The moral and political tone of Randall Packard’s magisterial history of global health is set from the start with its subtitle: “interventions into the lives of other peoples.” Time and time again, this history shows us, health interventions have failed because they were designed at some remove from where they were intended to have effect. Anthropologists of development have been saying this for years, with their focus on the importance of local knowledge, and Packard draws heavily on anthropological studies. This book should be essential reading for any anthropology and global health course, not just because Packard is friendly toward anthropological studies, but also because his book has much to teach about the history of these interventions. It embeds this history within a broader political economy of development emergent from shifting global relations. The book provides a much-needed historical rejoinder to the fallacy that there has been a fundamental rupture from the late 1980s, and that “global health” is a radical reconfiguration to “international health.”
The book weaves through the campaigns, organizations, and shifting political and economic terrain of the last 80 years. It starts with “colonial entanglements” and the Pan African Health Conference held in Cape Town in 1932, where yellow fever was debated. Why, asks Packard, did disease eradication models—military style campaigns—become central to the development of future interventions? Three factors were at play here, he suggests: New specialists were able to demonstrate their value; U.S. scientific knowledge was ascendant; and American imperialism became entwined with a narrative that demonstrated beneficence. We see here a pattern to be repeated across the 20th century: the movement of a few central health experts through the hallways of decision-making power of a few key institutions, where particular visions of global health were shared and reproduced.
In the interwar years, as the case of the League of Nations Health Organisation and its malaria, hygiene, and nutrition programs shows, progressive ideas attempted to address the social determinants of ill health. In case study examples from China, Ceylon, Mexico, and India, Packard demonstrates how these attempts were derailed by the inability of medical science and nutrition initiatives to overhaul land ownership and regional development patterns. In addition, paternalism prevailed with the lingering vestiges of colonialism.
World War II transformed all this, as economies were devastated, millions were displaced, and a new configuration of international organisations developed. The WHO’s mission to promote health in its broadest sense was part of the post-war commitment, and many saw health improvements as central to social and economic development. But these visions narrowed. One reason for this was the emergence of medical technologies that promised transformation in the disease landscape without all the messy social and economic reforms that attend development. For Packard, DDT is a symbolic example of this, as was the industrial production and widespread availability of increasing numbers of antibiotics and vaccines. These advances combined with the increasingly technocratic development culture and cold war tensions.
By the late 1950s, international health organizations had narrowed their interventions to become more technical, and, as Packard frames it, international health entered “the era of eradication.” In the section of the book on eradication, Packard compares the smallpox and malaria campaigns. This comparison is excellent, as it points to the quite distinct biosocial histories of these diseases. The legacy of the successful smallpox campaign has left the ideological certainty that the vertical application of limited technologies could be successful in the absence of social and economic changes. Unfortunately, the biological characteristics that made smallpox eradicable tend to be overlooked, and the idea of eradication remains an infective trace in much global thinking.
In addition to the concern with eradication was a concomitant one around the problem of population. Here, more extreme national policies like forced sterilization campaigns were overlaid with family planning programs. Economic development and the empowerment of women played a crucial role in shifting fertility patterns; however, family planning programs were the product of technical assistance and to some extent mirrored the infectious disease interventions.
Into the mix arrives primary health care, immortalized in the Alma Ata Declaration of 1974. Human rights and social and economic development became central tenets to the utopian dream of Health for All. The commitment to this vision, alas, was short lived. The global recession of the 1980s and the rise of neoliberal economics put an end to this, and health system strengthening became secondary to limited selective technical interventions.
As we move toward the present in Packard’s narrative, in 2007, a meeting was convened in Seattle to explore ways to combat the resurgence of malaria. The differences to the past are visible here: greater involvement of women in decision-making, the diversification of funding, and greater NGO presence. But this malaria forum symbolizes, in Packard’s view, a move “back to the future.” The fact that the Gates Foundation hosted the forum represented a shift in global health governance. Not only Gates but also the World Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria became global leaders. The meeting, held far from the centres where malaria affected populations, again fetishized a single disease, biomedical focus. The Gates Foundation was not interested in the need to address development problems, and economic determinants were not addressed.
The emergence of what we now call global health coalesced around a series of new threats, the most prominent of which was HIV/AIDS, and the rise of drug resistant strains of tuberculosis. Dengue, SARS, and various strains of influenza now spread with increasing rapidity around the globe. The events of 9/11 galvanized health and disease surveillance, the speed of information, and travel, and a resurgence of the idea that poor health was a drain on development potential. Neoliberal capping of public expenditure and the rise of the NGO sector mirrored concern with government inefficiencies and the bureaucratic ineptitudes of multilaterals. Economistic Disability Adjusted Life Year analyses arrived on the scene and foreshadowed the rise and rise of metrics that we see dominating the global health landscape today.
Packard’s book is about 350 pages long. There are limitations to such a sweeping history. I wanted more specific detail in many of the case studies, for example, of the fascinating history of the relationship between religious rituals with the goddess of smallpox, Sitala, and evolving interventions in South Asia. Packard also starts with, and tends to centralize, the United States in this global history, only touching on broader specific national and colonial histories and their influences. And while the central driving analytic narrative that makes the book so accessible is compelling, more detail about specific eras is likely to complicate this picture. Packard finishes with a look at Partners in Health and Médecins Sans Frontières, models for future engagements. But what of the many other examples of interventions by organizations that are less self-aware, perhaps less confident of their ideological and interventionist strategies, and less savvy at publicizing themselves?
These are minor quibbles with a book that has dared to provide us with such an important history. The points Packard makes—about overreliance on external interventions; privileging biomedical technology and western knowledge; lack of support for basic health service strengthening; short termism; and skewing the health/development relationship to one where health improvements aid development and not vice-versa—need to be made, and repeatedly. Sadly, what we might construe as the health/development industry today has a remarkable capacity to erase the lessons of the past.