Developing to Scale: Appropriate Technology and the Making of Global Health
At the World Economic Forum in Davos, Switzerland in January 2003, Bill Gates Jr. announced a $200 million dollar grant partnership between the Gates Foundation and the US National Institutes for Health to address what he called the “Grand Challenges in Global Health.” The fourteen “challenges”—enumerated in October of that year after the foundation’s scientific board publicly consulted with scientists and institutions around the world—focus overwhelmingly on the development of new technologies. How did the field of global health come to be understood largely as a problem to be solved with the right technology? In the face of critiques of over-medicalization in the global North and the under use of technology in the global South, the channeling of hundreds of millions of dollars annually into finding solutions to the health problems of the world’s poor may seem a welcome equalizer. Yet, as I show in my book project, "Developing to Scale: Appropriate Technology and the Making of Global Health," what may appear to be a 21st century phenomenon of techno-centrism has built heavily on an earlier movement—that in favor of appropriate technology.
The concept that there was an “appropriate” level of technology, between the traditional and the modern, which would lead to better social and economic development, originated in the writings of economist E.F. Schumacher in the mid-1960s. It gained considerable prominence in the 1970s, after the publication of his 1973 treatise, Small is Beautiful. Though different stakeholders interpreted “appropriate” differently, a relatively high-tech model eventually won out. I argue that the appropriate technology movement, and the model of novel technological development which gained favour among funding agencies in the 1980s, formed the techno-centric structure of the global health enterprise today. Though the movement itself faded into the background of donor agency’s prerogatives beginning in the mid-1980s, appropriate technology has had a lasting impact on how technology, health, and development are perceived to interact and, moreover, on how this interaction became central to defining global health and development practice today.
Over six chronological chapters, I trace how appropriate technology was theorized, interpreted, mobilized, institutionalized, and eventually banalized from the immediate post-war period to 2014. In doing so, it examines how appropriate technology policies fit into and were enthusiastically adopted into neoliberal reforms underway in 1970s agencies such as the US Agency for International Development (USAID); how different meanings of “appropriate” technology were negotiated between institutions and between developed and developing countries; how appropriate technology for health was often very gendered in its implementation; how localized and indigenous appropriate technology programs in the developing world, and Southern Africa in particular, gave the movement a new meaning and purpose which sustained it throughout the 1980s and 1990s; and how the model of novel appropriate technology development went from the signature of one Seattle-based government contractor, the Program for Appropriate Technology in Health (PATH), to the operating agenda of the largest player in the global health arena today, the Gates Foundation.
Multiple and overlapping contexts are relevant to this history. The Cold War contests between the United States and Soviet Union, particularly in attempting to win power and influence in the Third World, had a major impact on both multilateral and bilateral aid programs. At the same time, as the newly independent states of Africa and Asia began to assert their positions at the World Health Organization and with bilateral foreign donors, they were able to negotiate for the types of technologies they wanted transferred. In the 1970s and 1980s, as discussions about appropriate technology began appearing in the Southern African medical literature, South Africa was under the tight control of the apartheid regime, while Zimbabwe was in the midst of a civil war. These conflicts informed the way that appropriate technology was interpreted and mobilized by Southern Africans fighting for independence who saw technology as a means of gaining self-sufficiency. Finally, the global economic downturn following the 1973 oil shocks which lasted into the 1980s drastically affected the budgets available from major donor countries for health and development programs. The concept of appropriate technology was sufficiently flexible to be leveraged as a means for donors to overcome these financial limitations, while at the same time it offered recipient nations the space to negotiate for their own modernizing priorities. In examining these shifts, this study brings together the literature of Cold War development theory, the history of capitalism, the history of biomedicine, and the history and philosophy of technology to explore how making technology “appropriate” transformed the practice of international health, development, and American foreign aid.
Opening Hearts and Minds: Surgery as Humanitarianism in the Global Cold War
A January 2018 study published by the LancetGlobal Commission on Surgery noted that approximately two-thirds of the global population does not have access to safe and timely surgical care. Their study aimed to address the 2014 call by Jim Kim, until recently the President of the World Bank, to more effectively measure world surgical coverage. This recent focus on surgical access is a major shift away from historical Western views which saw advanced surgeries as largely inappropriate for post-colonial African health systems. Investment in the requisite health infrastructure?intensive care units, anaesthesia, medical oxygen, and post-operative pain management?was regarded by some, such as Halfdan Mahler, Director-General of the World Health Organization in the 1970s and 80s, as a waste of limited resources (Mahler 1976). Instead, the WHO?s focus on appropriate technology generated investments in discrete point-of-use technologies for diagnostics, immunization campaigns, and disease-specific interventions. This has led, in the long-term, to surgery being characterized as the “overlooked stepchild of global health” (Ng-Kamstra 2016). How did we get here? Opening Hearts and Mindstraces the historical roots of this gap in surgical capacity, paying particular attention to the historical role of South-South solidarity both in the construction of surgery as a form of activist humanitarianism and in enabling the willful disregard of the need to develop more sustainable surgical infrastructure.
Post-colonial local histories of biomedicine tended to focus on the decay of colonial-era hospitals (Hunt 1999) and the improvisational nature of many forms of surgical care (Livingston 2012, Mika forthcoming). Ethnographies of specific organizations have revealed how the practice of humanitarian surgery interacts with the embedded social relations of the communities in which they operate (Redfield 2013, Hannig 2017). These literatures tend to view the lack of surgical infrastructure as the inevitable result of reduced investment in health systems in the global South in the wake of structural adjustment programs and their continued legacies. They overlook both the ways in which multilateral organizations like the WHO have historically discouraged investment in surgical capacity and the ways in which newly post-colonial nations worked together to try to overcome these roadblocks. Opening Hearts and Minds’ focus on relatively “high-tech” surgical interventions follows directly from my dissertation on appropriate technology, however it takes the opposite point of view in examining those who believed that high-tech medicine, such as advanced surgeries, could be made appropriate to the biomedical landscape of the African continent. This involves looking at a different set of actors—at South-South cooperation within the Non-Aligned Movement and individual physicians whose celebrity was such that they were able to cross the Cold War political boundaries set up under the state-based international system.
Opening Hearts and Minds will comprise three major sections, each consisting of two chronological chapters. The first section of this project focuses on the conceptual shift from missionary and colonial medicine to humanitarian surgery as it coincided with the decolonization of many African and Asian states and the rise of the Non-Aligned Movement (NAM) in the 1950s and 1960s. I trace the early history of missionary medicine in Africa and humanitarianism under the International Committee of the Red Cross, to show how these two movements came together in the 1950s through two distinct but interrelated channels: collaboration between non-aligned nations and the efforts of individual Western physicians. This section will focus in particular on the complex relationships between Ethiopia, Yugoslavia, and Cuba, all of which were original members of the NAM, and their spillover effects on the African continent, particularly in the course of armed conflict. I open the second section of this project with the Biafran war in 1967 and the humanitarian crisis—and crisis in humanitarianism—that it caused. The conflict, which lasted for three years after peace talks chaired by Ethiopia failed in 1968, resulted in widespread starvation, the images of which inspired more direct intervention by Western activists and governments. The medical humanitarian organization Médecins Sans Frontières (MSF) centers their founding mythology around the imperatives of moral action during the Biafran crisis (Rostis 2016). A wave of surgical humanitarian organizations, many of them explicitly Christian missions, followed in the late 1970s and 1980s. In this period, as with the MSF model, surgical humanitarian engagements continued to be acute and short-term, though they departed from earlier humanitarian models in that Western surgeons took on more explicitly activist, moral commitments in their work. The third and final section of this project will focus on the impact global health research agendas have had on surgical humanitarianism. Beginning in 1987 with the founding of Partners in Health, the model of many academic medical humanitarian organizations has been one of collaboration and long-term engagement. MSF cites the Yugoslav war, beginning in 1991, as a turning point in their own model, wherein they questioned the political import of aid, which they saw as a “humanitarian alibi” for the lack of will to end the conflict, and the extent to which they should risk their own staff members’ lives to provide assistance (MSF 2015). Their 12-year engagement with the former Yugoslavia throughout the conflict marked the longest-term immersion in a humanitarian conflict up to that point in the organization’s history. So too with Cuban medical aid, which shifted from short-term intervention to longer-term partnerships for medical education and the founding of medical schools, as in post-apartheid South Africa (Gleijeses 2013).
I began research and writing for this second project as a recipient of the DeBakey Fellowship in the History of Medicine at the National Library of Medicine, particularly in Michael DeBakey’s personal papers. In May 2018, I was invited to give the 2nd Annual Michael E. DeBakey Lecture in the History of Medicine at the National Institutes of Health. The videocast is available here.