> A few months ago, when the big announcement was made about the Warren
> Buffet billions going to Gates Foundation, there was a article posted
> somewhere that critiqued a predominantly "high-tech" approach to
> public health problems.
I found it. Here is an excerpt:
[...]
One way to answer this question is to explore historical evidence of the factors that best explain the decline of mortality in developed countries from the mid-19th to mid-20th centuries. McKeown and colleagues' much-cited studies6 of the causes of the modern mortality decline in England and Wales concluded that improved nutrition and immunological resistance—stemming from economic growth and a rising standard of living—was the key explanatory factor, with medicine deemed largely irrelevant because effective interventions appeared only after mortality rates had already fallen substantially. This provocative thesis has stimulated numerous national and local level mortality studies which challenge McKeown's dismissal of the role of human agency in terms of social movements, public health measures—such as sanitation and housing improvements7—and political change8 and reveal an enormous complexity of factors and experiences,9–13 including discovery of an "urban penalty" of increased mortality in northern Europe during early phases of industrialisation.14 In his recent synthesis, Riley15 has shown that countries have historically chosen one or more of six strategies to reduce mortality: better income distribution; improved diet; public health; medicine; changes in household behaviour; and increased education—with no single factor universally successful.
Because these primarily European analyses focused on the era that preceded the expanded armamentarium of antibiotics, vaccines, and vector-control measures in the wake of World War II, some observers have speculated that falls in postwar mortality in developing countries might have derived more from technical and medical interventions than was the case in Europe.16 However, since these improvements in mortality were coterminous with improvements in social and political conditions (including decolonisation), education, income increases and distribution, and medical and public-health measures, it is nearly impossible to untangle the separate effects of each factor. A study of this question in the developing country setting of Uruguay offers some hints. Although Uruguay's mortality rates began dropping before 1900, its infant mortality rate was constant for almost four decades. From 1905 onwards, Uruguayan politicians and public health officials employed all but one of Riley's sextet of strategies to little avail—until family allowances were legislated in 1943 and infant mortality rates began a steep decline.17 This case suggests that redistributive measures—and the political struggles that undergird them—play a key enabling role in the successful implementation of medical, public health, educational, and household measures.
[...]
full: http://image.thelancet.com/extras/04art6429web.pdf
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Colin Brace
Amsterdam