Perspectives
Book Harnessing science for global health Global health is a rapidly growing academic subject in the USA and Europe. In Science and Innovation for Development, Gordon Conway and Jeff Waage mount a powerful case for the importance and value of investment in natural science research if we are to address formidable global health and development challenges this century. The book should be on the reading list of every global health course for its meticulous and much-needed detail on the science of the determinants of health: combating hunger through food and agricultural research, achieving environmental sustainability, encouraging innovation and translation of technology, and meeting the challenge of climate change. I read the book in Malawi, where our group collaborates with the Parent and Child Health Initiative of the University of Malawi, led by paediatrician Charles Mwansambo. Malawi is one of the poorest countries in the world. One of the most densely occupied countries in Africa, it depends on maize for subsistence and on tobacco as its principal export, with most households subsisting on 1 hectare farms or less. In 2005, soon after we started two randomised trials of community interventions to address maternal and infant mortality, Malawi teetered on the edge of famine. Hunger was the top concern of Malawians, crop yields were stagnant, and the lessons of the green revolution in south Asia hard to find. Conway and Waage’s book explains beautifully why technology used wisely can underpin the kind of transformation Malawi has made in just 5 years. For example, in 2002, the cost of a tonne of urea fertiliser was US$90 in Europe, $400 in coastal cities of East Africa, and a staggering $770 in landlocked Malawi. Maize yields were barely 1 tonne per hectare compared with 2·5 and 5 tonnes in south Asia and China, respectively. Irrigation was www.thelancet.com Vol 375 May 8, 2010
almost non-existent, and inputs to pest control and use of newer hybrid seeds limited. In 2005, the incoming President, Bingu Mutharika, developed a programme, heavily supported by the UK Department of International Development and other donors, to subsidise fertilisers and supply hybrid seeds. Treadle pumps were imported
“In Science and Innovation for Development, Gordon Conway and Jeff Waage mount a powerful case for the importance and value of investment in natural science research if we are to address formidable global health and development challenges this century.” to help farmers manage their own lowcost irrigation schemes. Results were immediate. Farmers supplied with the fertiliser and seeds could easily produce over 5 tonnes per hectare on their 1 hectare plots. The Malawi economy, after years of stagnation, became one of the fastest growing economies in Africa (9·7% in 2008), hunger and poverty levels declined, maize production exceeded national consumption, and the country began to export grain to countries like Kenya and Zimbabwe. It is difficult to know precisely how much this has affected the concurrent decline in child mortality rates, but we know that malnutrition underpins up to 60% of child deaths. There is emerging evidence that maternal mortality rates might also be falling. Of course there are still governance weaknesses with the purchase and distribution of coupons, treadle pumps, and fertiliser, and Malawi remains heavily donor dependent. But the message is clear: a scientific approach to agriculture, backed up by adequate finance and governance, can kick start a rapid green revolution in Africa.
But science and innovation for development face fearsome challenges in the coming decades. Grain production for consumption, livestock, and biofuels must increase dramatically to match demand. The green revolution has plateaued in India and other parts of Asia, and there are growing inequalities between the urban rich and the rural poor. India has come through the financial crisis better than many countries, but the effect of the worst monsoon for 30 years in 2009 is being felt in food price inflation of almost 20%. Globally, meat consumption will grow from 55 to 310 million tonnes per year over the next decade, with a concomitant increase in animal feed grain from 50 to about 640 million tonnes. Grain for biofuel increased four-fold over the past decade, and the amount of arable land worldwide divided by the total population has halved during the past 40 years, to 0·2 hectares per person. 1·2 billion people (20% of the world’s population) live in areas of water scarcity. Conway and Waage recognise that the causes of hunger vary from place to place, but they doubt whether social and economic policies alone can address food security. Amartya Sen’s analysis “Starvation is the characteristic of some people not having enough food to eat. It is not the characteristic of there not being enough food to eat” is a cry for justice, but Sen would also recognise the need for enabling technologies. Achieving environmental sustainability, understanding the science of climate change, and planning effective adaptation will be the most important political and economic issues of the next 50 years. The book’s sections on these crucial global health topics are comprehensive, up-to-date, and beautifully illustrated. There is a detailed analysis of climate tipping points, tropical convection, monsoons, tropical cyclones, and the El Niño–Southern
Science and Innovation for Development Gordon Conway, Jeff Waage. UK Collaborative on Development Sciences Publication, 2010. Pp 120. £20·00. ISBN: 978 1 84129 0829. See http://www.ukcds.org.uk/ publication-Science_and_ Innovation_for_ Development-172.html
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Oscillation. The science is explained clearly, but the doubts and uncertainties arising from limited data and uncertainties are underlined. Africa and Asia are expected to warm above the global average this century. Africa will be drier but there will probably be, as elsewhere, a general increase in the intensity of high-rainfall events. Africa’s climate is also a driver of global climatic changes, the dense cloud formations being a major heat source, and its rainfall correlated with Atlantic hurricane frequency. A recent Indian Government assessment of their own vulnerability to climate change concluded that “the quality of development would be the prime insurance…to deal with adverse impacts of climate change”. Poverty alleviation and equitable social and economic policies are the lynchpin to increase resilience, but science also plays its
part. In Bangladesh, early warning systems, management of mangrove forests, and strategically placed shelters have drastically reduced death rates during tropical cyclones. Managing water shortages in river basins through increasing supply and reducing demand is now a major development priority in China, the Middle East, and north Africa. Use of nanotechnology could reduce the cost of desalination by 75%, and a Canadian research team has discovered an energy-efficient way to make drinking water from sea water. Research into amelioration of coral bleaching and ocean acidification, forest management and expansion, preservation of biodiversity, epidemic prediction, and strengthening of public health systems remain major challenges for the next generation of scientists. And those scientists must come from the poor as well as the
rich world, because these are shared problems. There is a huge challenge for governments and funding agencies to train and empower scientists in all countries, to encourage innovation by bringing together scientists, entrepreneurs, and regulators, and to design and deliver research for impact on poverty and wellbeing. This book does not dismiss the importance of the social sciences and economics in tackling the problems of development, but Conway and Waage have reminded us of the power and optimism of science, and that the successes of the 20th century—penicillin, vaccines, oral rehydration solution, the green revolution—can and must be emulated for an environmentally sustainable and stable future.
Anthony Costello
[email protected]
In brief Book The story of smallpox
Angel of Death: The Story of Smallpox Gareth Williams. Palgrave, 2010. Pp 448. £18·99. ISBN 9-780-23027-471-6. The book is linked to a documentary Dr Jenner’s Miraculous Medicine broadcast on BBC Four on May 17, 2010.
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The first time I visited India, in early 1975, I had a routine smallpox vaccination. Later that year, after a massive vaccination campaign, India was finally declared free from smallpox, then Bangladesh. Only Africa was still reporting cases. In mid-1979, I was revaccinated, before my first visit to sub-Saharan Africa. At the end of 1979, the planet was declared free of smallpox by a group of international experts meeting in Geneva. On May 8, 1980, WHO ratified their declaration. My tatty vaccination certificate is now a historical document. On the 30th anniversary of WHO’s announcement, two centuries or so after Edward Jenner’s classic 1790s experiment with cowpox, Angel of Death recounts the fearsome history of smallpox—variola, from the Latin for pustule or pock, a term first used in AD 570 for a disease that surprisingly postdates the Bible and ancient
Rome. Gareth Williams, a professor of medicine at the University of Bristol in the UK, lives in a village associated with the Jenner family. In lively prose with unpatronising insight into past medical dilemmas, he dramatises the scourge and its treatment first by variolation (immunisation with live smallpox virus) then vaccination, but also shows how controversial smallpox vaccination was during the 19th century. In the UK, it was made compulsory by the 1840 Vaccination Act, “one of the most divisive and unpopular pieces of legislation in British history”. But eventually, after a 7-year Royal Commission, the act was repealed in 1909, for complex reasons, chief of them the claim that vaccination propagated other diseases. Jenner to some extent sabotaged his discovery by dogmatically insisting that vaccination gave protection for life and required no
revaccination. Despite indisputable contrary evidence, vaccinators stuck to the same line. As Williams makes clear, Jenner was “a conscientious doctor but an imperfect scientist”, who was slow and not thorough in his investigations—to the frustration of his mentor John Hunter. Nor can he fairly have the entire credit for vaccination, since others, notably Benjamin Jesty in 1774, had tried the same experiment with cowpox, though without publication. That said, Jenner was an unmercenary force for great good, who deserves his heroic status. “Yours is a comfortable reflection that mankind can never forget that you have lived”, the newly vaccinated President Thomas Jefferson told him in 1806. “Future nations will know by history only that smallpox has existed.”
Andrew Robinson
[email protected]
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