Book Review

Fighting the Diseases of Poverty

N Engl J Med 2008; 359:1530-1531October 2, 2008

Article

Fighting the Diseases of Poverty
Edited by Philip Stevens. 298 pp., illustrated. New Brunswick, NJ, Transaction, 2008. $29.95. ISBN: 978-1-4128-0744-9

The world's poorest people face formidable health challenges. According to the Population Reference Bureau, the average life expectancy in sub-Saharan Africa is 49 years, which lags far behind the North American average of 78 years. About one third of all children in low-income and middle-income countries are underweight, and rates of growth stunting in some of the poorest regions in countries such as India reach as high as 60%. At least 35 million people worldwide now live with the human immunodeficiency virus, and more than 60% of them reside in sub-Saharan Africa, with the majority living in impoverished conditions. In Fighting the Diseases of Poverty, editor Philip Stevens makes the provocative argument that the “top-down” approaches to these health issues promoted by United Nations agencies and other organizations actually work “to the detriment of the private sector, economic development, and human health,” and he identifies the promotion of free-market policies as the optimal strategy to improve health in lower-income countries.

In framing this argument, the book begins with a chapter by Indur Goklany, who describes marked improvements over time in indicators of global well-being, including availability of food supplies, life expectancy, infant mortality, economic development, education, and political rights. Goklany, a researcher and manager in the U.S. Department of the Interior and a former Visiting Fellow at the American Enterprise Institute, contends that this progress has been sustained by a combination of economic growth, technological change, and free trade, and that these forces are crucial to further improvements in global health. Several subsequent chapters highlight the potential disadvantages of centralized approaches to improving health and health care access, including the detrimental effects of corruption on the effectiveness of public health care systems.

Issues related to pharmaceutical development and access to medicines in less developed countries are featured prominently in the book. Closely echoing arguments he made in a 2004 report issued by the International Policy Network, titled “Diseases of Poverty and the 10/90 Gap,” Stevens critiques policy initiatives that would constrain research and medication development by addressing the “10/90 gap.” This term, popularized by the Global Forum for Health Research, is meant to convey that only 10% of global funding for health research is devoted to diseases that affect 90% of the world's population living in developing countries. Stevens argues that treatments already exist for many of the diseases that are of greatest consequence to poor populations, and he believes that the central issue is not inadequate drug development by manufacturers, but rather a lack of access to existing treatments due to poverty, inadequate health infrastructure, and governmental barriers. These points are taken up by other authors in subsequent chapters, who recommend reduction of governmental intervention in licensing, levying tariffs, and establishing price controls for pharmaceuticals, as well as strengthening intellectual property protection to stimulate drug development and reduce counterfeit drug production. In one of the book's strongest and most balanced chapters, David Bloom, David Canning, and Mark Weston discuss the role of vaccinations in improving health and well-being. They summarize the history and current state of vaccine development, and they cite evidence supporting the benefits of a strong international commitment to maximizing vaccination coverage.

The book's underlying themes culminate in the final chapter, an essay by Richard E. Wagner titled, “The World Health Organization: A Time for Reconstitution.” He envisions a market economy that efficiently generates health-related enterprises and outcomes, in which government agencies function primarily to ensure property rights and contracts; by his reckoning, the health-related interventions of the World Health Organizatiton (WHO) should be limited to preventing the spread of communicable diseases and possibly providing charitable services to the poor. His analysis of the 2006–2007 WHO fiscal budget suggests that the WHO's activities extend far beyond these limits, and in his words, the organization focuses heavily on “bureaucratic self-promotion.” Some readers may find his arguments for abolishing or radically diminishing the scope of the WHO's activities thought-provoking, but for many, especially those working in the field of public health, they are unlikely to be persuasive.

Marianne Hillemeier, Ph.D.
Pennsylvania State University, University Park, PA 16802
mmh18@psu.edu