[By David Werner and David Sanders with Jason Weston, Steve Babb and Bill Rodriguez].
A Healthwrights Paperback, 1997, 207 pp., Health Wrights, 964 Hamilton Ave, Palo Alto, CA 94301, USA,
Hlth. Pol. and Planning, Vol.13, No.1,March 1998.
CLAUDIO SCHUFTAN
schuftan@gmail.com
Here is a new book whose time had come; a book that succeeds in painting the big picture of the health situation in the 1990s worldwide showing us how often the trees do not let us see the forest. The book is a true wake up call to new realities.
It is a book written in a direct language by a group of authors who are no newcomers to the scene. They set out to write a book for a wide readership of students, health workers, activists, primary health care (PHC) workers, health and development planners and policy makers and is based on their respective long experience in the field.
The book makes a passionate call for rectifying what the authors see terribly wrong with PHC in the mid-nineties. It calls for strengthening international solidarity, networking and coalition building among the like-minded progressive health practitioners who agree with the book’s arguments. In so doing, it energizes the reader; it makes one question what one is doing and leaves one little chance, but to take a stand. Each of its 21 chapters is full of data carefully woven into a lucid argument that is convincing and compelling from beginning to end. The book’s many examples give a human face to otherwise faceless social problems and abuses thus exposing them to the scrutiny of the reader.
In short, we are sternly warned of the current global regressive trend in the health status of the growing number of the poor and are alerted to the so many unfulfilled promises of PHC and the Child Survival Revolution. The failures and successes of the current health and nutrition system to protect the life and health of poor children are chronicled in a way that show how ‘magic bullet’ technologies ultimately have only brought about some survival, but not without asking the key question: ‘survival at what cost?’…
Ultimately, the futility of all safety net approaches used as damage control measures to resolve deep rooted health problems is masterfully brought to the fore.
The rise and fall of PHC with its (too) many stopgap measures lends itself for the authors to drive their main arguments. One of them criticizes the prioritization of product over process and is presented in the form of an in depth critique of oral rehydration therapy (ORT). It contrasts the use of oral rehydration solution packets with the use of home-based, food-based ORT. The book basically objects to the pharmaceuticalization of this simple solution, a typical example of how PHC has been brought into the flawed Western medical model where doctors still feel unmotivated to promote social change and self-reliance.
All this analysis leads the authors to advocate that what really ultimately determines the health status of poor people are wider social equity issues that can only be addressed by embracing the political dimensions of the problem. Solutions are not about health per-se, we are told, but about triggering organized popular demands for an overall fairer treatment in society. This is made clear through showing us examples of poor people’s empowering initiatives from different continents. But they also show us how these initiatives systematically run into obstacles created by the existing national and international power structures. The role of international pharmaceutical houses, the IMF and the World Bank are reviewed in this regard. The latter is seen as excessively intruding into Third World health care policy-making, leaving WHO a weak second. The Bank’s 1993 World Development Report on health gets special attention. The authors brand it ‘old wine in new bottles’, and a report about how to achieve a ‘healthier poverty’. The complex concept of disability-adjusted life years (DALYs) introduced in said report is heavily and fittingly criticized as well.
The global roles of WHO and UNICEF are also scrutinized in a special Appendix under the optic of whether they do contribute to a ‘real Health For All’. Both agencies are shown to indeed have addressed the real, basic causes of ill-health in the world, but also of implementing measures that ultimately avoid tackling them; they are further made accountable for the non-sustainability of the measures they promote. WHO and UNICEF are thus written off by the authors as potential decisive leaders in the struggle for (needed) social change.
The authors show anger at the mockery made of the empowering part of PHC having replaced it by a drive for what really is a disempowered compliance by people together with a high dose of blaming the victim. A whole rhetoric has risen to justify some of the vital sins being committed in the name of the Alma Ata Declaration, namely sins related to going from genuine popular participation to compliance, from social to technological interventions, from cooperative approaches to private enterprise, from process to product, from problem-posing learning to pre-charted training, from critical analysis to social marketing, from Health for All to raising survival rates, and ultimately from not shifting from a humanitarian to a political agenda.
Too many actors in PHC still poorly understand the web of underlying causes of human ills leading them to the ill-conceived solutions we keep seeing. (“Trying to combat malnutrition by simply combating infection, without confronting the underlying socioeconomic problems is like trying to cure diarrhea with Kaopectate”). The interventions introduced simply do not simultaneously emphasize actions to address the root causes. Inequity and poverty cannot just be accepted as inalterable facts.
The authors think the prevailing reductionistic attitude towards PHC represents a veritable betrayal of its liberating components -with the real transformative potential of Alma Ata remaining largely on the drawing board. Therefore, they posit, PHC has never really failed; it just has never been tried!
On the economic front, good evidence is given correlating persistent high child mortality rates primarily with income distribution disparities and this leads the authors to assert that the alleviation of poverty is actually a precondition to health improvements.
How the global situation of pauperization is ongoingly and progressively affecting access to health care in the United States makes for additional interesting reading.
Additionally, we are given an insight into how, even in China -where political commitment to equity appears to be slipping- it is questionable whether the health gains attained will now endure.
In closing, the authors re on key issues. They think the grim current situation threatens to reverse the hard won global progress made during the last 20 years. We are reminded that it is possible for health workers to function within an inequitable social order while still working to transform it. A call is, therefore, made for them to work towards minimizing the inequalities of the existing power structure since this will do more to reduce high infant mortality than all preventive measures put together: social and political commitment to equity is the key determinant of good health at low cost.
The challenge is not only to find and understand the root causes of the problem, but equally to find workable solutions. No road map is offered. But different attempts to find a way are shown in which the social mobilization component of PHC was somehow resurrected.
I could not agree more with the authors in that a need exists to launch a concerted global effort to consolidate popular movements that think globally and act locally. This by creating opportunities for popular pressure to demand the social transformations needed to counter the regressive social trends we are seeing.
At the heart of the conclusions of the book is a call for a Child Quality of Life Revolution in which children will not only survive, but will be healthy in the fullest sense of wellbeing.
Everybody has to take a stand, demanding action and accountability, we are told. We have to stop the ‘progressive’ rhetoric and get down to meaningful business. We cannot sidestep the political challenge posed by a more comprehensive approach to PHC and must move away from calls for narrow-focused ‘cost-effective’ interventions that do not challenge the status-quo.
All in all, this is a one-of-a-kind book that reminds us of the ground-breaking role “Food First” by Lappe and Collins played some twenty years ago.
It is not without flaws, though, and some readers will find some chapter conclusions occasionally being over-simplistic, sometimes using sweeping one-liners. Nevertheless, even people politically unsympathetic to the book’s political line will find it worth reading. Students will find endless inspiration. A good glossary is included and the book is pleasantly and fittingly illustrated. References and endnotes are generous and there is a recommended further reading list plus some addresses to join groups that are working along the lines advocated by the book.
Claudio Schuftan, MD.
Ho Chi Minh City, Vietnam
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