Reviewed by: Low Income, Social Growth, and Good Health: A History of Twelve Countries Bruce Caldwell James C. Riley. Low Income, Social Growth, and Good Health: A History of Twelve Countries. California/Milbank Books on Health and the Public, no. 17. Berkeley: University of California Press, 2008. xvi + 229 pp. Ill. $45.00 (978-0-520-25286-8). James C. Riley’s new book builds on many years of work on the historical conditions that lead to sustained improvements in health. His particular interest is in a number of relatively poor developing countries whose average life expectancy rivals that of advanced industrialized nations. Riley notes that before the 1970s little attention was given to such countries, as it was assumed that the key to better health was economic prosperity, which made possible the material basis for better medical services. A reassessment was prompted by the success of a number of communist countries, including the Soviet Union, China, and Cuba, in providing [End Page 421] easily accessible health services using health clinics staffed by a limited number of doctors and minimally trained paramedics. These examples helped provide the conceptual basis for the primary health care model promoted by the 1978 Alma-Ata Declaration as the way to achieve “Good Health for All by the Year 2000.” However, although the model was attractive, the ability of most developing countries to implement it was in question. Communist countries were able to direct resources in a way that was not possible in most developing countries. More relevant examples seemed to be found in the success of a small number of developing countries that had achieved, as noted in the title of one influential report, “good health at low cost.”1 The countries most commonly included in such studies, notably Costa Rica, Sri Lanka, and the Indian state of Kerala, had a number of distinctive characteristics in common, in particular, a history of democracy, a concern for social justice, and a relatively high position for women, all of which have arguably contributed to more equitable societies where governments place more emphasis on social services, including health, and where households are in a better position to take advantage of those services. Although these characteristics are desirable, they are not easily obtained and, hence, the model would appear difficult to replicate. Riley argues that the lessons presented by these countries have been misinterpreted in large part because of a lack of historical perspective. Riley has assembled a summary table estimating, for all countries with sufficient data, when sustained increases in life expectancy commenced. By matching this with estimates of real per-capita income, he identifies twelve countries that achieved impressive mortality declines while their per-capita incomes were still low, namely China, Costa Rica, Cuba, Jamaica, Japan, Korea, Mexico, Oman, Panama, the former Soviet Union, Sri Lanka, and Venezuela. An assemblage of data like this inevitably raises difficult questions about the accuracy of the data underlying both the life and income estimates, but it does convincingly demonstrate how early the mortality decline began. All countries but Oman began their mortality declines before 1940, at a time when health infrastructure was largely undeveloped and before such major health interventions as antibiotics, DDT campaigns to control malarial vectors, and widespread childhood immunization. The initial mortality declines started with simple interventions such as the promotion of basic hygiene, including hand washing and the installation of simple latrines (initially to control hookworm but of great benefit in controlling diarrheal diseases) and household seclusion of the sick, as well as quarantine measures. Subsequent declines depended more on effective and accessible health services. Critical to both early and subsequent declines was popular receptivity to appropriate information campaigns and the services made available. Riley argues that a critical factor in achieving this was investment in social capital, particularly basic education. This, he suggests, overcame any cultural resistance, [End Page 422] noting that Muslim countries, earlier held to be resistant to such messages, have had particularly impressive mortality declines in recent years. Riley’s book is an important contribution to the literature on the conditions for mortality decline. Inevitably, however, in trying to cover the mortality declines of so many countries, the accounts of individual...
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Jun 1, 2012
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