In the 1960s, American aid and development agencies started talking about delivering ‘appropriate technology’ to what was then called the Third World: donating small-scale technologies fitting local needs – water pumps, grain mills, bamboo carts – or as a Haitian priest famously framed it, ‘shit for the poor’ (p. 2). Transferring technology appropriate to local rural economies, proponents argued, would enable self-sufficiency, social stability and happiness, whereas large-scale technological systems would import the ills of industrial life, such as urbanization and mass unemployment. Half a century later, in 2014, Bill Gates made headlines by downing a glass of water produced by the Omniprocessor, a high-tech plant for turning human waste into clean drinking water for use in low- and middle-income countries. Funded by the Bill and Melinda Gates Foundation, the so-called ‘Gates Poo Machine’ has been sold affordably to local entrepreneurs in Senegal, India and elsewhere. Although the humanitarian goal of health for all has remained constant, the technologies used – and their framing, packaging, transferral and reception – have changed in important ways.
Morefield offers the first scholarly account of how the appropriate-technology movement was adopted in international health discourse and transformed into the field of global health. The first two chapters provide an intellectual history of the idea of appropriate technology, recounting the well-known biography of the economist Ernst F. Schumacher, his intellectual circle and his most famous work – Small Is Beautiful: Economics as if People Mattered (1973). With a counterintuitive mix of Keynesian macroeconomics and small-town values, Schumacher argued for cultivating what he called ‘intermediate technology’ in developing countries – rather than transferring large-scale technology from highly industrialized countries, the focus should be on educating the predominantly rural population to help locals develop their own small-scale technological solutions.
In Chapter 3 the narrative expands horizontally to examine practical contemporaneous translations of Schumacher's ideas – within various countercultural environmentalist and feminist networks, with a particular focus on the importance of print media, catalogues and handbooks in spreading technology for social change. The following two chapters shift back to the world of politicians and bureaucrats and enter the historical focal point of the narrative: the UN Conference on Science and Technology for Development in Vienna in 1979. The Carter administration's adoption of ‘appropriate technology’ in 1977 was primarily an economic response to budget cuts to international aid and aligned with the UN's focus on low-cost primary health care interventions. But in Vienna, the US position diverged towards a more biomedical and industry-driven policy. Morefield carefully reconstructs the American debate to show how Congress deferred to industry, restricting aid to inexpensive low-tech tools and, crucially, excluding patented drugs. The next chapter follows various multilateral discussions taking place at the same time, at the 1974 Conference of Ministers of African States Responsible for the Application of Science and Technology to Development and the famous WHO Alma Ata Conference on Primary Health Care in 1978. At the former, while European policy makers extolled the value of education and simple tech, the leaders of postcolonial African states wanted high-tech modern solutions to level the playing field as quickly as possible. The 1979 Vienna Conference ends with the African delegates feeling betrayed by the US focus on cheap, universally applicable interventions.
By far the longest chapter, Chapter 6, is twice the size of most others. Here, the author draws on her interview material with members of the Program for Appropriate Technology in Health (PATH), which developed a new model of technological aid in the 1980s. This NGO and others, unlike Schumacher, were committed to making innovative tech affordable using global supply chains, such as their vaccine vial monitor (VVM), a heat-sensitive label which indicated whether the vial's contents had been degraded by heat exposure. As Morefield explains, these agencies’ success ultimately diluted the agenda-setting ability of state actors, resulting in the consolidation of global health investment under a few private mega-organizations. A fascinating Chapter 7 moves to the political adoption of appropriate technology in South Africa and Zimbabwe in the 1980s. Using (scarce) institutional archives and interviews with health care workers, Morefield follows the development of appropriate-technology health programs in newly independent Zimbabwe, before they were dropped in the 1990s for a focus on high-capital technology. The final chapter and epilogue focus on Gates's impact on global health and the COVID-19 vaccination effort and sees reasons for optimism in his admission that not only innovative biomedical tech but also health systems require investment.
The author adroitly brings the past to life with extensive archival material, interviews and her insider knowledge, telling a history up to the present. The granularity of the narrative is remarkable and the book is engagingly written throughout. The story is largely convincing. The critical perspective it develops focuses on the racialized and gendered social values embedded in Schumacher's appropriate-technology concept: small-scale technology meant more (typically unpaid) work for women of colour and hypostatized their role as village caregivers. Surprisingly, the story offers no substantive critical engagement with the various economic ideologies. Morefield argues that scholars tend to date the death of progressive debates around technology to the arrival of neoliberalism in the 1980s, but that key aspects of this ideology – privatization, quantification, cost-effectiveness – were already present in US aid policy in the 1950s, not as neoliberal ideology but as straightforward economic sense. It is right to complicate the simplistic periodization of neoliberalism, but there is a danger of overcorrection in assuming an impervious continuity in economic rationales (Berman, Thinking Like an Economist (2022)). Perhaps that is beyond the practical and present-day focus of this study, but the story it tells and the conclusions it draws – that health systems and infrastructure are as important as affordable biomedical technology – suggest that we desperately need critical alternatives to the likes of Gates and our present economic prophets. Finally, there is no list of abbreviations at the front of the book, no bibliography at the back and no images – all, presumably, due to economic reasons – which is a shame.
