Book Review

Low Income, Social Growth, and Good Health: A History of Twelve Countries

N Engl J Med 2008; 358:2851June 26, 2008

Article

Low Income, Social Growth, and Good Health: A History of Twelve Countries
(California/Milbank Books on Health and the Public. 17.) By James C. Riley. 229 pp., illustrated. Berkeley, University of California Press, 2008. $45. ISBN: 978-0-520-25286-8

Are increases in the incomes of countries necessary or sufficient for the good health of their people? In this book, James Riley argues that they are not. Woven into the case studies of 12 low-income countries that achieved high life expectancies are two interrelated themes. The first is that there is no single explanation for the rise in life expectancy in these countries. Increased access to health care, strict malaria-control programs, improved health education, and vaccination programs all played a role, but each country followed a different trajectory that was dictated by its local environment and the accidents of history. The second theme among many countries that now have higher life expectancies is the active participation of households in the production of health and an improved understanding of modern models of disease causation in the population at large.

Riley argues that gains in survival were difficult to achieve without decreases in mortality from diarrheal disease, malaria, tuberculosis, or some combination of the three. Each of the 12 countries that was studied made substantial progress in addressing mortality from these illnesses. Yet the timing of the declines in mortality does not necessarily support the usual factors that are associated with the control of these illnesses. Declines in mortality from diarrheal disease occurred well before the widespread use of modern sanitary improvements such as piped water and the centralized removal of wastewater. Similarly, in a number of countries, mortality from malaria and tuberculosis began to decline before the introduction of dichlorodiphenyltrichloroethane (DDT) or the use of antibiotics. The case study of Jamaica, for example, suggests that what really mattered for the control of fecal disease was a campaign that the Rockefeller Foundation led to encourage people to build and use their own latrines. Encouragement and support of behavioral change in the population may have been at least as important as biomedical advances or technical improvements in public health measures.

The view that no single factor was responsible for these declines in mortality resonates with findings from a body of work. It has been notoriously difficult to attribute declines in mortality to single factors such as better nutrition, sanitation, or the discovery of antibiotics. A natural question, then, is whether Riley's thesis — that changes in human behavior played a large role — will survive the test of time.

Encouragingly, evidence from carefully constructed recent trials in low-income countries suggests that the provision of information — when correctly targeted and demonstrated — leads to measurable changes in behavior. In India, people are more likely to boil their water when the advantages of doing so are clearly demonstrated. In Kenya, the likelihood of younger girls becoming the sexual partners of older men decreases when they receive information on the age profile of persons who are infected with HIV and AIDS.

Riley recommends that in countries where life expectancy is low, the focus should be on prevention instead of on treatment of the sick. He also says that the participation of the general public, and not the technical knowledge of experts, will ultimately lead to declines in mortality. Trials such as the examples mentioned in the preceding paragraph provide evidence for both statements. The challenges for policymakers will be to create the consensus for greater expenditures on preventive health care and health promotion activities and to scale up without diluting the message. In an era of increasing anxiety about the efficacy of such expenditures, the challenge will also be to demonstrate that campaigns to promote preventive care and behavior have an effect on health outcomes.

Jishnu Das, Ph.D.
World Bank, Washington, DC 20443
jdas1@worldbank.org