Books & Electronic Media

Human frontiers, environments and disease: past patterns, uncertain futures

by Tony McMichael Cambridge University Press, Cambridge, England, 2001. ISBN 0521 004942 UK £14.95

The public health professions are facing unprecedented practical, academic and political challenges. Along with the double burden of communicable and noncommunicable disease, there is increasing recognition of the importance of global environmental change for human health and disease. This 'third burden' of disease is especially challenging because it requires new methodological approaches outside the realm of those routinely used by public health scientists. This additional challenge comes at a time when public health capacity is insufficient, especially in developing countries, to respond to communicable disease prevention and control needs.

McMichael is a professor of epidemiology at the London School of Hygiene and Tropical Medicine, and at the leading edge of debate on the public health response to global environmental change. It is reassuring that the London School is taking a strong interest in these complex global issues, which are much more difficult to deal with than the disease-specific ones which have long been its focus. McMichael is one of the few public health scientists who have found ways to stand back from sectional interests and study the relationship between individuals, societies and the environment in which we live as a whole.

The scope of his latest book is broad, beginning with a fascinating historical view of biohistory and ending with concrete suggestions as to how we can and must reduce our ecological impact. Along the way we are treated to a detailed and chilling analysis of the impact we have had and continue to have on the earth's ecosystem. The information is well organized, well illustrated, easy to read and delivered with a welcome sense of humour. It is essential reading for public health scientists, practitioners, acaemics and students, and for economists of all specilizations and ideological persuasions, given their increasing influence on public health debates.

The modern phase of globalization is characterized by freer trade and unfettered flow of capital, and is radically strengthening global patterns of financial interconnectedness. A striking outcome of this process over the last 30 years has been the creation of huge national and personal wealth, especially in the already wealthy countries, and economic growth more generally, notably in South-East Asian countries including China. There are of course major regions of the world which have yet to benefit from this economic growth, notably sub-Saharan Africa and much of eastern Europe, especially Russia and the other countries of the former Soviet Union.

The relationship between economic growth and health is by no means simple. It has long been recognized that at low levels of GNP there is a strong relationship between increasing national wealth and overall population health status. However as the income level reaches about US$ 5000 per capita, the rise in health status plateaus. There are of course important exceptions to this relationship. For example, it has long been recognized that in the Indian state of Kerala, and in China, Costa Rica, Cuba and Sri Lanka, it was possible to attain high levels of health status with very low per capita income. However, with the notable exception of China, these countries have not been able to convert this health advantage into economic growth. Some economists assume that this continuing low economic growth must be due to lack of the market-based reforms advocated by the World Bank and the IMF. It should be noted, however, that several countries, both wealthy and poor, have followed this prescription with great enthusiasm and still not experienced rapid economic growth.

The economic growth that has occurred in the last few decades has undoubtedly led to major health benefits. For example, the proportion of the Chinese population now living below the official poverty line has been significantly reduced, presumably with a concomitant beneficial impact on population health status. But there have also been steep costs, such as the rapid rise in social, economic and health inequalities among and within countries. There is now a flourishing academic literature coming out of rich countries on health inequalities and the appropriate policy responses, though the response of politicians to this concern has not been commensurate with its public health importance.

A far higher potential cost of this economic growth is unsustainability. McMichael places this issue, which, unless solved, will overshadow all other health issues, firmly on the public health agenda. The world's population is on track for 9 billion people by the year 2050. It is irresponsible to ignore the effects this will have on the ecosphere – especially given the expectations the extra billions of people will have for a standard of living well above the poverty line. Health improvement for all is justified on humanitarian grounds alone but must be based on a sustainable and equitable economic system. Health improvement that is sought only for its contribution to economic growth is, at best, shortsighted and at its worst may speed up the global environmental degradation that is taking place. Economists who ignore the central need for redistribution of wealth may in the long run be contributing to, rather than alleviating, human distress and disease. This book makes a major contribution to the debate on health and development and is especially timely given the Rio + 10 summit next year.

Robert Beaglehole
Department of Health and Development,
World Health Organization, 1211 Geneva 27, Switzerland.