Randall M. Packard tells us he became interested in problems of health and development as a Peace Corps volunteer in eastern Uganda during the late 1960s. He was participating in a failing trachoma eradication program—a top-down, poorly designed project with little input from national experts and weak engagement with local communities. Packard’s Ugandan experiences led to a distrust of well-meaning outsiders who use biomedical technologies in narrowly focused, and often arrogant or misguided, efforts to eliminate specific diseases in poor countries. The pitfalls of disease control in Africa prompted him in the 1990s to teach a pioneering course at Emory on international health and development, a critical history of twentieth-century medical “interventions into the lives of other peoples,” which served as the basis for his valuable overview of the emergence of what we now call global health. In reading this illuminating synthetic history one should bear in mind Packard’s Ugandan experiences, since they evidently have shaped his evaluation of global health interventions. My slight involvement in the delivery of medical care in East Africa was significantly different from Packard’s, no doubt influencing my response to his book. As a medical student at the Kenyatta National Hospital in Nairobi in 1982, I witnessed the collapse of an ostentatiously, and perhaps meretriciously, modern medical system under duress from state corruption, the (belatedly recognized) ramifying influence of AIDS, and most seriously, the destructive structural adjustment programs of the International Monetary Fund. I was left with abiding respect for the national physicians who remained dedicated to their patients and were sensitive to the effects of poverty and disadvantage on health. Such local functionaries and activists are largely absent from Packard’s book, somewhat to its detriment. Across sixteen short chapters, Packard takes us on a revealing tour of the entangled histories of colonial medicine, international health, and global health. His recognition of the role of public health officers who traversed the United States’ empire in the early-twentieth century, often aligning with military endeavors, priding themselves on their progressivism and interventionism, is salutary. Packard shows how, in moving between colony and metropole and foundation, focusing on the control of specific diseases such as hookworm, malaria, and yaws, medical experts structured a model for later technocratic interventions. They concentrated on checking, or attempting to eliminate, diseases that imperiled white sojourners and settlers or reduced native labor power. They tended to disparage local cultures, deplore the behavior of other races, and blame victims. They showed little respect for situated knowledge and vernacular expertise. In the late-colonial period, a few of them came to accept the impact of poverty and deprivation on patterns of disease, particularly with respect to tuberculosis and child health, but generally they regarded any radical transformation of society as impractical or undesirable. Such attitudes hardened as the century wore on, becoming pervasive and conventional. New “international” health services between the wars did occasionally experiment with improvements in rural hygiene and economic development—in China, in particular—but the League of Nations Health Organization and the Rockefeller Foundation usually defaulted to specific disease control campaigns. Some investments in social medicine, or its rhetoric at least, persisted after the war, expressed in the expansive claims of the World Health Organization (WHO) and the rising ambitions of international development projects, but disease eradication programs predominated. The middle part of this account of the origin of global health concerns post-World War II, or cold war, tensions between disease eradication campaigns and the promotion of primary health care. Packard argues plausibly that a “biosocial” analysis can explain the failure to eradicate malaria and the success of the offensive against smallpox. According to Packard, most commentators have attributed the different outcomes to the tightly scripted character of the malaria campaign in the 1950s, and the flexibility, in contrast, of the smallpox campaign in the 1960s. Instead, he directs attention to the different modes of transmission and clinical features of each disease—which was, indeed, the (largely “bio”) way in which potential for disease eradication was discussed in medical schools in the late 1970s, as I recall. Packard goes on to provide a wonderfully nuanced narrative of the rise and fall of primary health care in the 1970s, a brief flare-up that culminated in the 1978 Alma Ata declaration of “Health for All by the Year 2000”—later much ridiculed but fervently professed at the time. Primary health care was meant to deal with the social and economic determinants of disease; it called for the building of basic health services and required community participation. Packard attributes its popularity, sadly evanescent, to the foundering of malaria eradication, the enthusiasm of WHO leader Halfdan Mahler, the growing criticism of development and “modernization” programs, and skepticism about biomedical hegemony—it was, after all, the 1970s. But it seems that advocates of “horizontal” primary health care from the start were on the defensive, fending off resistant and mercenary national physicians and international experts who believed the goals were utopian or quixotic. For many, the successful eradication of smallpox offered a more attractive, and neater, alternative “vertical” model. (It is telling that social and economic change often was viewed as utopian while disease eradication sometimes seemed so practical and easy.) Eventually, the rise of neoliberalism and austerity in the 1980s favored a selective version of primary health care, a compromise that focused on immunization against common diseases, neglecting health equity. So far the story will be familiar to those of us who, like Packard, taught courses in the early 1990s on colonial medicine and international health. Mine was quaintly called “Medicine and the Third World,” and it ended with structural adjustment and AIDS in Africa, and Ebola as a predictable coda. (In 1992, Richard Preston had written a long article on Ebola for the New Yorker, and Laurie Garrett in 1995 was to publish The Coming Plague.) No surprises here, then, except that Packard innovatively proceeds to link international medical interventions to population control or contraception campaigns; and he presses forward into the past thirty years of the new global health. The perceived conjunction of disease and population control suggests a novel genealogy for global health; while attention to recent developments, occupying merely one fifth of the book, vividly demonstrates the continuities and differences between the old health internationalism and how we do global health now. For Packard, the global health enterprise consists of efforts of governments and organizations based in the global north “to improve the health of people living in resource-poor countries” (6). They use biomedical technologies “to eliminate specific health problems through vertically organized programs” (6), which pay no heed to national health systems and the “underlying social and economic determinants of ill-health” (7). A mixture of biosecurity fears, humanitarian goals, and economic interest appears to drive the non-governmental organizations (NGOs), philanthropic foundations, and pharmaceutical companies increasingly in command of global health. While Packard insists on the continuities of colonial medicine and international health, he also implies that a distinctive form of intervention into the lives of other peoples has emerged since the 1990s. The new model of global health, he suggests with great subtlety, might find a precursor in postwar efforts to curb the global “population explosion.” Initially, at least, controlling the breeding of the poor in the global south was a preoccupation of rich states, NGOs, and the Rockefeller and Ford Foundations—newly independent nations and the WHO came late to the party. Often technocratic and coercive, family planning programs “remained separated from broader health efforts and from social and economic development” (224). That is, they were technical, vertical, shunned community participation, ignored socioeconomic conditions, and distracted from providing primary health care—not unlike the new global heath that entered the picture in the 1990s, according to Packard. The genealogy is intriguing, though the argument is frustratingly veiled. Packard spends the last fifth of the book describing how from the 1990s NGOs, foundations, and pharmaceutical behemoths took control of disease campaigns in the global south, displacing international bodies and bypassing or neglecting national governments. Emerging diseases like AIDS gave force and urgency to the new global health. Neoliberal monetary policies, national and international inefficiency and corruption, and the rise of audit cultures made circumvention of older, rigid institutions seem imperative and indispensable. Foreign experts parachuted in all over the global south with antiretroviral drugs and other technical fixes for specific infectious diseases, usually the big three of AIDS, tuberculosis, and malaria. Much good was done, no doubt, but national health infrastructures continued to decay, and other serious conditions, including cardiovascular disease, diabetes mellitus, mental illness, and cancer were set aside. Packard concludes with a revealing comparison of the mode of action of Médecins sans Frontières (MSF) and Paul Farmer’s Partners in Health: MSF tends to mobilize emergency relief where governments are weak, providing vital but unsustainable care; while Partners in Health engages in long-term missions, attempting to rebuild local health systems, but focuses on access to care rather than fundamental social and economic reform. For Packard, these organizations represent the two “poles” of global health, each exerting a magnetic attraction on liberal medical students and physicians in the global north. A History of Global Health gives us an unrivalled view from within the belly of the beast, revealing the physiology and pathologies of the organism. But it would be helpful, too, to see how the beast looks from afar, how it prowls the ground in the global south, and makes its way in the world. As I read this book, I kept wondering how national health workers, say the staff at the Kenyatta Hospital, see global health. Some historians and anthropologists—such as Ming-Cheng Lo in Taiwan, Claire Wendland in Malawi, Alice Street in Papua New Guinea, Gabriela Soto Laveaga in Mexico, and Hans Pols in Indonesia—have been listening respectfully to local and national subjects, even treating them as experts, but they contribute little to the narrative here. Packard aptly criticizes the new global health as it “circumvents national governments” (268) and views the people it serves “as part of the problem, rather than the solution” (331). And yet, with few exceptions he confers agency and sovereignty on figures in the global north—the “we” (339) who are to decide how best to intervene in the lives of those in the global south. To a surprising degree, this becomes an inquiry into white American agency and liberal virtue—perhaps a Peace Corps story after all. “I did not understand who was running the show, or what they did, or even what the Peace Corps actually was, apart from an enlightened excuse for sending us to poor countries,” recalled Paul Theroux (New York Times, 25 February 1986), a volunteer based in the 1960s in Nyasaland (Malawi). “Those countries are still poor. We were the ones who were enriched….” © The Author 2017. Published by Oxford University Press. All rights reserved. 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Journal of the History of Medicine and Allied Sciences – Oxford University Press
Published: Jan 1, 2018
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