Developing to scale: Technology and the making of global health By HeidiMorefield, Chicago: University of Chicago Press. 2023. 232 pp.

Developing to Scale provides a rigorous and nuanced account of how particular technologies came to be (and still are) envisioned as central to global health, and to developmental aid more broadly. These so-called "appropriate technologies" have typically been imagined by US actors as simple, low tech, inexpensive, and small-scale solutions to disease and poverty in the Global South. And, for the most part, they have been deployed at the cost of supporting robust public healthcare systems. On some levels, this is a story that medical anthropologists—long critical of "magic bullet" approaches—know all too well (Yates-Doerr et al., 2023). But Heidi Morefield's meticulous research also challenges aspects of our well-trodden critiques: for instance, by deconstructing oversimplified, linear accounts of "neoliberalism" as the downfall of primary healthcare (7–8, 64, 75) and by taking seriously aspirations of postcolonial actors who saw technological access as a liberating force (22–24, 80–81, 115–16). This book is thus a vital reminder of how attention to detail matters, of the importance of telling minor stories, and of the imperative to go beyond easy heroes and villains (9). The tale of technology's rise to prominence in global health—beginning in the 1950's and 60's—dovetails with the end of modernization theories, the end of large-scale infrastructure projects like the building of power plants, dams, roads, and manufacturing facilities. As faith in that "trickle down" approach to development waned, policymakers latched onto smaller scale interventions that sought to work from the bottom up to improve life for the most impoverished. What became widely known as "appropriate technology" was first proposed by British economist Ernst Schumacher. Drawing on his experiences in Burma and India, and with appreciation for Hindu and Buddhist principles, he critiqued the West's materialistic desire for unrelenting growth which was not only destroying the environment but also impoverishing rural communities as migrants flocked to cities in search of industrial work only to end up unemployed. In his famed 1973 book Small Is Beautiful, Schumacher argued for a new form of development and even a new economics (17). This approach sought to support small, rural communities through the use of what he called "intermediate technology": not too modern nor too traditional, this was technology that would ultimately "fix people in subsistence agriculture" (142). Tellingly, Schumacher's ideas were thoroughly rejected by the Burmese government he was sent by the United Nations (UN) to advise. Burmese leaders wanted the benefits of modern industry and dismissed the notion that they were too poor, too traditional, or too Buddhist for it. After establishing this origin story, Developing to Scale goes on to trace the highly varied consequences of this "appropriate" technology idea and how it came to fundamentally shape the last half century of global health. Perhaps the most important intervention of this book lays in drawing attention to the questions: "who decided what an appropriate technology was? And for whom?" (56). In answering, Morefield presents an insightful explication of the world-making stakes of definitional power, of how battles over meaning have profound material consequences. Not surprisingly, the United States promoted paternalistic and self-interested notions of which technologies are best suited to help poor populations of color elsewhere. Such technology was defined as: simple—so as not to require specialized training; small scale—thus avoiding investments in public infrastructure; cheap—and hence affordable within limited aid budgets; and off patent—to placate private industry like big pharma. Actors from the Global South, meanwhile, have "rejected Western versions of appropriate technology that positioned them as poor, helpless, and bewildered by complex technology" (76). Through coalitions like the Non-Aligned Movement and the New International Economic Order (NIEO), leaders from Asia and Africa have fought for equitable access to high-tech, cutting-edge science in pursuit of liberation and self-sufficiency. US actors worked to stymy these efforts and have largely been successful in doing so. Morefield's close reading of this process reveals the bureaucratic banality of the neo/colonial world order and the ways in which seemingly technical definitions serve to uphold and replicate it. As a historian, Morefield's methods are primarily archival, supplemented with oral history interviews and media and policy analysis. Her book is based on an impressive range of archival sources, drawn from 16 collections across four countries, and spanning the 1950's through the COVID-19 pandemic. The specific actors Morefield follows are mostly US-based, including governmental organizations like the United States Agency for International Development, textual catalogs like The Whole Earth, and nongovernmental organizations like the Program for Appropriate Technology in Health and the Gates Foundation. In analyzing international forums held by the World Health Organization and the UN, Morefield makes a compelling case for the over-representation of US interests and approaches in these spaces. Nevertheless, given that this is an account of technology being developed "for" the Global South, I was hoping to learn more about the actors in those spaces as well. Morefield notes that she "attempted to interview the people who were the intended beneficiaries of these types of global health programs in South Africa and Zimbabwe, although this was a difficult undertaking and generated mixed results" (9). Perhaps because of that, the one chapter specifically on Africa (Chapter 7) gives much of the narrative space to elite, White actors like colonial medical doctors in Zimbabwe and consultants and anthropologists in South Africa. There is a need for more diverse accounts of health technologies in and from Africa (Mavhunga, 2017), an endeavor that may require different methodologies, including decolonial approaches to the archive (Moore, 2023). Future research could also consider the increasing prominence of the Chinese state in the development sector and how it envisions the role of technology in its global health diplomacy. Its US-centric focus notwithstanding, Developing to Scale is the definitive text on the history and impact of "appropriate technology" in global health and development, and anyone working in this area—within or beyond academia—should definitely consult this text. The book will be an invaluable resource for graduate students and scholars studying the history and politics of global health policy, institutions, and ideologies. Given the density of historical information, though, it may not be accessible for entry-level undergraduate students. That said, there are myriad examples which could be used in teaching to help illuminate abstract concepts like projectification, neocolonialism, and techno-optimism. And, for more advanced undergraduate courses on development, global health, science and technology studies, or neocolonialism, I would particularly recommend Chapter 5 on competing visions of appropriate technology as it clearly lays out the stakes of different definitions and how and why US hegemony won out. The Epilogue's look at the continued prominence of techno-solutionism through the COVID-19 pandemic (and the outsized influence of the Gate Foundation today) would likely also be eye-opening for undergraduate medical anthropology students. Developing to Scale gives us an inside look into how (US-based) global health works: how ideas spread, are taken up, debated, and transformed; who the key actors are and how they navigate competing economic and political priorities; and the ways in which social and historical context shapes the contours of the thinkable in developmental aid. Morefield argues, compellingly, that "appropriate technology has made global health as we know it today" (147–48) despite the clear evidence that disease-specific, vertical, technological solutions fail, time and again, when implemented without investment in primary healthcare. This book is for anyone who wants to understand why such an approach has remained dominant for the last half century in spite of its evident failures. It is essential reading for global health practitioners and scholars seeking a deeper understanding of US foreign aid and/or looking to design more effective and more equitable global health policies.