States of Disease: Political Environments and Human Health by Brian King (review)

That human health is the result of the political and environmental conditions that produce inequities in exposure to infectious diseases and the conditions that contribute to noninfectious diseases is the central hypothesis of this new, refreshing book by Brian King, a geographer at Pennsylvania State University who has spent a career working and living in Southern Africa. While King acknowledges that this argument is not novel, especially to those who study the social determinants of health, he argues nevertheless that the tendency in research and policy circles is to "minimize the role of sociopolitical factors. Rather, disease is often presented as a 'natural' event that occurs because of ecological conditions or individual decision making. This tendency is derived, in part, from the Western biomedical tradition, which presents disease as a result of exposure to microbes while presenting humans primarily in biological terms" (p. 14).

While these points are inarguably true, it is also fair to point out that many academics have moved beyond the biomedical model and now appreciate and study the complex social, geographical and political contexts that so critically shape human health. Nevertheless, King presents fresh new ways of thinking about the ways in which political and economic environments shape human health, and his in-depth examples, born from years in the field and a deep understanding of the local, social, and political environments he studies, sheds light on how these broad processes shape both health vulnerability as well as public health responses to these health threats.

Much of the book focuses on South Africa and on understanding the history of the HIV epidemic and South Africa's uneven response. South Africa of course is a natural choice, a ripe example of the ways in which political, economic, and geographical forces impact human health. By the early 1900s, the system of migrant labor was already deeply entrenched, with the aim of providing mines with cheap black labor that could be sent "home" once they became sick or old, absolving mining companies of the responsibility for the health and wellbeing of their workers. This externalizing of the true costs of production, along with the deepening entrenchment of migrant labor laws, created conditions ideal for the spread of infectious diseases, first through hotspots of transmission on the mines, and then to rural areas as a result of (return) migration of miners. These patterns played out in the early part of the 1900s with the spread of TB and in the early 2000s with the spread of HIV. Although the conditions for these two epidemics were put in place more than a century ago, their continued importance is well illustrated by King who details the impact of these political, geographic, and economic conditions on the early spread of HIV in southern Africa.

Another example draws from King's work in Botswana. Seeming to take a detour from the book's focus on HIV in South Africa, the Botswana chapter details the central role that changing ecology plays in shaping human health. Drawing on years of detailed study in the Boteti River region of northern Botswana, King shows how water, particularly climate-change induced drought, shapes both social structure and human health. A looming crisis awaits those seeking to improve the health of populations in sub-Saharan Africa: climate change. From more (and more severe) storms, increasing drought to warming temperatures that shift vector habitats and expose people to diseases they have never before experienced, our response to climate change and our efforts to mitigate it will be a major determinant of human health in the coming centuries. King's local study of how these global forces impact the local is complex and interesting: some individuals, whether financially or through better social networks, are better positioned to take advantage of these changes by increasing their wealth and status while others are destined to lose out. Who wins and who loses is a central focus of this...