Saving lives millions at a time is not enough

I first became interested in the history of global health while serving as a Peace Corps volunteer in a trachoma-eradication campaign in eastern Uganda in the late 1960s. The campaign was well intentioned but poorly designed and implemented. It was sponsored by the Uganda Foundation for the Blind, a local nongovernmental organization that had no direct connection to the Ugandan Ministry of Health. It was, like many global-health programs today, a freestanding vertical program. It was staffed by teams of recent college graduates who had no formal public-health or medical training. There were no provisions for training Ugandans to work on the project or take it over after we left. The treatment required patients to attend our clinic once a week for 12 weeks. This was a challenge for many of those who lived miles from the clinic. In addition, the campaign was limited to one district, which was surrounded by other districts where the disease existed, but in which there were no trachoma-control programs. It thus ignored the fact that people frequently moved back and forth between districts. Our patients would disappear for weeks at a time, interrupting their treatment. Overall, the program's dropout rate was high. Finally, many of the people in the district lacked the economic resources needed to practice the basic sanitary measures that could prevent infection. It was little wonder that after two years of work the estimated prevalence of trachoma in the district had actually risen slightly.

This experience shaped my thinking about global health and influenced the course I have taught since 1992 on the History of International Health and Development, first at Emory University’s Rollins School of Public Health and now at the Johns Hopkins Bloomberg School of Public health. A central argument of the course and this book is that there have been remarkable continuities in how health interventions have been conceived and implemented over the past century. Many of the problems I experienced in Uganda have a history that stretches back to the early twentieth century and persist to this day.

Global health today centers largely around the delivery of biomedical technologies—vaccines, medicines, insecticide treated bed nets, vitamin A supplements-- aimed at eliminating particular diseases or health problems. Like the trachoma eradication campaign, I participated in, they are often designed outside the countries in which they are to be implemented. They are most often free standing programs, run by non-government organizations, and loosely connected with local health services.  They contribute little to the development of these services and fail to address the underlying social and economic conditions that foster the problems they seek to solve.

My book is an effort to explain why global health looks the way it does--why we continue to pour millions of dollar into programs which save lives, but leave the vast majoring of people living in under-resources environments without access to basic health care and in conditions that promote ill-health. The answer is not because no one has thought about addressing these conditions or building basic health services. There have been periods when global health leaders have focused their attention of these broader problems. But these moments have passed without much progress being made. Politics, the needs to act quickly, or make a big splash, has discouraged global health planners from pursuing these larger goals. My book has a simple message. We need to do better.

Randall M. Packard is the William H. Welch Professor and director of the Institute of the History of Medicine at Johns Hopkins University. He is the author of The Making of a Tropical Disease: A Short History of Malaria and White Plague, Black Labor: Tuberculosis and the Political Economy of Health and Disease in South Africa. His latest book, A History of Global Health: Interventions into the Lives of Other Peoples, is available now.