High-Tech Hopes for Global Health

It takes chutzpah to entitle your book The Grandest Challenge: Taking Live-Saving Science from Lab to Village, but the authors of this brash volume, Abdallah Daar and Peter Singer, have a valid claim to it. Both are senior advisors to the Bill and Melinda Gates Foundation—the world’s richest charity—in a program just as immodestly called the “Grand Challenges in Global Health,” which aims to innovate and introduce splendid new technologies to make the world’s poorest healthier ((Not to be confused with the Gates Foundation’s other programs that deliver the current interventions of global health, such as the usual battery of childhood vaccines, a vast philanthropy that has saved many lives.)). Both are professors at the University of Toronto and have illustrious medical careers behind them. Both have risen into second careers as high priests of global development, where they are much acclaimed, including by the Harper government, which has given them millions of dollars to oversee and direct Grand Challenges Canada as part of our country’s foreign aid system.

And both, much less happily, have written a pitiably weak book, one so self-regarding and naive that one almost prays it is ghostwritten. If this book accurately represents the thinking of these two leaders, then the prospect of Grand Challenges Canada lifting multitudes out of disease and poverty dims considerably.

The wincing inaccuracies arrive even before ink stains one’s fingers. At page one and footnote one, the authors claim that “roughly 90 percent of human beings live in poor regions of the world,” and “approximately 94 percent of the world’s population lives in lesser- and least-developing nations.”

It is not difficult to find data on the populations of poor or developing countries, but Daar and Singer provide no useable citation to their source (a suggested website does not work) and their statistics are simply wrong ((Daar and Singer claim to have got their statistics from United Nations World Population Prospects. In my check of those data in the “medium variant” (i.e., likeliest) scenario: in 2010, of 6.9 billion people globally, 4.8 billion are in less developed regions and a further 832 million are in least developed countries (for 82 percent). The UN does not keep statistics on “lesser- and least-developing” countries, as the authors claim it does, for doing so requires judgements as to the speed of development, and not just a snapshot.)). Nobody would consider that the Brazilians, Chinese and Indians—collectively nearly 40 percent of humanity—are living in lesser- or least-developing countries, for they are developing at a vertiginous rate; and once they are subtracted, it becomes arithmetically impossible for 94 percent of the world’s population to live in lesser- and least-developing countries. Likewise, because North America and the European Union are rich regions comprising a little over 10 percent of the world’s population, once they are subtracted, to claim that 90 percent of human beings live in poor regions of the world requires that Daar and Singer regard the whole rest of the planet as a “poor region”—including oh-so-backward Australia, Hong Kong, Israel, Japan, Korea, New Zealand, Norway, Qatar, Saudi Arabia, Singapore, Switzerland and Taiwan.

Thus certainly the authors’ own perception of the world’s rich and poor is inaccurate. Coming on the first page of a book about global development, this is rather confidence-shaking.

The book starts off embarrassingly because, with all the grand challenges of the world before them, the authors choose to focus their opening chapter on, well, themselves. Life stories are told, starting from childhood. Modesty is in short supply. “Here I was, a world-class transplant surgeon,” chirps Daar. Not to be bested, Singer retorts that “I had started the world-class University of Toronto Joint Centre for Bioethics.” Both genuflect before a colleague from Harvard, Calestous Juma, whom they describe as a “handsome, charismatic, energetic, confident man.” Juma repays the love: he writes a promotional blurb for the book’s back cover, touting it as “inspirational,” and the authors as “role models.”

On and on. There is so much shameless preening of alpha males here that one can be forgiven for thinking this is a book about grand challengers, rather than grand challenges. There is no question that the authors are highly intelligent, but in choosing to narrate and thoroughly personalize their book—“I” or “we” appear throughout—the authors’ ideas are twinned with and frequently outshone by their coruscating egos. This is a pity for reader and reviewer alike, because it obscures even the worthwhile things the authors have to say.

By Chapter 2, Daar and Singer are cultivating their lab-to–village thesis, which is one of their main themes. They argue there are certain grand challenges—14 of them, to be exact—concerning nutrition or infectious diseases in poor countries (collectively given the misnomer “global health”) that have the backing of the scientific community and the Gates money, and that cry out for laboratory research to develop new products that are effective and affordable in impoverished settings such as African villages. The authors were instrumental in choosing these grand challenges and offer a fascinating, idiosyncratic account of how they juggled something like an academic parlour game among scientific superstars to achieve consensus on those challenges (the authors admit taking playful inspiration from David Letterman’s top ten list). All the challenges aim to create new technologies, such as vaccines that work with a single dose or need no refrigeration, or staple food crops that contain a full range of nutrients. No doubt, these technologies would be revolutionary and could save huge numbers of lives.

But, curiously, no sooner have Daar and Singer impressed on us that their 14 grand challenges are well chosen and paramount than they commit hara-kiri on them. In Chapter 3, the focus changes to non-infectious diseases—diabetes or cardiovascular disease, not malaria or HIV/AIDS. Such diseases, they correctly note, are rising quickly with affluence and already cause more death than infectious diseases, but were “ignored” in the 14 original grand challenges. Daar and Singer concede that this realization only dawned on them “as time passed,” and so, four years on, they midwived 20 more Grand Challenges in Chronic Non-Communicable Diseases. More recently, they spearheaded 25 new Grand Challenges in Global Mental Health.

Taking Daar and Singer at their word, would their project not be better called Grand Arbitrariness? The notion that the most timely, necessary, indeed grandest goals for global health undergo a revolution every couple of years is, obviously, risible. Moses’s grand challenges (a.k.a. the Ten Commandments) have lasted several millennia; Daar and Singer’s 14 original grand challenges barely lasted as long as a secondhand jalopy before dozens more appeared. Such constant renovation tears at one’s confidence; it makes the challenges seem not grand but whimsical, not serious science policy but reality TV (“Extreme Scientific Makeover!”). In the beginning, Daar and Singer stressed leanness. Grand challenges should aim at “one or preferably several significant health problems”—but that is less true now that there are bespoke challenges for infectious disease, non-infectious disease and mental health ((Moreover, the authors chose disease categories that are murky. Even cancers can be infectious (such as cervical cancer, caused by human papillomavirus) and nearly all mental illnesses are non-infectious.)). Could it be that the Grand Challenges project, having grown to 59 research priorities, has become so bloated that it is no longer useful in setting priorities?

Especially in their chapter on infectious diseases, Daar and Singer show themselves to be technophiles who dream of finding magic bullets against illness. But they are also impresarios, whose skillful convening and suave networking have propelled their stream of grand challenges into priorities for the scientific establishment. Theirs is an exercise of ambivalent value: beneficial when it lures new money into research on the neglected ailments of poor persons (as with Gates), but damaging when its vagaries destabilize judgement about which research is scientifically tractable and worthwhile. Great edifices need money to erect, it is true, but one cannot build on shifting sands either.

Anyway, finding magic bullets is neither a new nor original quest. The term was coined by the great biochemist Paul Ehrlich, a century ago (Zauberkugel, in German). Since then, magic bullets in the form of antibiotics, vaccines, insecticides and so forth have advanced human welfare very far—indeed, so far that the bewitched forget that bullets have their ballistic limits. Daar and Singer are immensely guilty of this, and while their paean to magic bulletism is at times moving, it is also dismally ideological and naive.

As a natural scientist (a biologist), I too am an ardent magic bulletist, but as a social scientist (a lawyer), I know that humanity’s foibles affect health too—and this latter truth Daar and Singer admit, but only as an afterthought to technology. Yet evidence shows the social fixes to ill health can, at times, be far more important than the technological ones.

Take measles: it was a great killer of children in Victorian England and Wales. One might think it was vanquished by the magic bullet of measles vaccine—but one would be pretty wrong. By the time measles vaccine debuted in the 1960s, fatalities had declined more than 90 percent due to improvements in British housing, hygiene and nutrition; the vaccine only mopped up. This is not to denigrate the vaccine, which is essential to interrupting measles transmission (proved when ignorant parents in Britain, and now Quebec, balked at vaccination: many children got sick; some died). But the history shows that magic bullets can be secondary to social fixes. When Daar, Singer and the Gates Foundation pinned almost half their original grand challenges on vaccinology, they were too ideological.

Worse, Daar and Singer give short shrift to social interventions, although ironically those lie at the heart of their own Grand Challenges in Chronic Non-Communicable Diseases. Consider obesity. The authors acknowledge it leads to diabetes, heart attacks, strokes and more, but write that poor countries are “in no position to handle diseases like these” because they lack technology. That is nonsense: obesity and its constellation of diseases stem largely from societal changes, and technology is as much a cause as it is a cure. The historical evidence is unarguable: in contrast with the preceding 10,000 years of civilization, today’s societies are the first in which poor citizens are fatter than rich citizens—because it is now cheaper to eat greasy, cloying, salty, processed obesogenic junk than healthy foods. This reversal came about as humanity acquired, not shed, industrial technology at an unprecedented pace, and that affects even emerging countries. Thus, however much the argument rubs against the libertarian grain, including my own, avoiding obesity inevitably requires that healthy calories again become more affordable and accessible than unhealthy calories—which amounts to a challenge to reform laws and culture for better health. Doing so has saved innumerable lives before, from filthy slaughterhouses, deadly tobacco, unsafe workplaces, snake-oil medicaments, urban slums and open sewage. Therefore in a section on legal matters such as patents and privacy regarding genomic advances, when Daar and Singer dismissively write, “after all, what did legal issues have to do with the billion people living on a dollar a day, people who lacked the most basic health care, clean water or even adequate food,” their disdain is, characteristically, shockingly ahistorical ((It is hard to understand why Daar and Singer express such antipathy. If asked whether patent laws affect the developing world’s access to technologies such as medicines, which is at the heart of their magic bullet quest, they probably would agree.)).  Just a couple of centuries ago nearly all of humanity suffered Hobbesian conditions scarcely better than “living on a dollar a day ((In 1800, life was nasty, brutish and short everywhere. Average life expectancy at birth maxed out at 40 years and wealth at $8 a day and was substantially less in most countries. That the world changed so much, so suddenly, is surely the greatest tale in human history.)).”It was reforms to society’s laws and culture, usually long before biomedical technology, that first elevated them.

Other development thinkers, from both the technological and social perspectives, have pondered these subjects more wisely. Amartya Sen, in Development as Freedom, practically equates social equity and justice with development. The magic bulletist in me thinks Sen might go a bit too far, but the masterpiece of the genre, Paul Collier’s The Bottom Billion: Why the Poorest Countries Are Failing and What Can Be Done About It, also argues that development is fundamentally a social contest, between truth-seeking agents of liberalism and corrupt agents of tyranny. Kate Pickett and Richard Williamson’s The Spirit Level: Why More Equal Societies Almost Always Do Better competently but dryly argues that purely social factors, such as status or inequality, affect a staggering array of health problems. On the other hand, Jared Diamond’s incomparable Guns, Germs and Steel: The Fates of Human Societies satisfyingly explains how technology has advanced or retarded human development.

The Grandest Challenge cannot compare with these books, but it does make some valid points. Later chapters correctly argue that multinational corporations can help solve development challenges, that it is devilishly hard to move promising inventions from cloistered laboratories to commercialization and to villages, and that Africa lacks the virtuous circle of research, venture capital and commercialization. Some of the authors’ notions are controversial, such as their argument that the health technologies Africa uses should be made locally in Africa for development’s sake (counterpoint: the United States, a highly developed country, imports 80 percent of the drugs it consumes). Other ideas of theirs are brave and wise, such as their warning that an ideological core of anti–globalization, anti–technology Luddites impedes research, development and access to technologies that could help the poor. Showing that not all non-governmental organizations or do-gooders are angels is surely an excellent contribution of this book.

Daar and Singer, to be sure, are well intentioned, even if their grand challenges are a lofty disappointment. No new magic bullets have emerged from the 14 original grand challenges, and zero lives have been saved. Unfortunately, rather than explain why the grand challenges have been fruitless in this most significant of ways, the authors declare that their “journey” has only ”deepened” the conviction with which they began. Their patron, Bill Gates, is considerably more thoughtful: “We were naive when we began,” laments Gates candidly. “I thought some [of the Grand Challenges] would be saving lives by now.” With major changes to his grant giving and a decision to double the money, Gates admits “it’ll be more like in 10 years from now.”

This great man has the humility to admit his naiveté, the suppleness to change and thus the ability to do better in the future. Is the same true of Daar and Singer? Possibly not, for after narrating some 200 pages in the first person, strikingly the authors never ask, Gates-like, if they made errors. And yet, it is undeniable that some introspection would be valuable for these commanders of Grand Challenges Canada—wielding Canadian taxpayers’ money, towering over the world’s poor, dispensing nostrums that can either save or squander lives—so as to improve and succeed.