Rising Life Expectancy: A Global History.

Rising Life Expectancy: A Global History. By James C. Riley (New York: Cambridge University Press, 2001. xii plus 243pp.).

This book assumes that all human kind "want to live a long life" and that "society benefits from the experience and wisdom of older people".[p. 220] Yet as Jonathan Swift pointed out some time ago (Gulliver's Travels: 1726), these assumptions are somewhat problematic. Also problematic is Riley's frequent use of the nineteenth century British imperialist term, "traditional" when refering to any and all curative practices--past and present--which are not approved by the present-day western medical establishment.

Yet Riley is quite correct in assuming that in the years since c. 1910, among the fifteen percent of the world's population who live in the West and are not members of marginalized social groupings, life expectancy has risen dramatically. In these privileged regions (North America, West Europe, Australia and Japan), by the end of the twentieth century the majority of women could expect to live into their mid-eighties and the majority of men into their late seventies. And in a few selected corners of the non-West such as Costa Rica, Cuba and Kerala State in India, the percentage of people over the age of sixty actually found in regional communities was beginning to resemble the situation found in the West.

Riley holds that those societies in which longevity has become the norm have passed through "the health transition". Yet he is well aware that health transitions are in fact multi-faceted. Techniques and mind-sets which led the way in one society at one particular period (for example, sanitary "science" in England after 1830 and the germ theory in the German lands after the mid 1860s) succeeded in cutting down mortality rates from certain infectious diseases: this improvement was reflected in official statistics.

Yet before life-expectancies at birth could break through the barriers which prevented them from going much beyond the age of 45 or 50 (where they were at around 1910), other technologies and mind-sets also had to be brought to bear. Many of these new techniques had wonderfully benign effects on new-born infants and young children, leading to massive reductions in infant mortality. With the dropping away of infant death rates from more than 100-200 per 1000 to 10-15 per 1000, life-expectation at birth (as statistical artifact) obviously shot forward. With this, the beneficiaries--the world's economically and politically dominant groupings--had indeed entered a new era, unprecedented in human history.

In dealing with these multi-faceted regional and super-regional health transitions, in six separate chapters Riley discusses the contributions of, and limitations of, public health authorities, medical authorites, economic development, house-hold management, diet, and education. Some of the information he provides us in these chapters is useful, relevant and even insightful.

But when looked at from the perspective of a social historian, and from the perspective of the non-West where 85% of the world's population live, Riley's "global perspective" can more acurately be described as a view of the world through rose-tinted glasses worn in the leafy suburbs of a quiet Midwestern university town. In this "global history" Riley shows precious little awareness of power relationships between dominant groupings in any society and the subjugated many. No one reading this book, for example, would fully realize that the health history of African Americans in general and their recent slave ancestors (12-15% of the total US population) was and is quite different from the health history of Euro-Americans.

Looking beyond the shores of North America, it is apparent that Riley has no awareness of the real meaning of imperial hegemony in times past. Dependent on smoothly written secondary sources, he boldly states, for instance, that new-style western medicine was rejected by the tradition-bound people of India in and after the mid-nineteenth century. [p.90] He is unaware that after mid-1868, the high command structure of western medicine in India strictly forbad its doctors to apply the insights being used with such good effect to control the spread of cholera to, and in, the Imperial homeland itself. Within India--on instructions sent out from London--doctors were ordered to put into practice the denial that cholera and smallpox were communicable diseases which could be controlled by the isolation of the sick (in special hospital wards) or through the quarantine of the crew and passengers of ships. This harsh denial (in India) of new medical orthodoxy (used in the homeland, with a slight change of phraseology) happened because dominant UK interest groups--shipping magnates, gentleman capitalists, MPs--did not want their profits from trade with India (central to the well-being of the British economy overall) to be cut into by the impositition of long delays in quarantine at Suez (the Suez Canal opened in 1869). Following the dictates of logic, going beyond their bans on full or modified quarantine, the imperial command structure held that medical doctors in India should not regard the cholera sick or their excreta as infective: in the single year 1900, cholera cut down more than 900,000 indigenous men, women and children. Little wonder that even the first stages of a health transition could not begin to appear in India as long as health policies were dictated by the imperial masters. On the eve of independence in 1947, life expectancy at birth stood at 26, about the same as when that suspect statistical construct was first calculated in 1891.

In our own day, when (contra Riley) longevity has yet to become the global norm, "health transitions" in most non-western countries have run up against the seemingly insurmountable barrier of Structural Adjustment Programs. Imposed on debt-ridden governments by the US-based World Bank and International Monetary Fund from the late 1980s on wards, SAPS policy insists that free universal preventive medicine administered through low-tech clinics to which every member of a national population has ready access should be phased out and replaced by cash-for-service facilities of the sort found in free-enterprise USA. None of this is mentioned by Riley even though it is central to any fair-minded assessment of "rising life expectancies" either as global reality or as mythic statistical construct created to calm the consciences of well-meaning people living in the West.

In a typical non-western country like Egypt, less than 5% of the population has actually reached the age of sixty. Given present trends in Egyptian health provisionment (much influenced by SAPS), it can be predicted that "wise older people" will long remain rareties. For a realistic assessment of the health situation of typical non-western countries--home of 85% of the world's population--one must turn not to Riley, but to a book published in the same year as the book under review: Paul Farmer, Infections and Inequalities: The Modern Plagues, University of California Press, 2001.

Sheldon Watts

American University of Cairo