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Randall M. Packard A History of Global Health: Interventions into the Lives of Other Peoples, Baltimore: Johns Hopkins University Press, 2016. xii + 414 p. $26.00.

2017; Wiley; Volume: 43; Issue: 2 Linguagem: Inglês

10.1111/padr.12067

1728-4457

Landis MacKellar,

Global Healthcare and Medical Tourism

The title of this book can be broken down. It is not “the” history; it is “a” history, a personalized one by an eminent scholar of public health. It is not a history of “health,” the long march toward longer life expectancy and higher quality of life; it is a history of “global health,” which the author might with more precision have called “global public health”—the concern of international organizations such as the World Health Organization and the United Nations Children's Fund, aid agencies such as the US Agency for International Development and UK Aid (formerly Department for International Development), non-governmental organizations such as Médecins sans Frontiers and Partners in Health, philanthropies such as the Bill and Melinda Gates Foundation, global pharmaceutical firms, and research and academic institutions and health ministries across the world. Health's Empire would have been a good title had Ronald Dworkin not already appropriated the imperial metaphor for Law. While written as a somewhat informal narrative history, the book fits comfortably in science and technology studies and is free of the post-modern babble that sometimes hobbles that genre. There is a welcome absence of pious citations; the author speaks for the most part with authority. The reader may occasionally get bogged down in the wealth of institutional detail, but this is never so serious that it cannot be solved by skipping a few pages ahead. The major contribution of the book is to demonstrate effectively that what the author terms (with a nod to Ivan Illich) the “medicalization” of global health—the preference for Western biomedical technology over health system institutional strengthening and social development—can be traced directly back to colonial health practices. Without Gorgas's successful eradication of yellow fever in Panama, there would not have been the successful campaign to eradicate smallpox, but there would also not have been the costly and failed campaigns to eradicate malaria and to tame tuberculosis; nor the currently struggling campaign to eradicate polio. The “central motivations, organizing principles, and modes of operation” (p. 7) of global health have not greatly changed since the late nineteenth century. More social, systemic approaches to health development have not been wanting, but they have been ephemeral: cropped up and then gone. Again and again, the hard medical approach has proved, like John Barleycorn resurgent in the old song, the strongest man at last. Part One, “Colonial Entanglements,” describes the inextricable nature of colonial rule and colonial medicine, which, in part through influential institutions such as the Rockefeller Foundation, set global health firmly on the path of applying Western technologies, often in military-campaign style, to eliminate disease in tropical settings. Local knowledge was excluded and local populations were construed as backward and incapable of propriety in sanitation and hygiene. One theme that emerged as early as the yellow fever eradication campaign is the now-ascendant global public goods argument. This emerged in its current incarnation through the work of Inge Kaul and colleagues at the United Nations Development Programme in the early 2000s (a story that the author misses) but is now firmly entrenched at all aid agencies. The basic rationale for public health support abroad, or shall we say the best rationale to present to those who hold the purse strings, is to protect the population at home. As a result, noncommunicable disease, despite desultory efforts at WHO (recently described in the pages of this journal; see Weisz and Vignola-Gagné 2015), has failed to attract funding commensurate with its growing share of the burden of disease in poor settings. The book begins with a deft narrative stroke: a description of WHO's paralysis when confronted with the Ebola epidemic, which had its roots not in the sanitary or funerary habits of its victims but in the lack of functioning public health systems despite hundreds of millions of dollars of past health aid in the affected countries, as discussed by this reviewer and the epidemiologist José Siri in The Wall Street Journal of October 20, 2014. The successful international interventions undertaken by the US and others were made feasible by the scientifically incorrect but politically effective message that Ebola was an exquisitely infectious disease poised to jump to Europe and America. Even in the early years of the twentieth century, however, there were influential voices urging a more social approach to disease; voices that have been raised right up to the present time but have never managed to take and hold the citadel of global health. Part Two, “Social Medicine, the Depression, and Rural Hygiene,” describes how the misery of the Great Depression led to a distinct social turn in global health, but one that never quite caught on. All of the aspects of a broad, heuristic, and systemic approach to health were very much present at the creation of WHO, but failed to thrive in the wake of World War II. In part this was because of the promising new health technologies that had emerged. For an increasing number of medical conditions, there were now treatments available. Treatments mean products, with rents to be earned every step of the way from the flash of inspiration in the laboratory to the moment when the pill is popped or the needle is jabbed. As this is a book about poor countries, what is now euphemistically called “development cooperation” (it used to be “foreign aid,” and vestiges of that appellation persist) is a central theme. The structure of aid programs has encouraged medicalization at the expense of system strengthening. Health system strengthening is a task requiring, perhaps not decades, but at least seven to ten years’ nurturing in this reviewer's judgment. It is poorly implemented via project modalities, which rarely exceed three years in duration and whose excellent photo opportunities come at the expense of ruinous administrative and transaction costs. Recall Arthur Okun's leaky bucket analogy: when a public authority carries a bucket of money from Point A to Point B, a lot leaks out along the way. So-called budget support, in which financial resources are simply transferred to the partner government on a regular, predictable basis (usually backed up by an infusion of Western technical supervisory expertise to the ministry) against an agreed set of performance criteria, is more efficient. But that requires that there be a health-sector policy worth supporting in place, a sine qua non not always satisfied. Moreover, the budget support approach is uniquely European, and major European bilateral donors have turned against it because of concerns regarding the quality of public financial management. The great health-sector budget support programs—Philippines, Egypt, etc.—are already history; so too are the great World Bank sector loans and bilateral donor health-sector programs. Finally, and applying to all forms of development assistance, as the supply of aid funds shrinks as a result of competing fiscal priorities, the market for them is shrinking pari passu. This is a consequence of “graduation” (countries moving into Upper Middle Income Country status and hence losing eligibility for overseas development assistance or ODA); remittances and foreign direct investment, which dwarf aid in volume; the rise of Western philanthropy; and the availability of resources from countries that are not members of the donors club, the Organization for Economic Cooperation and Development's Development Assistance Committee or DAC (China, Saudi Arabia, and others). Their resources do not come with irritating Occidental admonitions about gender, sexual minorities, human rights, democracy, death penalty, civil society, etc. The Age of Aid may persist for another decade or two, but it is dwindling down to its end with a whimper. The section likely of most interest to the readers of this journal is Part Five, “Controlling the World's Populations,” on the effort to reduce global population growth. This effort was at the center of the international development agenda from the 1950s through the 1994 Cairo International Conference on Population and Development, when the “population control” agenda was displaced by a sexual and reproductive rights one under conditions that amounted to a feminist revolt. The section is accurate and informative. This being a personality-rich narrative, the “turning” of John D. Rockefeller 3rd by Joan Dunlop—his conversion from a strict family planning perspective to a moderately social and engendered one at the hands of a committed assistant, a change of heart that led to his then-heretical address to the 1974 World Population Conference in Bucharest—is recounted. So, too, are stories involving many other forceful characters of the day, among them Senator Ernest Gruening (D-Alaska), the ex–Puerto Rico family planning administrator who was a stalwart of US family planning policies under Lyndon Johnson; the obsessive Reimert Ravenholt of USAID, who essentially built that institution's family planning program; Paul Demeny, the Population Council demographer (and founding editor of this journal), who interrogated the family planning agenda from within that institution; and Stephen Enke, the economist whose RAPID model USAID used as a global marketing tool (after the Futures Group stripped out the economics because it was just distracting audiences). Packard's view focuses on contrasting the biomedical solutions (family planning programs) to the broad systemic and social problems (poverty, social injustice, gender inequality) that underlie high birth rates. Public health students interested in demography would profit from reading these chapters; so too would younger demographers wishing to give finer resolution to their perception of global population policy during its distant glory days. By Part Six, “The Rise and Fall of Primary Health Care,” the plot is becoming familiar and some readers may start to skim. Efforts are made, particularly at WHO, to encourage a broad-based, systemic, pro-poor approach to health but meet resistance from those advocating for specific interventions—oral rehydration therapy, immunization, etc. All approaches are attractive and cost-effective, but the whole fails to be more than the sum of the parts. Then came the structural adjustment and reform policies of the 1970s and 1980s, with disastrous results for public systems of all sorts, health included. The closing section of the book brings us to the present, with the AIDS epidemic concentrating health spending into a sub-sector that is far, in burden of disease terms, from deserving the sums it receives. The final blow is the rise of NGOs as privileged partners, their responsibility to the polity no deeper than their mission statements; diminishing, displacing, de-legitimizing, and ultimately angering the public sector. Also noted with regret is the prominence of single-issue mega-philanthropies, e.g. Gates and polio, again with potential to marginalize governments and override their priorities. The externality argument, by which disease-targeted programs have beneficial spillover effects on health systems as a whole, has never been as compelling as the more straightforward crowding-out argument. As Lenin asked, with commendable economy of words, “What is to be done?” The answer of this book is straightforward: stop targeting individual diseases and conditions with biomedical technological interventions and concentrate on strengthening old-fashioned public health systems, as well as social development more broadly. The basic policy prescription is sound and will raise few eyebrows among health development practitioners, especially those out in the sun. But there are fundamental challenges to be overcome. One has been described: health system strengthening is slow and far from glamorous. A second has to do with access. The greatest challenges to health care systems in many poor countries now are Ricardian; they have to do with socially marginalized and/or geographically remote populations who are costly to reach. A third is the rising tendency to view development cooperation as a means to address internal policy concerns, particularly those related to migration and security. The poverty focus of aid has withstood this threat to it so far (April 2017), but it is early days yet. A final challenge, and perhaps the most difficult, is the now not-to-be-questioned human rights–based approach to health, which whets a moral thirst that far exceeds the resources and political will available to satisfy it. The choir of the deserving—the female, the young, the old, the disabled, the addicted, the LGBTQ, the conflict-displaced, the crisis-affected, the victims of discrimination, the just plain down-on-their-luck—grows larger by the year; each member trying to out-sing the other. This cacophony is the downside of all rights-based approaches, which are, as a result, more honored (by a country mile) in the invocation than in the application. There are some striking gaps in the book, even considering that choices must be made in a volume of some length. For one, the author never comes to grips with health care finance, the bedrock of any health system. When health ministries send their budgetary requests to finance ministries, the two do not meet as equals. To some extent, this is because of the persistence of the Soviet model, which views health as a parasitic sector. “Development planning” remains the core paradigm of development practice (and in the strangest places, too, e.g. the World Bank) despite its loss of credibility. Add to this the fact that, particularly in Africa, policymakers who cut their political teeth on structural adjustment and fiscal discipline tend to regard anything that smacks of entitlement, including universal access to health care, as the enemy of responsibility and enterprise. In East Asia, there is fear of undermining traditional family and community arrangements. Another major gap is that the human resources crisis in health goes almost unmentioned. It is one of the stunning examples of Policy [in]-Coherence for Development that the HIV/AIDS response sucked health professionals into aid-financed projects, while at the same time personnel-strapped health systems in countries such as the UK and US were importing cheap medical labor from poor countries. There are issues of tone as well. The reader is subjected to a stiff dose of post-colonial breast beating; one would have thought that the statute of limitations on that interlude had run out and that a more nuanced assessment could be entertained. The author is weak on economics, especially in the section on “neoliberalism” and the Washington Consensus. The truth never spotlighted is that, while good health can promote development and bad health can impede it, the one sure prescription for improved health is economic growth backed up by equity. A reasonably free market to maximize the size of the pie and a reasonably transparent and accountable governance regime to divvy it up combine to stimulate both the supply of quality health care and the demand for good health that ultimately drives it. If there is one thing we know about health, it is that Say's Law does not apply—all the health care supply in the world will not create the demand for it. Countries do not vaccinate, eradicate, medicate, operate, etc., nor do they contracept, their way out of poor health; they grow their way out of it. Boston was once malarial, as was much of the American South; the English convict in Great Expectations shivered from that disease; Cromwell died of it in Ireland. The highest life expectancy in the world now is in South Korea—a desperately poor, overcrowded, farm-bound, war-ravaged, ancestor-worshipping patriarchal country three-quarters of a century ago—where women have recently broken the 90-year age barrier. All in all, though, this is a good volume, by turns informative and entertaining; always opinionated; occasionally tedious, but only because the author insists on being methodical. Old-timers will enjoy a romp through the eras that marked their careers, and those starting out will learn how we got to where we are and have a gauntlet thrown down on where we ought to go.