I’ll start with one of the most compelling graphs I’ve come across in this area: Thomas McKeown’s depiction of tuberculosis mortality in England over the last 150 years.
This echoes the conclusions Rudolf Virchow made over a century prior, when commissioned by the Prussian government to investigate a typhus outbreak in Upper Silesia. Virchow astonished his commissioners by pronouncing the outbreak an “artificial” epidemic, faulting the elites for their neglectful social and economic policies. Virchow’s report includes perhaps my favorite medical recommendation: “full and unlimited democracy.” Because, according to Virchow, “medicine is a social science, and politics is nothing else but medicine on a large scale."
Why quote 19th century Prussian physicians? Because Virchow (and McKeown) are incredibly relevant for analyzing how global health priorities are shaped today. Particularly in the polarized debates for targeted medical interventions or technologies versus those who propagate a community or population-level focus on social determinants of health and changes to political economic structures. We see this manifest in many ways, for example in what Virchow would undoubtedly view as the modern day “artificial” epidemic of HIV/AIDS. This conceptualization underlies proponents of interventions tackling issues of equity, women’s empowerment and social networks over the development of HIV/AIDS microbicides or vaccines.
In practice however, this dichotomy is also artificial. And as any Haitian grann will tell you, we must expand our capacity for complexity.
It is important to note that McKeown’s thesis has been lambasted in recent decades, with more robust analyses like Arthur Nesholme’s gaining credence among medical historians. Nesholme argued that the 1834 Poor Law, which quarantined destitute TB patients from workhouses, served as a key component to declining TB mortality, as it had the unintentional effect of increasing early diagnosis and preventing TB spread to the general population. Thus medical and public health interventions (intentional or otherwise) do have a role to play. What I think can be mutually concluded from Nesholme and McKeown is two-fold:
- Poverty or inequity is a salient underlying characteristic in both analyses; whether as a key target population in Nesholme, or as a target in and of itself for McKeown.
- Targeted health interventions and those focused on systemic change don’t exist in opposition, but rather as “essential complements to each other.”
What becomes interesting then are the nuances and trade-offs inherent in balancing technological interventions with strategies addressing systems change. At the conclusion of her Foreign Affairs article, Garrett describes a “doc-in-a-box” idea, which proposes converting shipping containers into ready-made clinics as a solution for deficient health delivery systems. While ostensibly only a “mental exercise,” it belies the facile appeal of silver-bullet technological solutions for even the most vehement advocates of systems approaches. In this instance, Garrett seems off-balance, as Alex de Waal and other critics expound, “doc-in-a-box” should more appropriately be termed “box-for-a-doc,” as it oversimplifies the challenges of health workforce maintenance and training. I’ll return to this specific challenge in later posts, especially with regards the use of community-based health workers for maternal, neonatal and child health.