Peter Piot, the head of the world-renowned London School of Hygiene and Tropical Medicine (LSHTM) and former executive director of the Joint United Nations Programme on HIV and AIDS (UNAIDS), has written what is in many ways a fascinating but also a frustrating book. The fascinating parts are when he opens himself up to reflection and vulnerability, admitting uncertainty and even confessing transgressions, and moves away from the drudgery of describing one meeting after another with an extensive list of named characters big and small. Let’s get this out of the way: for much of the second half of the book, for which he has indeed prepared us in the first half, he leads us right into the minutiae of a great number of these meetings.

In doing so, Piot missed a great opportunity to show us a crucial lesson he would eventually learn: Disease control isn’t about health care or even health. It’s about money and politics. The sooner we understand this, the sooner we can get on with the “business” of fighting diseases, of understanding why Dengue fever, malaria, and other tropical diseases continue to plague the developing world.

To his credit, Piot fully disclosed his intentions in the fine print. His preface says as much:

His intended audience is the layperson, but undergraduates, graduate students, policy professionals, medical doctors, and academics will find at least some parts of the book useful for their work. Let me disclose that in the next paragraphs are some random but interesting tidbits worth sharing, at least in my view as someone who studies the political economy of diseases.

Piot can be disarmingly honest—and self-serving—when writing of isolating bacteria subtypes from people and animals in the lab where he first got started as a lowly research assistant, granted, one with a medical degree: “These weren’t worldclass discoveries, but they validated my feeling that I was where I needed to be—that I had that particular, slightly obsessional, very meticulous skill that microbiology requires, an approach that crucially involves not throwing away things that don’t fit into your preconceived scheme of ideas” (p. 11). His observations about the nature of medicine in the developing world are spot on and give his memoir particular credibility when he describes how, in the African context, “Anything you ingested $\dots$ was hopelessly weak. An injection was $\dots$ proper medicine—something strong and effective” (p. 49). This is true, too, in Cambodia, Indonesia, and even in Korean communities in America, where an IV drip is the next step up from an injection. ^{Reference Nir and Ham1}

He shows flashes of color when he describes mid-level United Nations Development Programme (UNDP) and United Nations Children’s Fund (UNICEF) staff whose “mediocrity was often matched by arrogance” (p. 215), and he is at his best when he quips, “I often fantasized about the following experiment: a team of junior African economists goes to London or Washington, and tells the government what they must do to reduce the public debt or to reform health care $\dots$ but isn’t that what happens every day in low-income countries?” (p. 338). And yet while he cultivates an image of himself as far as possible from Joseph Conrad’s Heart of Darkness, he can sometimes play on those very stereotypes:

When it comes to politics, he can sound naïve when, after much frustration, he admits, “So, that’s how it goes. Unless something is a political [emphasis original here and elsewhere] priority, figuring out how to save lives is not a big issue” (p. 16). Yes, politics matters in global health. It always has and, unfortunately, it always will. Moreover, when he writes that, “Scientific evidence without political will has little impact on people’s lives, and politics going against evidence can harm people” (p. 352), his statement reminds me very much of a favorite Winston Churchill quote—“Science on tap, but not on top”—by which Churchill meant that scientists are not politicians, they are not elected, and while they can advise, the ultimate decision must remain in the hands of the elected (politicians).

Thankfully, it’s not all bad government, as Piot observes later: “Whenever I heard people say we didn’t need government, I reminded them what it is to live and do business in a country without a functional government and without the rule of law” (p. 82). Along the way, he also discovers the power of money, that other bugaboo: “We wondered if people were hiding the disease so as to avoid the crippling economic effects of a quarantine” (p. 91). This might explain why political economy has become so fashionable these days. Ultimately, in the realm in which Piot operates, international politics really boils down to two things: economics and security (p. 248). That much is clear.

Throughout the book, I, as an international researcher, could not help but feel a kinship to various themes Piot returns to again and again: language, mixed methods (qualitative and quantitative research), and political economy. Language brings you into the family when at first you seem to be the alien other. Relaying his arrival at ground zero (a term he does not like, but uses) of Ebola, he writes: “Although she was speaking French, I could hear from her accent not only that she was Flemish, but also the region that she was from, near Antwerp $\dots$ There was a very emotional scene as the three nuns $\dots$ broke down” (p. 37).

In terms of mixed methods, Piot remarks:

Indeed, without qualitative research, thinking outside the box, letting people respond without confining them to a number or value, is impossible.

Finally, in terms of political economy, he shares gems like these:

Not speaking for himself, but putting on the hat of a competitor, he writes: “If I’m not running this project, it won’t happen” (p. 208). As the legendary Africanist David Leonard, who chaired my doctoral dissertation, long ago warned me: coordination is not truly in any agency’s incentive. Why should or would it coordinate? Indeed, as Piot notes, “Each agency needs to raise funds to survive, which creates competition among them and drives their often aggressive communication work $\dots$ careers depended on promoting your own organization, not on how well you contributed to an overall UN effort” (p. 340).

Add to this disincentive to coordinate the absence of those most affected and most concerned, whether one calls them beneficiary or recipient countries, development partners, or another politically correct term. Piot remarks parenthetically,

The idea that the countries most affected would not be consulted seems ludicrous, but this happens again and again

But what is the solution to what seems like an intractable problem? How is it possible to achieve change from outside when it’s the folks inside who ultimately must choose their own path? Piot has an answer, and one that I agree with wholeheartedly: “I didn’t want us to actually run programs on the ground, as I felt strongly that this should be done by local governments, NGOs, and businesses, rather than by expensive international civil servants who may actually undermine local capacity by doing work that locals could do” (p. 220). And, I would add should do.