In 1973, economist E. F. Schumacher published Small Is Beautiful, which introduced a mainstream audience to his theory of “appropriate technology”: the belief that international development projects in the Global South were most sustainable when they were small-scale, decentralized, and balanced between the traditional and the modern. The first critical book on “appropriate technology,” Developing to Scale shows how global health came to be understood as a problem to be solved with the right technical interventions. Read on for an interview with the author, Heidi Morefield, about her research.

What is “appropriate technology”? And how have various stakeholders interpreted this term?

Appropriate technology is the concept that there is a level of technology that was optimal for developing nations—not too traditional, but not too modern. It was a “Goldilocks” idea. The “just right” level of technology would give people something that was just a little bit better than what they had before, but not so good as to encourage them to leave their rural subsistence living and move to the city, as Schumacher thought mass urbanization led to the “immiseration of the poor.” His idea gained a lot of traction in international development circles, including at the World Health Organization (and United Nations more broadly), the World Bank, and USAID. In these fora, high income countries like the United States used the concept to argue that the modern technologies many low-income countries were lobbying for were inappropriate to local contexts, ultimately to save money on international development programs during the 1970s and ’80s and to protect their countries’ patent rights around “high-tech” technologies like pharmaceuticals.

Why is the distribution of small-scale technologies not sufficient to achieve global health?

Small-scale technologies can do a lot to address discrete issues within global health—hepatitis B test kits, vaccines, and oral rehydration salts are all great examples of easily mass distributed technologies that have had major success in saving lives. My concern is that global health is often reduced to just the distribution of small-scale technologies, and there isn’t sufficient infrastructure backing up their use. The distribution of individual doses and devices is far easier and less expensive than investment in communal infrastructure and its maintenance (well-resourced local health clinics, pipes and water treatment facilities to deliver clean water, sufficient power grids to support a temperature-controlled supply chain in rural areas). Such investments involve difficult questions around governance and long-term resourcing, however that infrastructure is needed in order to provide full-scale health services. The WHO defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Small-scale technologies can help to reduce the prevalence of certain diseases through short-term distribution campaigns, but they alone cannot maintain a person’s health throughout their life cycle.

What does the history of technology in global health tell us about the field? How does it shape global health practice today?

Looking at global health through the lens of the history of technology helps to reveal why a lot of global health campaigns have not been successful. For a long time, health technologies were developed in a lab somewhere in the Global North, with scientists and engineers making a lot of assumptions about how they would be used and by whom. Developed in a vacuum, there wasn’t much interaction with the users and their needs, so a lot of health technologies that eventually made their way to the developing world either broke, were not used, or were used in unintended ways (e.g., mosquito bed nets used to catch fish, rather than prevent malaria). My hope is that we can learn from the past and start to engage users much earlier in the design process for global health programs—perhaps the distribution of technologies is still required, but their buy-in and a true understanding of local needs would ensure that health technologies are used, maintained, and supported by relevant infrastructure in such a way that they are effective.

What experiences and research inspired this book?

I studied international development in undergrad at McGill University and was so enthralled that I went immediately into a master’s program in global health and public policy at the University of Edinburgh. There, I took a heavy load of courses in epidemiology, health systems, and health inequalities. Following that, I took a job as a project manager at a USAID contractor based in Washington, DC. In that role, I was primarily responsible for running a multimillion-dollar project in the Democratic Republic of the Congo. As I toured the local health clinics to assess needs and talk to the staff, it struck me that a lot of the aid they’d received were technologies that were distributed without any real thought as to how they would be used. One example that stands out in my memory is a clinic that had received a refrigerator so that they could keep vaccines cold, but there was no local power grid for them to plug into, and there were such widespread gas shortages in the region that they had not had the generator working in over a year. The fridge was brand new, but had never worked because they had no infrastructure to back it up. I eventually went back for my PhD in the history of medicine at Johns Hopkins University (and a postdoc at the Princeton University Global Health Program), thinking there must be a way we can learn lessons from our past to chart a better path for our future.

What is lost when nonprofits, governments, or philanthropists focus solely on health technology? And what kinds of questions should they ask instead?

A narrow focus on health technology neglects health systems and the social determinants of health. Oral rehydration salts without clean water to mix them into won’t do much good. People need access to comprehensive healthcare, which includes resilient local infrastructure so that, for example, the roads to the health clinic don’t wash out during the rainy season. Rather than starting from the perspective of eradication a single disease, like malaria, I wish global health investors would take a holistic and preventive view of health as the goal, empowering local health systems and governments with the resources needed to offer sustainable, low-cost access to care. Incidentally, robust health systems would make the world much better prepared for the next pandemic. However, it is in many ways thankless work—it requires extensive coordination with local and national governments, involves tricky questions around sovereignty, governance, maintenance, and responsibility, and doesn’t make for splashy, tech-driven headlines. It’s harder to measure impact, as you’re no longer simply counting doses delivered or units distributed. But, with proper scale, it would radically transform global health.

Heidi Morefield is a historian of medicine and global health. She currently works for a global consultancy.

Developing to Scale is available now from our website or your favorite bookseller.