to postdevelopment, what is distinctive is the rejection of development. Yet the rejection of development does not arise from postdevelopment insights as a necessary conclusion, so there is no compelling logic to postdevelopment arguments. A major weakness of postdevelopment is that the experience of East Asia and newly industrializing countries is typically not discussed, even though they are the current trendsetters of development.

Summary

Globally, cancer is a leading cause of death, with the burden expected to increase in the future. However, the burden of cancer is not uniform. Geographical and HDI-based variations are evident when one examines the distribution of common cancers outlined in this article. Furthermore, trends in incidence and mortality differ by geographical region and HDI, indicating the complex diversity of cancer as well as future cancer transitions that will see the incidence and mortality of certain (Westernization-related) cancers to increase and corresponding rates of a number of (infection-orientated) cancers to decrease. Many countries lack both formal cancer registries and the interoperability of health information systems to capture data on cancer incidence, mortality, and prevalence. Furthermore, for countries and regions where such data are available, there are often problems with data accuracy and whether they are representational (Ferlay et al., 2015). Thus, there is a need for surveillance systems to collect accurate data on cancer incidence, mortality, and prevalence (as part of population-based systems collecting data on the occurrence of all cancers and on all-cause deaths), as well as to determine the risk factors for various cancers. These data are critical for cancer prevention and early detection and for the establishment of risk reduction programs (Glaser et al., 2005). The GICR as a collaboration of international partners working with governments to ensure cancer registries becomes a cornerstone of cancer control; the focus is to strengthen cancer registration in the very countries in transition where surveillance is limited and for which an increasingly high proportion of the global cancer burden will be observed, as documented here.

Prostate Cancer

In the United States, prostate cancer is the second most frequent cancer that claims lives of men every year. The risk of developing prostate cancer is higher among African-Americans. The geographic contribution to prostate cancer appears to be significant since the prevalence of this cancer is higher in ‘Western’ countries and among second- and third-generation immigrants when compared to those in their respective native countries. Furthermore, diseases attributed to ‘westernization’ usually have a significant dietary component.

The DNA repair gene, XRCC3, is responsible for repairs of double-stranded DNA breaks. It is hypothesized to also protect against DNA adduct formation, based on the observations that individuals who have a polymorphism in this gene also have higher levels of DNA adducts. Since adduct formation is a key event in carcinogenesis, its association with cancer incidence is currently the focus of cancer studies. Because of its wide distribution in the general population, it is hypothesized that if XRCC3 polymorphisms are related to prostate cancer, there is likely to be a significant contribution from the environment.

Dietary factors such as a high-fat diet or frequent consumption of fried, smoked, or processed meats have been observed to be common among men diagnosed with prostate cancer. Dietary fat is hypothesized to facilitate prostate cancer cell growth via the increase in the bioavailability of androgens, a downstream product of dietary fat metabolism. In fried, smoked, or processed foods, the chemical compounds of interest have been nitrosamines and nitrosamine precursors. These compounds have been shown to cause cancer in experimental animals, although they are not currently classified as human carcinogens. However, to date, the mechanism(s) that would explain the relationship between nitroamines and human cancer remains elusive.

Recent epidemiological studies in the United States and Asia have found that men who eat high-fat diets have a higher rate of prostate cancer than those whose diets are low in fat and high in vegetables. The evidence has been so compelling that cancer prevention advisories have discouraged consumption of diets high in fats, meats that are cured or smoked, and foods cooked at high temperatures, such as fried foods. Specific aims of future studies will likely include the estimation of the distribution of the XRCC3 polymorphisms among the general population and the relationship of these polymorphisms to the dietary habits among men who are disproportionately affected by prostate cancer.

Community-Based Health Promotion

Social scientists have played an important role in the development of interventions based on community development and empowerment models of social change. Community-based approaches date back to the mid-twentieth century with the involvement of anthropologists and sociologists in projects aimed at the modernization of traditional communities in both developing and industrializing countries. Many of these projects included health and nutrition improvement goals as it became obvious that widespread urbanization, industrialization, and Westernization often entailed undesirable health-related consequences. Deleterious lifestyles and diet often replaced more salubrious traditional systems; thus, the goal of these early interventions was to introduce modern medical practices such as water boiling, immunization, and antibiotic treatment without disrupting desirable traditional practices such as breastfeeding and locally grown food systems. The community development model received a significant boost through the Alma Ata Declaration of 1978 (WHO and UNICEF, 1978), which advocated for basic health services at the community level, with heavy reliance on local resources and participation. Anthropologists and indigenous social scientists joined multidisciplinary teams to help implement community health programs globally in the latter part of the twentieth century.

Although the community development model evolved primarily in the context of rural populations, it has been successfully adapted to urban settings as well. Widespread urbanization throughout the world, along with dramatic population shifts to cities, have created new communities of need. Beginning with the community empowerment movement of the 1960s, local citizens have been increasingly integrated into health promotion programs. Community-based interventions have addressed diverse public health issues such as infant mortality, homelessness, cardiovascular disease, HIV/AIDS, teen pregnancy, and mental health. Particular attention has been given to community-based interventions to reduce coronary heart disease, such as the North Karelia Project of Finland and the previously mentioned Alameda County Study of California. While approaches vary in their degree of community involvement relative to the role of external professionals, key underlying principles include community control and ownership, community empowerment, multisectoral activities, and meaningful participation by affected groups. Because of the complexity of the process and the attendant political issues arising from diverse stakeholder interests, there are many challenges to successful implementation of community-based interventions. To help plan such comprehensive programs and anticipate challenges, a number of organized frameworks for community interventions have been developed. These include the Planned Approach to Community Health (PATCH) developed by the CDC, the Mobilizing for Action through Planning and Partnership (MAPP) framework from the National Association of County and City Health Officials and the CDC, and the PRECEDE/PROCEED and Intervention Mapping (IM) models for intervention design and evaluation. While all of these frameworks differ in their specific foci, they share the important fundamental principles of community input, data-driven design, and evaluation (Buhi et al., 2010).

Knossos in Crete and Cyrene

Under the veil of cleansing the Mediterranean of pirates, Crete became a focus of Roman attention. With the exception of cities such as Gortyn, the island was strongly opposed to Roman rule and during the early part of the first century BCE there were valiant attempts to dispel the Romans from the island. Crete's resistance finally collapsed and the island was taken by Metellus. In 69 BCE Crete and Cyrene become joint province with the provincial ‘capital’ at Gortyn. By 25 BCE Knossos had become the praetorian provinces' only colony, Colonia Julia Nobilis Cnossus and while there is limited evidence to suggest a significant ‘westernization’ of the city, she certainly appears to have flourished.

Knossos has not been affected by contemporary urban growth, but the bias of archaeological investigation has clearly been on Minoan material. Even with detailed archaeological survey, research into the Roman remains has often been curtailed by the desires to focus on the Bronze Age material. Coupled with this is a dearth of historical sources for the province of Crete and Cyrene. In recent years, the increasing academic attention that is being paid to Roman Knossos with more research (rather than rescue) excavation and synthetic studies of the material culture, a more in-depth understanding of the nature of change from Greek city to Roman colony is viable.

There is limited evidence for Roman occupation of the city in the first century BCE/CE, however it is clear that by the late first century CE Knossos has developed into a prosperous peaceful city with evidence for many of the architectural manifestations of an Eastern Roman city.

In the first half of the first century BCE, the epigraphic and numismatic data from Knossos clearly points to early attempts to run colony on formal lines: for example, with coins, Italian duoviri, and official administration documents in Latin. In the ceramic assemblage there is an initial favoring of Italian wares which by the mid first century CE are replaced by the Asia Minor-originating Eastern Sigallata B but all the time, domestic production continues. In contrast to the Latin public and official inscriptions in the first century BCE, all evidence thus far suggests that private inscriptions continued in Greek. Greek burial customs (such as rock-cut tombs and tile graves) persisted with no significant evidence for Roman burial customs. By the late first century CE a perceptible change in the material culture with the construction of the so-called Civil Basilica and the theater is visible. This is enhanced with evidence from a range of buildings representing a good cross section of society such as the Villa Dionysos and the small bathhouse close by and the town house complex at the Unexplored mansion with its associated industrial area. In terms of the sacred landscape, material culture is limited, but excavations at the Demeter Sanctuary have shown it to continue in use until the Late Antique period. The inclusion of Roman buildings, particularly administrative buildings in the late first century CE suggests a change in the Knossian landscape. It seems that finally, a century after the foundation of the colony, the city began to fit into the developing koine of the Eastern Empire, but this was taken on, a process decided on by both the local and Roman population, rather than forced.

Development Thinking

Development is often discussed in relation to ‘developing countries’, but is a concept which relates to all parts of the world at every level, from the individual to global transformation. Whilst ideas about the best means to achieve human aspirations are potentially as old as human civilization, the study of development and formal development planning originated after World War II. It has been suggested that development studies ‘barely’ made it to the twenty-first century, whilst the object of study made it rather less effortlessly. The following section traces some of the principle changes in thinking regarding the ideologies and strategies of development over this history and identifies some of the ways in which ideas of sustainable development have impacted on these through to the current period. Although these shifts are considered chronologically, existing theories are rarely totally replaced, rather that new ones find relative favor and contestation over the prescriptions are a continuous feature.

From the late 1950s, development thinking was firmly centered on the potential of economic growth and the application of modern scientific and technical knowledge as the route to prosperity in the less developed countries. In short, the global development problem was conceived as one in which these nations needed to enter the modern age of capitalism and liberal democracy and to ‘catch up’ with the West. A modernization thesis dominated mainstream theories of development to the early 1970s within which development was modeled as a series of stages along an unconstrained linear path. Modernization was equated with the characteristics of westernization (in terms of economic prosperity, but also in terms of aspects of society, culture, and politics). It was an optimistic time in which underdevelopment could be overcome through imitative processes and the transfer of finance, technology, and experience from the West to less developed countries and from urban centers to rural areas. All countries were considered to have an equal chance of development. It was an era in which the contribution of neoclassical economics was to the fore, in which understandings of development were largely confined to the history and experience within Europe, and when an almost unquestioned faith in urban-based industrial growth as the driver for development persisted. The discourse of development at this time was largely separate from that of the environment; the constraints of development were seen as internal to those countries in terms of an insufficiently developed industrial and commercial base and insufficient levels of investment and national savings. Strengthening the material basis of society was the key to becoming mature, developed economies and societies. Too little industrialization, rather than too much, was the dominant message coming from development thinking at this time.

Into the 1980s, the optimism of a speedy end to underdevelopment faded with rising levels of debt and the problems for oil importing countries in the context of the oil crisis. Rising economic inequalities and rural–urban differences (rather than any understanding of environmental impacts of development) led to growing dissatisfaction with ideas of development as modernization. During the 1970s, a radical critique of mainstream development thinking emerged (particularly through scholars from regions strongly linked to the US such as Latin America and the Caribbean) in which politics were to the fore. The ‘dependency school’ forwarded explanations of underdevelopment (framed in terms of the socioeconomic structures as well as the economic conditions of these countries) as outcomes of the exploitative/dependent relations with other parts of the world. The root cause of underdevelopment was modeled as the structural disadvantages external to underdeveloped countries and regions and the processes of colonialism in the past and of the capitalist economy generally that linked the periphery with the core. The radical critique found wider support within Europe at this time, where there was a reinvigorated interest in the work of Marx and an emerging ‘New Left’ movement that linked with the struggles of the Third World anticolonial movements. In consequence, rather than seeing the US and Europe as the source of solutions, dependency theorists saw the role of these regions as actively creating the problems of underdevelopment.

Despite some core differences between modernization and dependency theories, both encompass a common notion of linear progress and a shared belief in the role of the state to realize that progress (although they disagreed on the nature of that role). From the late 1970s, however, greater attention started to be given to how development should occur rather than with theorizing social change. Dependency theory moved out of fashion as a broad sweep of changes in thinking regarding the meaning of development and how best to achieve it emerged (commonly captured under the umbrella term of ‘another’ or ‘alternative’ development). Whilst economic growth remained important within development ideas, phrases such as ‘growth with equity’ emerged and encapsulated the recognition that it was critical to ensure that the benefits do not fall solely to a minority of the population. Furthermore, development itself became conceived as a multidimensional concept encapsulating widespread improvements in the social as well as the material well-being of all in society. In turn, the strategies forwarded for achieving development became diverse and multiple rather than single and top-down and were considered to require investment in all sectors, including agriculture as well as industry. It was asserted that development needed to be closely related to the specific local, historical, sociocultural, and institutional conditions, focused on mobilizing internal natural and human resources, appropriate technologies, and giving priority to basic needs. Rural-based strategies for development were particularly important amongst those promoting ‘development from below’.

In clear contrast to development thinking to that time, development was to be more inclusive, with individual and cooperative actions and enterprises becoming the central means for development rather than the state. Strong notions of participatory development emerged in recognition of the shortcomings of top-down, externally imposed, and expert-oriented research and development practice. It was understood that development needed to be sustainable (in encompassing not only economic and social activities, but also those related to population, the use of natural resources, and the resulting impacts on the environment) and a consensus emerged surrounding the characteristics of interventions that were more likely to be sustainable. These challenged both academics and practitioners to make a number of ‘reversals’ in their work including; putting people’s priorities first, combining the strengths of both indigenous and scientific knowledge, and moving from a blueprint to a learning process approach to planning. The centrality of security of resource rights and tenure were exposed as were the benefits of locally based, smaller-scale initiatives and the capacities of NGOs to foster these orientations in development.

However, the experience through the 1980s of many developing countries (with the exception of the ‘Asian Tiger’ economies) was of previous gains being lost and in many cases being reversed. By the mid 1980s, the sister institutions of the WB and the International Monetary Fund (IMF) were concerned about the threat of the severe balance of payment difficulties being experienced by many developing nations to the international financial system as a whole. Comprehensive, long-term solutions were considered to be required to address the debt crisis, based on packages of broad policy reforms known as structural adjustment programs (SAPs). SAPs became the requirement for lending from these institutions and increasingly became conditions for access to bilateral assistance and private investment, such that SAPs increasingly defined the entry of many developing nations into the global economy. Whilst each package in theory was tailored for the particular country, SAPs generally included many common elements as shown in Figure 8 and reflected strongly the ideals of neoliberalism that emerged as the predominant idea in defining development policy and practice through the 1990s. From the late 1980s, dissatisfaction with the record of state involvement in the economy and social life more broadly had taken root within the governments and policies of the North. Neoliberalism is an approach to development that heralds the free market as the best way to initiate and sustain economic development, such that typical policy responses involve removing the influence of the state in the domestic economy and external markets as shown in Figure 8.

By the mid 1990s, private capital flows to the developing world exceeded official aid and markets appeared triumphant. However, the 1997–98 Asian crisis revealed how rapidly such capital could be removed and progress dismantled. Debt burdens rose rather than fell through the decade and whilst modifications to the adjustment paradigm were made in response to the evidence of widening socioeconomic differentiation and environmental degradation under reform packages, there was little challenge made to the fundamental, neoliberal rationale. By the end of the decade, rising dissatisfaction with conventional models of development was increasingly being articulated on the ground through popular struggle and the activities of new social movements. Protest within countries of the South coalesced around the combined issues of the failures of the state and the market to deliver prosperity or well-being, around prominent environmental problems, and the hardships created by the debt crisis (both its impacts and those of the solutions designed to resolve it). The legitimacy of the International Financial Institutions was also questioned by mass demonstrations on the streets of Seattle and Davos, for example, around meetings of the World Trade Organization and the G8 Finance Ministers. Questions over the utility of existing models for development were also raised by the collapse of communism that undermined the strength of Marxist analyses and the ‘postmodern’ critique within the social sciences more widely was challenging fundamental notions of modernity. In addition, the rise of globalization was changing the position of the nation-state and national governments across economic, social, and political spheres. A number of ‘post’ and ‘anti’ development versions of development thinking emerged in response to these varied concerns; in short, questioning the whole discourse of development for the way in which it served Eurocentric interests. A post-development era depended on breaking the ‘holds of westernization’ be it as organized by the aid industry or activities of western private capital and ‘defending the local’ (through ecological, women’s, and peoples organizations) against the forces of globalization. Heated debates over policy also emerged, including within the IFIs, where prominent figures conceded that neoliberal reforms were failing. At the turn of the century, the arena of development as a discipline, as an institutional practice, and as a popular struggle was considered to be in substantial and pervasive ferment.

Historical Background

Japan already had a well-established network of practitioners mainly in the Japanese form of traditional Chinese medicine (TCM) by the middle of the eighteenth century. Medication was the main treatment, to the extent that these practitioners were often known as apothecaries. Payment was theoretically made only for the cost of medication since it was regarded as morally unacceptable to charge fees for performing a humane service. However, the unstated quid pro quo was that patients were expected to pay according to their ability, and therefore munificently if they had the means. This norm served a useful purpose for the government. It was absolved of the responsibility of providing public assistance for medical care because the practitioner's duty to provide services and the patient's obligation to pay were not directly connected.

Medical practice was an exception to the rigidly divided society of that time because it was open to all classes and there was competition based on skill. Practitioners recognized a hierarchy among themselves, with those appointed as personal physicians to the feudal lord being ranked the highest. Compared with Western nations, there was little development of guilds and professional identity among traditional practitioners in Japan. Another distinguishing aspect was the lack of institutional care for the sick and indigent by religious organizations or by the government. The selfless practice of philanthropy was not a religious duty for the popular Buddhist and Shinto sects, which promised the granting of secular wishes, nor was it a secular duty under the Confucian ideology favored by the rulers, which emphasized practical ethics. Care of the ill, disabled, and elderly, was regarded as the responsibility of the family (Ikegami, 1995).

With the inauguration of the Emperor Meiji in 1868, the government embarked on a policy of rapid Westernization. However, little could be allocated to health care because the country was facing foreign aggression and internal discord: The limited resources were invested in defense and building the industrial infrastructure. In health care, the government decided to target their resources in establishing a state of the art medical school at Tokyo University, to which German physicians were invited as professors. Its graduates went on to become the faculty of other national universities as they later came to be established. The general population continued to receive care from the preexisting traditional practitioners, who together with their sons as their successors, were given a license to practice medicine in 1882. However from 1883, new entrants had to graduate either from a university medical school or from a vocational school and then sit for the license examination. The latter had equal legal status to the former as physicians. Unlike other East Asian nations, official recognition of TCM was limited to granting a license to those practicing acupuncture and moxa.

Following the policy decision to adopt Western medicine, the government established hospitals for teaching purposes and for treating infectious diseases, but most hospitals were opened and managed by physicians as an extension of their private clinics. Hospitals were not associated with care for the indigent; in fact, hospitals were the first to introduce regular fees because they were not constrained by the old rule of not demanding payment from patients. The hospital was regarded as very much the doctor's workplace, and a medical doctor as the director carried both clinical and administrative responsibilities. Nurses were trained almost solely for the purpose of assisting physicians since the family continued to provide care even after the patient had been admitted to a hospital.

Because of the lack of trained physicians and well-equipped hospitals, a close and long-standing relationship developed between the professor and chair of the university clinical departments and their affiliated hospitals. Physicians tended to remain attached to their university clinical departments and to practice in the hospitals that were affiliated with each department. The hierarchical and closed structure of physicians retarded the development of professional specialist organizations. Since career advancement depended on the evaluation by their professors, young physicians tended to focus more on research than on acquiring clinical skills. Their objective lay in obtaining the research degree of Doctor of Medical Science, which came to be regarded as a mark of professional competence by the public because there was no formal system of certification as specialists. However, there were alternate career paths for pursing professional goals outside of the university clinical departments. Some physicians dispatched to small affiliated hospitals were able to develop their department so that it became the regional medical center and/or were promoted to be the hospital director. Others could go into private practice, upon which they would have to focus on primary care, but continued to maintain their identity as specialists. Not a few of the latter expanded their clinics to small and then to large hospitals.

After the defeat in World War II, the occupying forces tried to reform the system based on the American model with some limited success. The two-tiered system of medical education was abolished by upgrading or closing vocational schools and a national licensure examination was made mandatory for all upon graduation. Nurses took on the responsibility of caring from the families and were made more independent from physicians. The post-war economic growth led to a major expansion of the delivery system, with the number of hospital beds increasing by threefold from 1954 to its peak in 1993. However, the hierarchical yet competitive system has remained resistant to change (Ikegami, 2014a).