‘Up is the Curve: A Genealogy of Healthcare in the Developing World’, written by Dr Kiran Raj Pandey, is a compelling tale of the evolution of health systems and services in the developing world. This insightful book provides a clear understanding of the evolution of health services, shedding light on the underlying motives and interests driving this progress.

Ideal for healthcare workers, public health professionals and anyone curious about healthcare history, the book delves into a wide array of topics, seamlessly blending economics, history, politics, and healthcare. The motifs in the book transcend niches, and the author manages to artfully assimilate topics ranging from history to economics, politics, and, obviously, healthcare. It answers fundamental questions, such as the proliferation of private hospitals in developing countries—including Nepal—and the workings of global organisations like WHO and UNICEF.

The book’s central argument revolves around the fact that advancements in health and life expectancy in developing nations have occurred independently of income levels. The author presents this argument in the concluding chapter, where he talks about the Preston curve, originally proposed by Samuel H Preston in 1975, establishing a connection between per capita income and life expectancy. Notably, Preston’s research unveiled a remarkable discovery: the curve has had an upward shift throughout the 20th century. This implies that life expectancy has risen across multiple nations, irrespective of fluctuations in income levels. Preston attributed the advancements in health to factors such as education, technological advancements, widespread vaccinations, enhanced accessibility to public health services, oral rehydration therapy, and improved nutrition. Further, Preston accredited the developments in health technologies for 75 percent to 90 percent increase in life expectancy, with increases in income levels accounting for the rest.

The author suggests that the continuous progress in health technologies will continue to enhance life expectancies worldwide, causing the curve to rise consistently. Furthermore, the author argues that healthcare systems in developing nations are significantly influenced by scientific breakthroughs, politico-economic paradigms, and epidemiological realities.

During the 19th century, the introduction of Quinine by colonial powers brought about a substantial decline in Malaria-related deaths in Africa and India. This resulted in an overall increase in life expectancy, irrespective of changes in income levels, thereby supporting the author’s argument. Similarly, in the early 20th century, the discoveries of Salvarsan (a treatment for Syphilis) and Penicillin led to a significant rise in life expectancy, further emphasising the crucial role of technological advancements in health metrics.

Moreover, the eradication of Smallpox and the establishment of immunisation programs in the 20th century played a significant role in reducing mortality rates and improving life expectancy, serving as additional evidence for the impact of scientific breakthroughs on enhanced longevity.

The decline in Malaria mortality during the 19th century provided an opportunity for colonial powers to assert their dominance over poor tropical nations and resulted in the invasion of Western Medicine into the fabric of the developing world. This strengthens the author’s argument regarding the influence of politico-economic factors on the healthcare systems of developing countries.

The establishment of WHO in the aftermath of World War II and the resulting changes in health systems that ensued further affirms the role of political paradigms in the evolution of healthcare.

UNICEF’s Selective Public Health Care programme, which was born amidst the clash of Socialist and Capitalist ideologies during the Cold War, saved the lives of millions of children across the globe. This provides additional supporting evidence for the impact of politico-economic paradigms in shaping healthcare.

In the late 20th century, the Neoliberal policies championed by organisations such as the World Bank and the International Monetary Fund led to significant transformations in global healthcare. This period witnessed an increased privatisation and market-oriented turn of health systems in the developing world, further solidifying the influence of economic paradigms in the evolution of healthcare.

The HIV epidemic in the late 20th and early 21st century prompted the establishment of health policies rooted in advocacy and activism, marking the initiation of a global response against a common threat. In addition to HIV, numerous epidemics and pandemics throughout history, including Malaria, Cholera, and Syphilis, have compelled health systems to undergo positive transformations. A more recent illustration of this is the Covid-19 pandemic, which undeniably brought about significant changes in healthcare systems worldwide. All this evidence effectively supports the author’s argument regarding the influence of epidemiological realities on the development of health systems.

In recent times, considerable progress in vaccine technologies, extensive research on cancer treatments, and ongoing efforts to optimise medications and treatment procedures have resulted in notable improvements in global life expectancy. Considering the potential of emerging technologies like Artificial Intelligence, it is reasonable to anticipate that health systems will undergo rapid evolution in the future, leading to a continual upward shift in the Preston curve.

This book presents an optimistic perspective on the future of health systems and services. As human civilisation progresses, advancements in healthcare technology are inevitable, and they will undoubtedly contribute to increased life expectancy in both developed and developing regions. The author further asserts that the interplay of technological advancements, politico-economic circumstances, and epidemiological realities will continue to shape health systems in the coming years.

This book is entertaining and informative at the same time, which is an amazing feat given the density of information packed in it and the gravitas of the topic. It challenges, informs, and entertains readers while also asking us to critically examine the existing healthcare systems and the diverse seen and unseen forces that seek to bring about change.

While there are no glaring shortcomings in the book, a revision is already due as it was written before the pandemic. One cannot help but wonder about the impact of the Covid-19 pandemic and its aftermath on the evolution of healthcare. Similarly, in the book, the author points out the health system of Sri Lanka as an exemplary model. In recent years, however, Sri Lanka has plunged into its worst-ever economic crisis, which has indubitably impacted the healthcare of the island nation. All these questions, and more that will continue to arise, will hopefully be addressed in future editions.

Up is the Curve: A Genealogy of Healthcare in the Developing World

Author: Dr Kiran Raj Pandey

Year: 2020

Publisher: Adroit Publishers