Global Health and Medical Technology: A Historical Examination

Medical Aid: Health as Foreign Policy

Two conferences, nearly 40 years apart, tackle the topic of foreign aid as a form of health-care, and how best to assist struggling or developing economies with their medical infrastructure. As a subsection of developmental aid at large, medical aid to developing nations was most common in the 1960s-1980s, before stagnating in the 2000s in lieu of financial aid. 1963’s Medical Aid for Developing Countries is far more descriptive than its later counterpart, mostly acting as a contemporary overview of medical aid rather than a critical analysis of its setbacks or potential improvements. Indeed, this makes sense, as the conference acknowledged a lack of debate due to general Anglo-American alignment on these issues - so was looking to materialise already existing views rather than laying the foundations of consensus. The opening statement recognises the breadth of the field, and opts to hone in on five key points, which are best categorised as either medical education, interventionist assistance or aid. This statement is given to indicate parameters: ‘To consider the policies and programs of medical aid to developing countries of Britain and the United States and the possibilities of greater co-ordination between them, and with those of other advanced countries.’ This includes training medical staff, research, and placements. It frames it within an ‘exchange of information’ paradigm, especially regarding technical assistance within the voluntary sector with the American foundation A.I.D.

The argument, common to the early 1960s, was in favour of a move away from small-scale, decentralised, and out-sourced aid from the charity sector and towards Government intervention that engages in strong communication with the host country, with a ‘teach how to fish’ mentality. Notably, state education was a key intersection, working with Universities meant Britain didn’t have to give up on UK doctors needed in the NHS, and graduated or junior doctors get an opportunity to work abroad where they are required. However, capacity was limited in both the UK and the US - although operating under very different funding structures, they both struggled to have participants spare. This short-term solution can be replaced with a long-term drive to train native doctors to a large capacity. This includes native students studying at neighbouring countries’ medical schools rather than the UK, if capacity is an issue. At this point in time, there were very few international students from developing countries studying medicine in the UK or US, especially as there was little international standardisation of degree recognition. Ultimately, the goal must be to build up the medical tertiary education sector in developing countries, by donating teachers and occasional graduate students to these nations. Anglo-American projects are particularly helpful for global health due to alignment on values and breadth of resources, with the African Research Foundation’s work in East Africa during a malaria outbreak in Tanzania cited.

Although the 1963 conference was admirable for an attempt to cast the net wide on medical issues, 2003’s Health as Foreign Policy acknowledges that a focused approach breeds more specific and practicable solution-making. These two conferences - both addressing foreign medical aid - were almost forty years apart, and both tackle health issues with an eye to their contemporary contexts. The 2003 conference was held in partnership with the Nuffield Foundation, and included more third-sector policy experts rather than government officials - who dominated in 1963. The aim, therefore, was to bring together a range of perspectives to examine ‘links between health issues and national foreign policy interest’ within an multilateralist framework. Unlike previously, the discussions delved more deeply into what ‘health’ was and how it impacted other aspects of life, such as sense of security and economic integration. Furthermore, it noticed the causal link between health and development in the long-term, rather than working back from development as a starting point. From an international perspective, major infectious diseases and animal variants (such as the foot and mouth epidemic of the previous decade) were more important in a modern, inter-connected, globalised world. Indeed, with a new integrated internationalism came a greater appreciation for intersections with other major issues, such as the economy, education, and the environment - citing inspiration from contemporary ecological preservation movements. Interestingly, despite looking at ‘foreign policy’ with a macroscopic lens, war was largely omitted from discussions of health, body, and foreign policy - perhaps due to its status as a hot-button topic in wake of the Iraq invasion.

A key administrative difference between these two conferences, which can be observed across the other sections which I shall examine, is a shift away from the nation-state as the arbiter of international policies and interventions. The Director, in 2003, observed the ‘heightened’ role of NGOs and multinational corporations (MNCs) in administering medical aid to developing countries, claiming they have ‘more credibility’ in the third-world than foreign powers. Given the high level of globalisation and commercialisation since the 1960s, with wider international connections and developments in communication technology, this shift is apt and understandable. As is the more frequent harnessing of technology - especially computing - as a key tool in tackling health inequality and education.

Infrastructure and Politics: A Comparative View

Funding structures and a ‘comparative’ view on medical infrastructure comprises much of Ditchley’s examinations of health-care. 1985’s Modern Medicine, at what price? was conducted in the midst of several major vaccine developments as well as the international HIV/AIDS crisis in the mid-1980s. Aptly, the conference aimed to look at ‘trends in modern medicine’ with a specific lens on ‘major infectious diseases’ - such as HIV - across countries of different stages of socio-economic development. This discussion took a more philosophical approach to medicine, considering ‘ignorance and poverty’ on equal standing as malnutrition and infectious disease, expressing concern for the disproportionate prevalence of ‘societal ills’ such as alcoholism, smoking, and substance abuse in developing nations, despite similar death rates to the first-world. Indeed, likely due to the inclusion of humanities academics in the guest list, topics of ‘quality of life’ and sociological perspectives were included in the discussions. In regards to wellbeing, the paternalistic conclusion that ‘developing countries may be able to learn from the experience of industrialised countries’ reflects the conference’s belief that the most important improvements in health have stemmed from advancements in public health and economic gains.  This highlights the importance that high politics and infrastructure building has in facilitating high quality, high-tech health-care.

The Shaping of Health-care Systems conferences in 1993 and 1994 differ from Ditchley’s normal pattern in a number of ways. It ran as a two-part pair in collaboration with the United Kingdom Health Education Authority and the University of Bath, attended by the sitting Secretary of State for Health Virginia Bottomley, with the aim of producing a book from discussion findings. A report was eventually published in 2009, entitled Six Countries, Six Reform Models: The Healthcare Reform Experience of Israel, The Netherlands, New Zealand, Singapore, Switzerland and Taiwan: Healthcare Reforms “Under the Radar Screen”. The book itself focuses more on systemic reforms of small- to medium- sized nations in the Asia-Pacific, with some examinations of the Middle East and Europe. For the conference itself, context massively impacted the topics under consideration, with significant reforms across developed nations, including the US, on expenditure and out-sourcing. Most notably, the then-recent collapse of the Soviet Union ushered the large-scale transformation of Eastern health-care systems - including rapid privatisation of research and development as well as outsourcing equipment manufacturing - leading to struggles with funding allocation. Ditchley’s discussions, especially the Director’s notes, implied that a ‘transference of ideas’ were necessary to strengthen the sector via centralised R&D privatisation, instilling neoliberal capitalism into Eastern Europe and Central Asia. Indeed, this debate was far more economic than social in nature, incorporating terminology such as ‘effectiveness’, ‘customer-acceptance’, ‘efficiency’, and ‘financial sustainability’, providing the conference with a more corporate overtone than the welfare and wellbeing oriented discussions of the mid-1980s.

2001’s Systems Design for a Quality Health-care: A Future Perspective shared many of these traits, run in collaborated with the RAND corporation. It advocates moving away from a ‘people’ focused approach and towards a structural analysis of health-care funding, prioritising efficacy and statistical results over qualitative data. The Health-care Funding conference later that year develops this view to orient towards technological funding, thinking more consistently about research and development and the need to align professional, financial, and other incentives operating within the medical system so as to maximise the drive for improvements in quality, as well as incorporating the emerging Information Technology field for more efficient administration. These changes in theme, although reflective of the Anglo-American consensus in the early 2000s, also reflects the attendees - a stark move away from public policy professionals and towards those in the private sector and corporate worlds, as well as technology experts.

Technological Development: Early and Modern Perspective

Focusing purely on technology and science within health-care is fairly new for Ditchley. 1995’s Advances in Genetic Science: Issues for Public Policy saw the first full-conference delve into biomedical science, introducing a somewhat more philosophical look. Discussions honed in on medicine from a ‘bodily’ or ‘human’ perspective, situated within a wider mammalian context, rather than a sociological ‘people’ project or form of political infrastructure. It took a more existential and microcosmic view that, ironically, was quite distinct from public policy. It asked who health-care was for, how it should be restricted, and how it differs from concerns in animal science. This integrated a more long-termist view into discussions, moving past former myopia, to speculate about future developments such as the then on-going human genome project. These speculations often tapped into wider societal fears around rapidly emerging technology, with the Director noting worries about eugenics with advanced pre-natal technology and the one-child policy in China. This more ‘high science’ schema was continued in 2000’s International Concerns about Biotechnology, involving a higher number of scientists and researchers rather than policy researchers or government-adjacent officials. The event was sponsored by the Royal Agricultural Society, which clearly swayed the decision to look at genetically modified organisms (GMOs) and human/animal genomics. This led the attendees to look closely at role of media as mediator between government, science, and the public - sensationalism, trivialisation, and inaccuracy led to widespread lack of education on biotechnology and genetic science. ‘Risk’ was perceived to be overexaggerated and selected, especially with concerns about xenotransplantation. Both these biotechnology conferences show the shift from ‘people’ to ‘human’ health, looking at the human body as a site of science and permanent improvement rather than holistic wellbeing. 

A return to ‘people’ was seen in 2004’s Biogenetics: The Impact and Advances on Politics and Society. Although, like the previous two conferences, you now see the human situated within a wider biome, the conclusion of the human genome project meant an end to speculation and a return to ethics and regulatory policy, albeit with a transhumanist tinge. A particularly philosophical quote - ‘biogenetics represented an alliance between science and a popular passion for the pursuit of perfectibility or self-mastery, in which nature’s errors could be corrected’ - encapsulates the optimism and enthusiasm surrounding the field, involving ideas with a futuristic undertone, which led to the Director noting more controversial disagreements in the proceedings than prior conferences. Notably, there was a feeling that developments were moving faster than debates and ethical considerations, for example, with reproductive cloning. This led to definitions being blurred, with a ‘back-to-basics’ approach to morality and regulation concluding that even vaccination could be ‘considered a form of enhancement’. However, this doesn’t mean the material impact was not considered. The issue of ‘freedom of information’ was key, especially an individual’s freedom - or lack thereof - to discover facts about their genetic and biological data, and whether this should be a right despite any ethical quandaries. For example, in France, the MMR injection was compulsory on grounds of public health protection while it was not possible to insist on a DNA test for an accused rapist. Legal issues in themselves were palpable, as the University of Wisconsin’s blanket patent on human embryonic stem cells had caused problems for the scientific research community who might not wish to face a legal challenge in developing specific aspects of the general technology. Ditchley discussions stood on the side of innovation, believing unnecessary regulation to quash intellectual curiosity and experimentalism in the biomedical field, and restrict the democratisation of interest.

2019’s Machine Learning and Genetic Engineering is the most recent conference to address medical technology, featuring solutions-oriented discussions, and considering genetic engineering in a world in which technology-based solutions are normalised and accepted. This includes in genetics, noting more ‘commercialisation’ - although not elaborated, this can assumed to be mainstream companies such as 23&Me offering genetic testing to paying consumers. It continues a transhumanist undertone claiming ‘the physical becomes digital’, and asking more metaphysical questions such as ‘what does it mean for the human body to flourish?’. The main change from 2004 is more opportunities than risks are perceived - although this may be due to the inclusion of several philosophers and business owners in the attendees. ‘Genetic expression’ can be part of one’s ‘identity’ - a term which appeared, I believe, for the first time here. This is clearly a response to socio-political contexts, as is the acknowledgment from Ditchley of Western privilege by noting minimal research into ‘southern hemisphere’ diseases, gene therapy pricing, and the impact of genetic alterations on stigma against disabled populations. This, although new in social perspectives, marks a return to more old-school Ditchley concerns about infrastructures and economic inequality, considering the lack of funding for genetic consellors (therefore a more apparent discussion of mental health for the first time) and how science works for populations in developing nations. In its conclusions, it both aptly analyses the contemporary and moves forward in its propositions. Globalisation of tech and health, the Director notes, means that geopolitical tension are a barrier to multilateral scientific developments, for example, secretism in Chinese and Russian data sets. We therefore need better maps of technology pathways - especially using computational models and visualisations, more realistic regulation, and focusing more strongly on the public’s priorities, which lie in everyday issues such as cancer treatment and prevention of chronic diseases.

Conclusion and Further Investigation

An interesting development could be to look at the changing role of mental health in Ditchley discussions. Psychological problems are mentioned throughout conferences I’ve examined, including 2001’s Systems Designs and 2009’s Machine Learning. Contrasting these modern perspectives - situated in a context of ‘normalised’ discussions surrounding mental health and its treatment - with earlier conferences such as 1971’s Psychiatry and the Law. Furthermore, a look at the more abstract category of the ‘body’ could be taken in two interesting directions; looking at the body in science within the technological developments section of this paper as well as wider scientific conferences across Ditchley, and the ‘body’ in the violence and negative health impact of war. In terms of going forward with discussions on health and medicine within Ditchley at large, I note that, historically, conferences have been at their strongest when focused on the ‘back-to-basics’ approach of direct public policy recommendations and working within existing frameworks. We live in a time of exponential technological developments, and it can often be tempting to question the ‘what ifs’ - and there is certainly a place for that within Ditchley discussions and beyond. However, focusing on the practicalities and actionable solutions has always been the strength of conferences at Ditchley. Third-sector sponsorships and attendance has tended to support this - with 2001’s Health as Foreign Policy and 2001’s Systems Design, both in partnership with the Nuffield Foundation, having a more solutions-based approach due to the inclusion of organisations that can action change. Going forward, collaborating with on-the-ground institutions can help with this transition - and I hope to see Ditchley discussions on medical health maintain their ability to emphasise the need for innovation whilst incorporating real-world impact into proceedings.

Conferences considered [1]:

1. Sept 1963: Medical aid for developing countries
2. Nov 1985: Modern medicine, at what price?
3. Oct 1993: The shaping of health-care systems 1 & May 1994: The shaping of health-care systems 2
4. April 1995: Advances in genetic science: issues for public policy
5. Oct 2000: The new Luddites? International and national concerns about biotechnology and its true worth
6. May 2001: Systems design for a quality healthcare: a future perspective
   Sept 2001: Healthcare funding
7. April 2002: Health as foreign policy
8. March 2004: Biogenetics: The Impact of Advances on Politics and Society