The HIV pandemic: local and global implications

897Bulletin of the World Health Organization | November 2007, 85 (11) Globalization and health Editors: Ichiro Kawachi & Sarah Wamala Publisher: Oxford University Press, New York, 2006 ISBN: 9780195172997; hardcover; 360 pages; price US$ 59.95 Globalization has captured the imagi- nation of politicians and policy-makers alike, and has become the most widely used label to make sense of the profound economic, political and social changes taking place in today’s world. Publica- tion of this book is to be welcomed because it provides a very wide-ranging survey of many of the most important trends that impact on global health. The book consists of eighteen chapters written by internationally ac- knowledged specialists, and is divided into three parts. Part I, “The health consequences of globalization”, which comprises more than half of the book, maps out some of the key health chal- lenges involved. The authors of these chapters draw upon an impressive array of statistics, as well as the current literature, to develop authoritative but accessible accounts that will have wide appeal beyond public health specialists. Among the areas covered are surveys of long-standing health challenges such as smoking, the car culture and infectious diseases, as well as topical concerns such as climate change and obesity. The chapters in this part of the book are in- variably good at assessing patterns and trends, but are often more equivocal about attributing these developments to globalization. The slimmer Part II, “Monitoring the impact of globalization and health”, examines the tools used to assess the impact of globalization on health, including a somewhat provoca- tive critique of summary measures of population health. Finally, the six chapters of Part III, “The international response to globalization”, focus on the roles of the World Health Organization, the World Trade Organization (WTO) and the World Bank. The book notes that globalization produces winners and losers, with the Books & electronic media a Department of Management, King’s College London, Strand, London WC2R 2LS, England. Correspondence to Stephen Bach (e-mail: stephen.bach@kcl.ac.uk). increased inequalities within and be- tween countries creating major health challenges. It extensively documents the impact of globalization on women’s health, and some positive conse- quences are noted in terms of increased opportunities for migrant workers in conjunction with growing awareness of human rights that transcend national boundaries. The book also reflects some of the polarization surrounding the debate about globalization, with contrasting views presented about the degree to which the WTO has incorporated health as a key principle in its deliberations. In a similar vein, some of the contributors remain highly sceptical about the incorporation of poverty-reduction strategies into World Bank and International Monetary Fund thinking. To attempt to survey all the challenges to health that arise from glo- balization is an ambitious undertaking, and inevitably some themes receive less prominent coverage. Because of the considerable health challenges that confront sub-Saharan Africa, its burden of disease is discussed at some length in the book. In contrast, little attention is devoted to the role of the European Union and its increasing role in health affairs or to the challenges that confront eastern Europe. The book’s contents also reflect the fact that its contributors are chiefly interested in public health, and only a few broaden their perspective to encompass the role of health systems or engage with concerns about the global health worker crisis. Overall, this book provides a very useful synthesis of global health chal- lenges and demonstrates the promi- nence of globalization as it becomes an increasingly important framework of analysis for assessing health challenges. It signals that governments and the wider policy community have implicitly accepted that global health risks require global health responses. However, since the book reflects the current state of the debate, it fails to specify with any precision the relationship between glo- balization and health. Moving beyond a description of the associations between health and globalization to an analy- sis of underlying causes may remain elusive for some time to come. ■ Stephen Bach a The HIV pandemic: local and global implications Editors: Edward J Beck, Nicholas Mays, Alan W Whiteside & José M Zuniga Publisher: Oxford University Press, Oxford, 2006 ISBN: 978-0-19-852843-2; hardcover, 840 pages, £65.00 This is a comprehensive authoritative monograph, consisting of 50 chapters, 22 of which are thematic and 28 of which are case studies. It was written by total of 165 authors, many of whom are world-renowned experts, from 30 countries. The book, which focuses on the response to HIV by health systems, governments and donor agencies, is divided into five sections. Section 1 deals with the size of the pandemic and with its social and eco- nomic impacts. The four chapters in this section are concise and informative. Section 2 describes HIV preven- tion, treatment and care. Among the topics dealt with in its seven chapters are HIV prevention strategies, antiretroviral therapy in resource-poor settings, HIV vaccines and cost-effectiveness analysis. Group-based and community-level interventions are discussed, as are the implications of the pandemic for health systems. There are also chapters on legal and human rights implications and on ethics. This section, while informative, could also have examined the coverage of HIV prevention strategies, the bar- riers identified to increased uptake and the opportunities for integration of pre- vention with treatment. The section on antiretroviral therapy is largely clinical and does not discuss strategies for deliv- ery and support. Nor does it mention monitoring of patients in resource-poor 898 Bulletin of the World Health Organization | November 2007, 85 (11) Books & electronic media settings, especially rural areas, where health systems are particularly weak and travel to clinics is difficult. Section 3 is the largest and con- sists of descriptions of 28 countries’ re- sponses to the pandemic. It is not clear how the countries were chosen, but the selection represents a broad range of the developed and developing world. Most chapters were written jointly by HIV and health policy specialists, including at least one local author in each case. The topics covered include the epidemic’s evolution and impact in each country, the health system, the political response, and future challenges and priorities. These challenges and priorities are usually the opinions of the authors, based on their understanding of the local situation. This section of the book is detailed and will serve as a valuable resource for those studying the global effects of HIV and for individuals who are new to any of these countries, especially those working for international and donor agencies. It would have been more useful had there been a summary chapter that contrasted the differences in response between countries and the effects of this on the epidemic. For ex- ample, what may have worked in some settings and what has not? This analysis is essentially left for the reader to do. Section 4 deals with global and na- tional responses. Each of these chapters is interesting and informative, and top- ics include the responses of the UN and donor, lender and research agencies; financing of HIV control; fiscal and macroeconomic aspects; public-private partnerships; development of human resources; and contributions of civil society. Section 5 is on strengthening the response to the HIV pandemic. This is a short summary section on effective responses to the epidemic and on lessons learned. It covers a broad range of issues, including the roles of UNAIDS, other agencies and civil society; public-private partnerships; political commitment; decentralization; increasing capacity; and monitoring of programmes. There is also a short section on research, focused largely on data-collecting processes. Much of this material is the opinions of the authors rather than findings supported by evidence. The need for high-quality research to inform and prioritize the response to HIV, especially in resource-constrained settings, is not highlighted either here or elsewhere. Overall, this is an informative and interesting book, with the case studies from the different countries being par- ticularly interesting. It will serve as a valuable resource to individuals work- ing for international agencies, donors and researchers in providing important background information on the HIV pandemic. ■ Shabbar Jaffar a The bottom billion: Why are the poorest countries failing and what can be done about it Author: Paul Collier Publisher: Oxford University Press, Oxford, England; 2007 ISBN: 978-0-19-531145-7; 205 pages; £ 16. 99 (hardback) Disadvantaged populations, such as the poor, pose a complex set of challenges to the process of economic develop- ment. While a girl child born in Japan in 2005 is expected to live for 86 years, deliver her child in a medical institution under skilled supervision and receive appropriate attention during her old age, her contemporary born in Angola, Lesotho, Sierra Leone, Swaziland, Zambia or Zimbabwe is expected to live for about 40 years, deliver her child at home without any skilled supervision and struggle to receive adequate care during old age if she survives that long. The child cannot be faulted for this diverse prospect of length and quality of life: countries that are home to such disadvantaged population groups are in extreme poverty and express their helplessness to rescue such groups. When countries are poor and small, their economies or governments are not in a position to respond effectively to diseases that predominantly affect their poor citizens. This inability to deal adequately with complex situations further impedes such countries’ growth. As a result, many low-income countries, a Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England (e-mail: shabbar.jaffar@lshtm.ac.uk). where most of the world’s poor live, are drifting away, in developmental terms, from the rest of the world. On the other hand, the poor living in countries that are doing well economically face a different set of problems. Such people live alongside the rich and face similar market condi- tions due to increased globalization and monetization of economies. Possibilities to deal with the problems of poverty exist in better-off countries, but the poor often lack access to them. In such countries, the usefulness of economic growth lies in what it does to enhance people’s health and welfare. “Growth” has no meaning if millions of the poor lack access to basic amenities, such as health care. Whether developing or not, many low-income countries are caught in several traps which prevent them from prospering. To make things worse, the present global economy is unfavourable to the bottom billion people and the countries in which they live. Hence, it is much harder for disadvantaged coun- tries to break out of the traps in which they find themselves. In this book, Paul Collier discusses four such traps that have previously received little attention. Interestingly, what many people would consider to be a source of prosperity – natural resources – is seen as a trap by the author. The other traps he discusses are conflict, being landlocked and sur- rounded by bad neighbours, and bad governance. The author claims that low-income, slow economic growth and high depen- dence on primary commodity exports are the key determinants of civil war, which is likely to continue longer if a country’s income is low. Civil war also tends to reduce a country’s economic growth by about 2.3% per annum. He notes that 73% of people among the bottom billion have been affected by civil war recently, 29% live in countries where natural wealth dominates the economy, 30% live in countries that are landlocked and resource-scarce and have bad neighbours, and 76% have lived through a prolonged period of bad governance and poor economic policies. The future progress of the bottom billion people is crucial for health and health system development. These are 899Bulletin of the World Health Organization | November 2007, 85 (11) Books & electronic media the people caught in the poverty/ill- health trap. Inequities in access to health care suffered by this group further disadvantage it. Conflicts, bad governance and lack of development clearly have an effect on the national health systems of the worst-affected countries. Breaking out of the traps discussed in the book is important for future health system development, and understanding these and other barriers to development is the essential first step. The book is a welcome contribution to health development literature and makes excellent reading for those who are concerned about poverty and the poor, and for those who tend to think that economic growth is the sum total of human welfare. The book powerfully describes the increasing income divisions between sections of populations; the difficul- ties that development agencies face in placing materials and staff in areas with maximum needs; governments’ inabilities and failures to deal with the situation; and investment failures in poor settings. The book also serves as a timely reminder for carrying out suit- able policy and development responses. The author’s rich African experience is reflected in the valuable country exam- ples provided, while the narrative style makes the book read well. A deliberately pessimistic view of the future prospects of the bottom billion is presented, but the book does provide some sugges- tions that the affected countries and the Group of Eight (G8) countries could adopt to improve the status quo. The book would have benefited from use of an analytical framework to better depict the evidence presented. ■ Varatharajan Durairaj a a Health Financing and Policy, Health Systems Financing, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland. Correspondence to Varatharajan Durairaj (e-mail: durairajv@who.int).