PREFACE
This book emerged from a simple realization: Just because a good health
technology exists does not mean that it will be delivered, used, or achieve its
potential to bring good health, especially for poor people in poor countries. Over
the past several years, this realization has gained increasing acceptance around the
world. Acceptance has grown with many organizations in global health—including the Bill & Melinda Gates Foundation, which has invested huge sums of
money to support the development of new technologies for global health. In early
2005, the Gates Foundation was criticized in The Lancet for focusing too much
on technology development. The author alleged that the Foundation held to “a
narrowly conceived understanding of health as the product of technical interventions divorced from economic, social, and political contexts.”1 Ironically, at just
the same moment, the Foundation had asked us to help it address these precise
issues. What could the Foundation do to improve the chances that the over 50
products under development with Gates support would achieve their potential in
health improvement? They specifically asked us to explore the economic, social,
and political contexts in detailed case studies. This book is the result.
For some time, the Gates Foundation has been aware that developing technology alone is not sufficient to improve health conditions in poor countries. This
recognition is reflected in the sponsorship announcement on U.S. National Public Radio for programs supported by the Gates Foundation: “making sure life-saving advances in health reach those who need them most.” Bill Gates made a similar
point in his speech before the World Health Assembly on May 16, 2005, when he
said, “The world has to devote more thinking and funding to delivering interventions—not just discovering them.”2 And subsequently the Foundation reorganized itself into three divisions—discovery, development, and delivery—to
emphasize the critical importance of bringing technologies to the people who
need them.
We began this project in March 2005 with the goal of seeking to better understand and more effectively plan for success in the introduction of new technologies to help fight the diseases of the global poor. Throughout the project we have
interacted with the team inside the Gates Foundation assigned with this task. We
agreed to create a framework for thinking about the challenges of introducing
good health technologies in poor countries along with a series of case studies illustrating a range of different kinds of technologies. We intentionally avoided the
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approach of certain consulting companies that present their analysis and results in
a thick deck of fancy PowerPoint slides. The Gates Foundation asked us to develop
a series of narratives, rich in contextual and historical detail and based on solid
academic research, to convey the multiple complexities in creating access for
health technologies in poor countries. We were not looking for simple answers.
We sought out broad lessons that could help guide the foundation, its grantees,
and others around the world concerned with the gap in access. We called the cases
our “access stories,” from which would emerge cross-cutting themes and lessons.
The two senior members of the research team were Michael R. Reich at the
Harvard Center for Population and Development Studies, where he was serving as
director until July 2005, when he moved to the Instituto Nacional de Salud Pública
in Mexico for a year’s sabbatical, and Laura J. Frost at the Center for Health and
Wellbeing at Princeton University, where she was researching and teaching until
July 2006, when she moved to the Democratic Republic of Congo for two years. In
the first year of the project, the research team also included Ilavenil Ramiah, after
she completed her post-doctoral studies at Harvard and until she accepted a senior
post at UNAIDS in Geneva. Within the Gates Foundation, our main contact was
Dan Kress, along with Hannah Kettler; throughout the process they guided and
supported us with sound advice, constructive criticism, and warm humor. We also
appreciate the enthusiastic support we received from Tachi Yamada after he arrived
as the new president of global health at the Foundation in 2006.
We would like to thank the experts who reviewed the book and provided
detailed comments. The following people provided comments on individual chapters: Joseph Cook, Sybil Eng, Dirk Engels, Scott Gordon, Doug Holtzman, Dai
Hozumi, Karin Jacquin, Heidi Larson, Carla Lee, Kyle Peterson, Laura Reichenbach, Allan Schapira, Craig Shapiro, Veronika Wirtz, Katherine Wolf, and Patrick
Zuber. Several people reviewed and commented on the entire manuscript: Richard
Cash, Michael Goroff, Joel Lamstein, Adetokunbo Lucas, and George Zeidenstein.
We are especially grateful to the many people we interviewed about the cases for
generously giving us their time and sharing their stories. We also appreciate the gracious support we received during the review process and the decision to publish our
book, from Barry Bloom at the Harvard School of Public Health and Lisa Berkman
at the Harvard Center for Population and Development studies.
The book benefited from superb support we received from research assistants
and editors. Beth Anne Pratt, Jennifer Nanni, and Taeko Frost provided research
support for Laura on the case studies. James Hammersley contributed to an early
draft of chapter 3 on praziquantel. Sarah Madsen Hardy copyedited each chapter
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during the first half of 2007 and again in early 2008, and Jessica Perkins read and
commented on the full manuscript during the summer of 2007. Meghan Reidy
assisted in collecting the photographs and arranging for permissions. Sarah Coit
Timmins assisted us greatly with bibliographic research and formatting. Carol
Maglitta provided superb graphic design for the tables, figures, cover, and text of
the book, and guided us through the production process.
We wrote each chapter in a slightly different manner, while achieving a full
coauthorship of the entire volume by the end of the process. Laura took the lead
on drafting chapters 2 and 9, and Michael wrote the first draft for chapter 1.
Laura drafted chapters 4 through 7 (the cases on hepatitis B vaccine, malaria rapid
diagnostic tests, Norplant, and vaccine vial monitors), with Michael providing
comments and revisions. Michael drafted chapter 3 on praziquantel (with Alan
Fenwick and Howard Thompson at the Schistosomiasis Control Initiative), and
Laura provided comments and revisions. Laura drafted chapter 8 on the female
condom, with Beth Anne Pratt as coauthor, and Michael provided comments and
revisions. All chapters were drafted in 2006 and then went through multiple versions and seemingly endless discussion and alteration, as drafts bounced back and
forth between Michael and Laura, as we sought a common style of narrative and
a common framework of analysis. Our discussions about access continued as we
moved around the continents, crossing national boundaries, dragging drafts to
read, communicating by cell phones, land lines, skype, email, texts, and sometimes even face to face, working hard to produce the book’s final draft.
This book expresses our profound belief that access to good health technologies can be addressed and resolved for poor people in poor countries and can produce tangible benefits for them. The two of us have worked on access issues with
various public, private, and partnership organizations over the past two decades.
This book represents our collaborative effort to show how progress can be
achieved—and how to make it happen more rapidly than is now happening.
Finally, we wish to thank our families for supporting us throughout this project and for allowing this book to pervade our lives over the past several years.
Laura J. Frost
Kinshasa, DRC
Michael R. Reich
Brookline, Mass.
May 2008
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Endnotes
1
Anne-Emanuelle Birn, “Gates’s Grandest Challenge: Transcending Technology as Public
Health Ideology,” The Lancet 366 (2005): 514–519.
2
Bill Gates, “Remarks of Mr. Bill Gates, Co-founder of the Bill & Melinda Gates Foundation,
at the World Health Assembly,” Fifty-eighth World Health Assembly, Geneva, Switzerland,
16 May 2005, http://www.who.int/mediacentre/events/2005/wha58/gates/en/index.html
(retrieved January 2, 2008).