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SECTION II

TOWARDS MORE APPROPRIATE PRIORITIES IN DEVELOPING WORLD PRIMARY HEALTH CARE

We should ascertain whether natural resistance to infections could be conferred on man by definite conditions of life. Injections of a specific vaccine or serum for each disease, repeated medical examinations of the whole population, construction of gigantic hospitals, are expensive and not very effective means of preventing diseases and of developing a nation's health.

Alexis Carrel in Man the Unknown, p.207

THE REAL DETERMINANTS OF HEALTH
Eclipsing the Spirit of Alma Ata
Emerging--A More Practicable Primary Health Care Model

THE REAL DETERMINANTS OF HEALTH

IN a recent article in the WHO publication World Health, Khan et. al suggest that normatively health services in the Developing World continue to be either substandard, inaccessible, unaffordable and under-utilized, or to "suffer from a combination of these factors." The authors go on to comment that while the governments of many nations "have spent millions on building physical infrastructures at district levels, the over-all health status, especially of the urban and rural poor remains deplorable."¹⁸¹

This and a number of like articles on Primary Health Care and UCI, suggest that the prime weaknesses now requiring rectification relate to inadequate local involvement in and the non-sustainability of medical services. Without any intent to lessen the critical importance of local participation and sustainability in development, I would put forward the view that each of the specific problems and weaknesses as identified, including the larger issue of overall ineffectiveness, stem from the very principles and nature of conventional selective medicine itself Primarily the medicine (both vaccines and drugs representing the arsenal of what is postulated as a "war on disease") and secondarily the established system whereby it is "delivered," is what is ineffective. In place of the popular drumbeating for local communities to further embrace and sustain this system, there are far more urgent and fundamental health priorities that must be addressed.

In a chapter on "Health and the Human Environment" found on the classic work Health, Food and Nutrition in Third World Development, M. Sharpston provides critical insights on how multiple social and environmental factors ultimately serve as the real determinants of survival, or alternatively death. In his words ". . . there is a limit to what conventional health services can achieve in an unchanged physical and social environment." He then refers to the experience of a medical school affiliated hospital in Cali, Columbia which had a special program for premature infants. During their period of critical care, survival rates remained comparable to those found in North American critical care settings, however within three months of being discharged, 70 percent of the infants had died. With reference to those regions within the Developing World where notable health improvements have occurred he suggests that:

The most likely factors leading to health improvements . . . are a rise in the levels of nutrition and the slow spread of modern ideas of personal hygiene. Across the Developing World, per capita incomes are rising, and transport systems are improving,, the result is more food, better quality food, fewer localized food shortages, and a more varied diet. In other words, the principal factor behind the improvement in health . . . in Developing countries is probably not any form of health measure, but economic development itself. . . . Mere exposure to a disease agent need not produce clinical disease and very frequently does not do so. Malnutrition is of such significance essentially because it hampers the body's resistance. Malnutrition acts "synergistically" with disease agents to increase the incidence of clinical disease and aggravate its severity."¹⁸²

In a very recent article focusing on the major influences on health in the Developing World, Thomas McKeown, past Chairman of the World Health Organization (WHO) Advisory Group on Research Strategy also articulates a view that clearly takes the issue of human health out delimiting bounds of selective medicine. His incisive conclusion follows:

. . . evidence is now available from a number of Third World countries that have advanced rapidly in health: China, Costa Rica, Cuba, India (Kerala State), Jamaica, Sri Lanka, Thailand, and a few others.. . . The improvement in health was almost entirely due to a reduction from infectious disease. To assess priorities in health policies in the Third World the chief requirement is therefore to come to a conclusion about the reasons for the decline of the infections.

. . . All the countries that advanced rapidly achieved a substantial improvement in nutrition, which led to increased resistance. Indeed in some countries this was the only important direct influence. It is perhaps surprising that immunization appears to have contributed relatively little to the advances . . . the reduction in mortality occurred during a period when vaccine coverage was still low.

To anyone who has traveled extensively in the rural areas of the Third World, the common causes of ill health may seem self-evident. Many children are visibly malnourished, sanitary conditions are primitive, drinking water is unclean, the food . . . is contaminated, and the number of people competing for the means of life is clearly excessive. Our conclusions concerning the determinants of health can be epitomized by the simple statement that people must have enough to eat and must not be poisoned.¹⁸³

In a World Health article highly germane to the "determinants" as raised by McKeown, Finland's H. Hellberg (a former Division Director at the WHO) postulates that the success of any genuine effort to alleviate disease in the Developing World must incorporate "intersectoral and multisectoral action." In his words "involvement of specialists other than the traditional healing professions; water, food, housing, sanitation and education are all important prerequisites for health. If they are neglected curative repair . . . may even be impossible."¹⁸⁴

To conclude these critical observations on Developing World health development priorities, it would prove instructive to consider the similar conclusions reached by K.L. Standard (Professor and Head of the Department of Social and Preventive Medicine, University of the West Indies).

. . . . mere survival is not enough. With no improvement in their standard of living and nutrition, they (children) frequently succumb to infection, with repeated relapses . . . . It will be extremely difficult to make further reductions in mortality rates in developing countries without significantly raising standards of living, including nutrition. Among the general measures of primary prevention that may be considered, an increase of food production is of paramount importance. Environmental sanitation deserves high priority, and health education of the public is a key activity at both national and community levels. . . . The final and permanent answer to the problem will rest in. social and economic development . . . taking into account the need for nutritional improvement of the present generation.

For obvious reasons, the highest priority must be given to preventive measures. If good nutritional status is maintained in the first years of life, successive attacks of most infectious diseases of moderate virulence will probably produce no more than mild effects.. . . Optimal maternal diet during pregnancy, prolonged breastfeeding, progressive weaning with appropriate foods, and education of mothers on infant-feeding practices are the basis of good nutritional status in children.¹⁸⁵

ECLIPSING THE SPIRIT OF ALMA ATA

It would be instructive at this point to go back to relatively recent history to see how this vitally sound and rational perspective was officially recognized at an international level, but then practically scuttled in favour of the annamentarium of Universal Childhood Immunization.

On the opening page of the recently completed Evaluation Assessment of the Canadian International Development Agency's (CIDA) Health Sector the observation is made that by the mid-seventies, "after more than 30 years of international health assistance, it had become apparent that curative strategies that directly addressed disease causing agents had failed . . . recipient countries . . . [in meeting] their long term health needs."¹⁸⁶ It was a recognition of this reality that presumably led Canada and other industrialized nations to the signing of the historic Alma Ata Declaration in 1978. The basic principles of Primary Health Care as embodied in this Declaration follow:

By 1980 CIDA published a public affairs statement on CIDA's Involvement in Health thereby reaffirming that in its support of Bilateral Primary Health Care initiatives in the Developing World, the Agency would place central priority on: the training of health auxiliaries; health and nutrition; essential education; adequate food production; potable water supply; family planning; and provision of simple equipment and supplies.¹⁸⁸

Despite the virtual eclipsing of these priorities by Canada's massively increased support for Universal Childhood Immunization in the late 80's and into the 90's, the Canadian Govemment's Official Development Assistance Policy as embodied in the 1987 policy document Sharing Our Future, actually emphasizes that a fundamental priority of CIDA "must be to supply all the basics of health" which is defined as "clean water, sanitation, (and) adequate nutrition." Furthermore there was to be a mobilization of the poor at the community level as "partners" in the design, implementation and evaluation of health activities.¹⁸⁹

Canada's aforenoted actions have not been singular, as it must be noted that virtually all of the industrialized nations had likewise overshadowed their earlier vision and commitment to ensuring fundamental health improvement measures by instead allocating a major portion of their "health" investments to mass artificial immunization and selective curative programs. In response to this major reversal, in November of 1985 alarmed community health specialists and practitioners from several developed and developing nations convened at Antwerp, and there articulated what is called The Antwerp Manifesto For Primary Health Care. Some key excerpts from the Manifesto follow:

. . . In spite of the lessons of history and of past experiences, major and international donor agencies are diverting scarce resources into a short term approach known as "selective primary health care. . . " This approach is in total contradiction with the fundamental principles underlying Primary Health Care. These principles are:

• The main roots of poor health lie in living conditions and the environment in general, and more specifically in poverty, (and) inequity . . . of resources in relation to needs
• Since health is . . . of people, it is self defeating not to consider them as partners who are able to play a great part in the protection and improvement of their own health
• Health services must provide . . . promotive and rehabilitative measures. This has to be done in a coordinated and integrated way which responds to the peoples needs.

This manifesto is issued because the proliferation of selective health intervention programmes undermines . . . Primary Health Care. It is issued also because these interventions purport to offer "quick solutions" and "instant success" for which they divert scarce resources from the solution of the real underlying and continuing problems, thus helping to maintain ill health. In addition, experience has taught us that selective interventions tend to become permanent even though they are presented as "interim" responses only. . . . And above all, the selective approach rules out the possibility of people's participation in decision making about their own health.¹⁹⁰

EMERGING--A MORE PRACTICABLE PRIMARY HEALTH CARE MODEL

Table E which follows on the next two pages, was developed with the appreciated assistance of medical sociologist L. Chetelat. It provides a clear picture of the paradigmatic contrasts existing between the selective war on disease model as exemplified in Westem selective medicine, and the emerging causal based approach to health sustenance and restoration.

The causal model is strongly predicated on the principle that man's relationship to the laws of nature (natural law) and life, must undergird any effective health maintenance and or restoration strategy. Such an approach is recommended as inherently more sensible, balanced, and cost effective for attaining and sustaining public health, whether among Developed or Developing World populations. The causal based model strongly emphasizes the importance of strengthening self-knowledge, self-responsibility, and self-care and thus far more closely corresponds to the challenge and direction mandated in the historic Alma Ata Declaration. It also affords genuine respect for the integral principles which undergird the practice of participatory development. As a final point its characteristic qualities of local accessibility, manageability, affordability, and effectiveness herald its great promise for humankind.

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