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Friday, November 5, 2010

Artificial Epidemics

Rounding out our first week, I want to reflect on some themes introduced by fellow MethodLogicians. Namely, the intersection of political economy and health, and the way global health and development priorities are set.

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.

It demonstrates that significant mortality reductions occurred prior to effective modern medical interventions for TB treatment and vaccination, and propelled McKeown’s thesis that medical interventions are largely irrelevant in the face of greater socioeconomic and political forces which drive improved standards of living. 

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:
  1. 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.
  2. Targeted health interventions and those focused on systemic change don’t exist in opposition, but rather as “essential complements to each other.”
These conclusions are increasingly reflected amongst global health actors, whether in the WHO Commission on Social Determinants of Health, or the widespread revival of Alma-Ata principles of an equity and community empowerment approach to primary health care and overall health systems strengthening. And, as Adam mentioned, amongst thought-leaders like Laurie Garrett.

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.


  1. Really interesting post, Danika. I had a few thoughts:

    It's a fascinating paradox that we are calling for large-scale social change but also population-level interventions. I think this is largely consistent with the theory that democracy is a grassroots-based institution, or as Tip O'Neill was fond of saying "All politics is local." Is this 100% true? I believe that empowerment leads to calls for inclusion and rights. In "Political Man," Seymour Martin Lipset demonstrates pretty convincingly that democratization correlates strongly with economic development. What he and many scholars since have been unable to do is tease out causality. Do economic fortunes lead people to demand rights to protect acquired wealth or is a democracy a catalyst for economic development? Probably, it's a cycle with an undefinable genesis. I'm left wondering if we can substitute local empowerment for economic success and expect changes in governance with a trend towards democracy, with resultant improvements in health and development.

  2. There's a positive association between democracy and economic development, but it's pretty weak and exceptions are everywhere. However, there is evidence that good governance can substitute for money in generating certain public health outcomes. Kerala comes to mind as a place in which democracy has done this, but Cuba is perhaps a counterpoint; democracy is just one path to successful governance.

  3. Great post Danika - regardless of the extent to which the McKeown hypothesis holds, it's a fantastic reminder for humility in our efforts as public health workers


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