In A History of Global Health (Johns Hopkins University Press, 2016), historian Randall M. Packard examines why initiatives to prioritize and implement comprehensive approaches to health, as opposed to narrow technological ones, have failed to be sustained over time. This book centers on a tension that most of us working in global health have long felt—between the urgency (and perceived efficiency) of addressing health problems through technological fixes/vertical programs and the critical yet painstaking work of supporting health systems and addressing underlying structural determinants of health.
Some years back, this was a central theme in my own doctoral research studying efforts to eliminate trachoma through the SAFE strategy (Surgery, Antibiotics, Face-Washing, and Environmental Improvements) via the Alliance for the Global Elimination of Trachoma by the Year 2020, a partnership launched by WHO in 1997. Though the SAFE strategy was a well designed, comprehensive approach to the elimination of the world’s leading infectious cause of blindness, I questioned whether equal or greater financing and attention would ever be given to the F and E components— strategies that address the underlying causes of trachoma and require a longer-term commitment from, and collaboration between, donors, governments, and implementing agencies. Indeed, throughout the almost 20 years of the global trachoma elimination initiative, the administration of antibiotics has, in practice, remained at the center of trachoma programs (Freeman et al, 2013). And despite impressive progress in countries like Morocco (Levine, 2007), recent analysis suggests that annual antibiotic administration alone is unlikely to achieve sustained elimination of infections, particularly in highly endemic communities, without concomitant improvements to the environment (Jimenez et al, 2015). Renewed efforts are thus underway for increased collaboration between the WASH and neglected tropical disease sectors and more funding for the F and E components of the SAFE strategy.
What makes A History of Global Health an essential read for students and practitioners of global health is the detail that Packard provides, beginning with colonial settings and ending with the West African Ebola outbreak, to demonstrate why efforts to broaden global health’s frame have failed to gain momentum. Packard begins by showing us how a focus on disease elimination campaigns began during the colonial era and became central in subsequent international health efforts which were, in many instances, led by former colonial medical officers. Efforts to go beyond such disease elimination campaigns in order to strengthen health systems and address the structural determinants of health have periodically been attempted —notably in the 1930s and 1940s with the emergence of social medicine and universal health care systems in Europe, and later with attempts within international health to build a primary health care (PHC) movement in the 1970s – however, public health paradigms persistently returned time and time again to vertical, disease-based approaches. These more comprehensive efforts have not taken hold in global health for a number of intersecting and mutually reinforcing reasons.
For example, following WWII, crises due to epidemics and food shortages among war-affected populations in Europe and Asia required rapid responses that could not wait for longer-term, integrated strategies. At the same time, new technologies and innovations emerged during the war years and inspired optimism amongst international health actors that these innovations could be used to rapidly improve health. For example, the discovery of DDT offered the possibility of addressing malaria, yellow fever, the plague, and typhus. Furthermore, political contexts in some settings meant that broader approaches to health and development were distrusted. This was particularly the case in the U.S. amongst right-wing politicians during the McCarthy era who were isolationists and had misgivings about the UN, and were suspicious of any program that looked to be “socialist” (such as national health insurance).
Packard also traces the barriers to implementing the PHC model. Advocates failed to provide successful examples of programs that had gone to scale for countries to learn from. There was also unanticipated resistance in some countries to redirecting investments in health that were necessary for implementing the PHC model. In addition, the successes of the disease eradication campaign for smallpox refocused attention on the potential of technological strategies to solve health problems, while the feasibility of PHC was questioned in terms of expense and human resource requirements, leading to the adoption of “selective PHC” delivered through targeted programs. Furthermore, changing economic environments marked by the global recession of the 1980s made it difficult for governments to invest broadly in development and address inequalities. Countries borrowing from the IMF were faced with structural adjustment policies that forced them to reduce spending, particularly for social sectors like health, with negative effects on the availability and accessibility of health services.
In the 1990s and 2000s, the field of “global health” emerged as “a set of practices, organizations, and ideas (p. 273). A diverse array of organizations and partnerships involved in planning and implementing health programs were established, and vastly more funding became available for the global health sector. Such initiatives often recognized the need to address the structural determinants of health; however, this recognition was rarely translated into operationalizable, well-financed policies and programs. This period was also marked by conditionalities set by funding organizations because of concerns about the ineffectiveness and inefficiency of development aid. Selective approaches were encouraged by donors. NGOs were prioritized over national government and the private sector’s role was increased. Finally, public sector accountability was emphasized.
The focus on accountability led to an emphasis on prioritizing evidence-based interventions in global health, often via randomized controlled trials (RCTs) which became the gold standard for generating evidence on interventions. Such evidence-based interventions tended to favor interventions focused on technologies, as these are easier to study in trials than broader, comprehensive approaches. Parallel to the growth of the focus on RCTs, an increasing reliance within schools of public health on research funding meant that in many schools, students were trained to conduct research on health problems and interventions rather than to build and sustain health systems and collaborate across sectors.
Packard demonstrates how all of these trends led to an increased commodification/ medicalization of global health, and to a situation where health systems in poor settings remain unsupported and unable to fully address the health needs of their populations. This medicalization and commodification, Packard argues, has undermined ministries of health to plan and manage health programs, and led to the weakening of health services in many countries.
Finally, Packard stresses that decisions in global health have always, and continue to be made, by people and in locations far from those affected by these decisions. Increasingly, he argues, organizations that do not represent a consensus of nations on the receiving end of global health aid are making decisions about policies and programs for the improvement of population health in these nations. As anthropologists Joao Biehl and Adriana Petryna (2014) state, “we find ourselves face-to-face with profound disconnections between campaign designs and intentions and the complex ways in which those campaigns are actually received and critiqued” (p. 380). The consequences for the health of the poorest are grave. Disease is never just one thing, requiring a single solution. An individual’s health is influenced by biology as well as social, economic, and political factors. Until we seek to understand and engage with the complexities within which people’s lives are experienced and the systems within which interventions are implemented, sustained improvements in the health of the world’s poorest will remain elusive.
In global health, we are continually confronted with difficult decisions, particularly in times of crisis when we need to act with urgency. This book reminds us that our choices are not made in isolation—instead, we operate within a global health system that is governed by history. Moreover, the decisions we make may have collateral effects and unintended consequences. In this SDG era, we are increasingly committed—at least in our discourse—to working multisectorally in health and supporting countries to provide universal health coverage. To ensure that the pendulum does not swing back, once again, to an overwhelming focus on technical, vertical approaches, we must do better than before. We must put people in the center of our endeavors and make a concerted effort to better understand and confront the forces, some of which are listed above, that over time have limited actual and sustained achievements in comprehensively and collaboratively improving population health around the world.
References
Biehl J, Petryna A. (2014). Peopling global health. Saúde e Sociedade. 23(2): 376-89.
Freeman MC, Ogden S, Jacobson J, Abbott D, Addiss DG, Amnie AG, Beckwith C, Cairncross S, Callejas R, Colford Jr JM, Emerson PM. (2013). Integration of water, sanitation, and hygiene for the prevention and control of neglected tropical diseases: a rationale for inter-sectoral collaboration. PLoS Negl Trop Dis. 26; 7(9): e2439.
Jimenez V, Gelderblom HC, Flueckiger RM, Emerson PM, Haddad D. (2015). Mass drug administration for trachoma: how long is not long enough? PLoS Negl Trop Dis. 23; 9(3): e0003610.
Levine, R. (2007). Case 10: Controlling Trachoma in Morocco. In Case Studies in Global Health: Millions Saved. Sudbury, MA: Jones and Bartlett Publishers. Pages 73-80.
Packard, Randall M. (2016). A History of Global Health. Johns Hopkins University Press.