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Nevin S. Scrimshaw
Foreword
I don't quite know how to convey the sense of privilege and pleasure that I experienced when I was invited to give the Ruth Hueneman lecture for 1987. There is no colleague for whom I and my anthropologist wife, who worked with Ruth in Guatemala, have greater respect, admiration, and affection. Our esteem is based on many years of personal association in a variety of activities in several countries. Ruth is an outstanding professional because of her knowledge, experience, judgement, and skill, combined with a conscientious capacity for hard work. She also has special attributes that are even rarer: kindness and generosity to both colleagues and students, and grace under pressure or adversity. She is always a lady. I know that this is an an old-fashioned word, but I cannot very well use the word "gentleman,,; the thrust of both words is the same - she is dignified, courteous, and kind - always.
This lecture focuses on the concept that improving the nutrition of populations is best approached as part of a more comprehensive health effort. This theme is closely related to Ruth Hueneman's lifelong professional interests. With the shift in WHO's approach to primary health care following the Alma Ata Conference in 1978, there was a change in which she participated in the orientation of the WHO nutrition unit. It is also noteworthy that some of the insights presented in this lecture come from research on the actual experiences of peasant women with the health care system in Guatemala, a study in which Ruth Hueneman participated .
Introduction
In most developing countries with high mortality among infants and young children, Western medicine does not reach the majority of the population, even in a grossly deficient manner. What care is available is too often provided by an auxiliary health worker with limited training, no medicines, and essentially no medical supervision or back-up. Such individuals can do very little to cope with the health problems of the population for which they are supposed to be responsible. Moreover, in developing countries with high morbidity and mortality, health centres, even when well staffed by physicians, usually do not have the activities required to prevent malnutrition and infection.
Attempts to lower high rates to morbidity and mortality by increasing the availability of curative medical services alone invariably fail. What is required is measures to prevent malnutrition, diarrhoea, and the common communicable diseases. Such efforts would have more than the benefit of preventing single diseases because of the synergistic interaction of malnutrition and infection and of one disease with another. Correction of malnutrition reduces morbidity and mortality from infections, and, conversely, infections are the major precipitating cause of frank nutritional disease. The primary health care approach recognizes these relationships and, as defined by WHO, places more emphasis on the prevention of disease and the promotion of health than on curative medical services. The child-survival strategy of UNICEF focuses on a set of primary health care activities for mothers and young children.
Unfortunately, like other health professionals, neither non-medical nor medical nutritionists have traditionally been trained in this concept. This lecture will try to explain, for those concerned with nutrition' the rationale behind the primary health care approach and what is required to implement it effectively. It will also analyse the place of specific child-survival strategies within the health care system. I will emphasize the need for the integration of nutrition activities into other aspects of health care, and for a change in the way most public health nutritionists are trained and accustomed to think of their responsibilities.
Limitations of curative medicine
I can say with the conviction of personal experience that curative medicine alone at the village level can do very little to lower high child mortality. I maintained weekly clinics in two Guatemalan highland villages for over a year, and the only lives I may have saved were those of two children whom I took to the regional hospital [1] .
INCAP then established a study in three other villages that compared programmes of medical care in one and supplementary feeding of preschool children in another, and left the third as a control. The treatment village, Santa Marķa Cauque, was staffed daily by a well-trained physician and public health nurse, who had virtually unlimited medicine available but provided no preventive services. Over a period of five years, there was no discernible effect on the high child-mortality in this village [2]. However, in the village of Magdelena Milpas Altas, with only the supplementary feeding of preschool children there was a significant drop in mortality, including that from infectious diseases, despite a lack of additional medical attention.
From these and other experiences I discovered for myself what is well known by health providers who have had such field responsibilities: the largest part of seeing patients involves general support, and very few persons need either highly trained specialists or secondary- and tertiary-care facilities. At all levels of the health care system, time spent on prevention can do far more to improve the health of populations than that spent on seeing patients, especially under the conditions prevailing in most primary care facilities. The most important of the preventive measures are those that directly or indirectly improve nutrition.
Some years ago I had an opportunity to observe a dramatic example of the potential significance of preventive compared with curative services. In 1967 a young public health physician, Warren Berggren, arrived at the Schweitzer Hospital in Deschapelles, Haiti, and found one large, desperately overcrowded ward for children with severe protein-calorie malnutrition and another similar one for neonatal tetanus, These disorders were the leading causes of the very high infant and preschool mortality rates in the region. Most infants admitted with tetanus died. Many of the severely malnourished died in the hospital, and others succumbed at home when they were discharged, only partially recovered, to make room for new admissions.
Dr. Berggren began his work in Haiti by using a jet injector in the neighbouring markets to administer tetanus toxoid in order to immunize all women of child-bearing age, and within a year the neonatal tetanus ward was emptied of patients from the district. He then attacked the more difficult problem of severe malnutrition in young children by establishing so-called Mothercraft Centres, an approach pioneered in Haiti by William Fougere and Kendall King [3]. These centres were similar to the contemporaneous "recuperation centres,, of Colombia and Guatemala [4] and to those subsequently established in the Philippines [5]. Young children in every village were weighed to find those so malnourished as to be at risk for marasmus or kwashiorkor, as judged by low weight for age. The mothers were then persuaded to bring the children identified in this manner to a special kind of daycare centre in which they received three good meals, and in which the mothers participated in rotation in the purchase, preparation, and serving of the food.
The children did improve; the mothers did learn; and there were few recurrences either in the children treated or in their siblings. The effect on the malnourished children was as startling as it had been for those with neonatal tetanus; soon no more cases of severe malnutrition were coming from the district. No investment in curative medicine could have produced such a reduction in mortality, to say nothing of the benefits to more normal growth and cognitive development. Preventing disease at any age makes a great deal more sense than allowing it to develop unnecessarily and then treating it. Moreover, prevention is far less costly than treatment.
The decline of mortality in industrialized countries
There is a long history of human experience demonstrating that most disease need not occur. In Europe there was a decline in mortality in the latter nineteenth and early twentieth centuries from infectious diseases such as gastroenteritis, measles, whooping cough, diphtheria, tuberculosis, puerperal sepsis, and pneumonia, long before the advent of any effective specific therapy [6] Figure 1 (see FIG. 1. Death rates of children under 15 from whooping cough in England and Wales (Source: ref. 7)) and figure 2 (seeFIG. 2. Death rates of children under 15 from measles in England and Wales (Source: ref. 7)) show the dramatic fall in mortality from whooping cough and measles in England and Wales from 1850 to 1960, despite the lack of any therapy for this disease until the recent development of vaccines [7]. In the 1960s before the use of a measles vaccine nearly every child in both industrialized and developing countries contracted measles; yet in the industrialized countries medical treatment was rarely required and measles was not a significant cause of death. In the developing countries, however, measles mortality rates were 100-400 times higher.
Figure 3 (see FIG. 3. Death rates from respiratory tuberculosis in England and Wales (Source: ref. 7)) shows the fall in tuberculosis in England and Wales before BCG or therapies such as isoniazid and streptomycin were available. Similar declines were observed for the other common infectious diseases. McKeown concludes that improvement in food supplies and nutrition is the only reasonable explanation for these declines in mortality. Similar trends are occurring in developing countries today in areas in which some nutritional improvement has occurred despite little or no access to medical services.
Fortunately, effective specific methods of prevention, particularly immunization, are now available against many of the more serious infectious diseases, and better nutrition and improved environmental sanitation and personal hygiene can reduce the occurrence of other diseases. Moreover, food enrichment or fortification can eliminate the specific nutritional diseases associated with deficiencies of iodine, vitamin A, and iron. The combination of controlling infection and improving nutrition has had dramatic effects in those developing countries that have applied it conscientiously. Examples are China, Chile, Costa Rica, Cuba, Vietnam, Singapore, Sri Lanka, and Taiwan.
Thus far, my remarks have focused on the integration of nutrition and other health measures in developing countries. I believe strongly, however, that preventive nutritional measures are important for minimizing morbidity and mortality in all countries. We are steadily learning more about the importance of diet in the prevention of mortality from the chronic diseases that are the leading causes of morbidity and mortality in industrialized countries. The nutritionist is at least as important as the cardiologist in the prevention of hypertension and ischaemic heart disease and has a role to play in the prevention of some forms of cancer. In short, improved nutrition has direct benefits, whether in developing or industrialized countries, on morbidity and mortality from a wide variety of acute and chronic diseases.
For this paper, however, I will continue to focus on the integration of nutrition and other health efforts in the developing countries, beginning with the WHO primary health care strategy. Because primary health care has become the major focus and basis for current global efforts to improve health in developing countries, it is essential to understand its origins and what it requires.
The Alma Ata primary health care approach
In the 1970s there was increasing awareness that in the developing countries, where three-quarters of the world's population live, hundreds of millions of people were suffering and dying from malnutrition and diseases that could be prevented. Even in the industrialized countries, many millions of people were not enjoying a level of health which the application of available knowledge could assure.
In September 1978, ministers of health or their representatives from 134 countries met in Alma Ata under the aegis of WHO to discuss the failure of health programmes to meet the needs of their populations. From this meeting emerged the goal of health for all by the year 2000. This would have been just another well-meaning pronouncement if it had not been linked to a new and comprehensive approach: expanded primary health care [8]. Primary health care represents the first level of contact of the community with the health care system. It is provided primarily by multipurpose community health workers who must receive training in health promotion and disease prevention as well as curative medicine. It is a strategy that makes the individual, the family, and the community the basis of the health care system.
TABLE 1. Elements of primary health care (WHO Alma Ata conference, 1978)
Health education
Proper food supply and nutrition
Safe water and basic sanitation
Maternal and child health care
Immunization
Prevention and control of locally endemic diseases
Appropriate treatment of common diseases
Promotion of mental health
Provision of essential drugs
Table 1 gives the elements appropriate for primary health care identified by the Alma Ata conference in the significant order in which they were listed [8]. First on the list is education concerning prevailing health problems and the methods of identifying, preventing, and controlling them. Second comes the promotion of a proper food supply and nutrition. Next is an adequate supply of safe water and basic sanitation, and then maternal and child care, including family planning, followed by immunization against the major infectious diseases, and the prevention and control of locally endemic disease. None of these is the curative medicine for which physicians are trained. The appropriate treatment of common diseases is listed seventh; the promotion of mental health is eighth; and the provision of essential drugs appears last.
As the Director-General of WHO, Halfdan Mahler has explained: "'Health for All, implies the removal of the obstacles to health - that is to say, the elimination of malnutrition, ignorance, contaminated drinking-water, and unhygienic housing - quite as much as it does the solution of purely medical problems,, [9]. It is on primary health care that all health programmes and the health infrastructure should be built, However, this approach entails a thorough reorientation of the existing health systems in most countries. Not surprisingly, this transformation has proved difficult and only a few countries have come close to achieving it.
Targeting mothers and children - the origin of GOBI
At a meeting at UNICEF headquarters in 1983, five years after the Alma Ata conference, individuals with extensive field experience with nutrition and public health programmes in many countries were brought together to discuss approaches to improving maternal and child health that were not sufficiently emphasized in most primary health care programmes. In this meeting, what is now know as the UNICEF-WHO child survival strategy was developed, and the mnemonic GOBI was devised. GOBI stands for growth monitoring, oral rehydration, breast-feeding, and immunization. The full significance of each term represented by the letters of the mnemonic needs to be understood by everyone responsible for its implementation .
Clearly, promotion of breast-feeding can do little for child morbidity in populations in which breast-feeding is universal. Under these circumstances, timely and appropriate complementary feeding of breast-fed infants must be promoted. Similarly, growth monitoring is a meaningless ritual unless the mother is enabled to understand the significance of growth trends as they influence the feeding of her child during the critical weaning period. It is essential that health personnel and mothers comprehend this and ensure that growth monitoring becomes a guide to appropriate remedial actions.
It must also be recognized that, even though it can save lives, oral rehydration does not prevent diarrhoeal disease. Moreover, it does little for the more frequent mild-to-moderate episodes that do not require oral rehydration for survival and that have the greatest cumulative adverse effect on nutritional status. Prevention of diarrhoea! disease requires environmental sanitation and personal hygiene, programme elements that are not captured by the mnemonic. To clarify matters further, the suffix FFF is sometimes added to GOBI to stand for feeding the preschool child, family planning, and female literacy, although these may or may not receive any emphasis, depending on local programmes [10]. Still missing from the GOBI mnemonic is a reminder that effective health education of the mother, the community, and health-care providers is as necessary as technology to success.
The GOBI approach, dramatized as a potential revolution in child health, has been enthusiastically adopted by a large number of countries on the basis of strong UNICEF and WHO support. It has been more successful in stimulating specific preventive measures than the general promotion of primary health care. The genius of this approach to primary health care for mothers and children is the appealing message that appropriate technology is now available to bring about a revolution in child mortality in developing countries. Its major weakness is that most of the measures proposed require genuine understanding and effective application by both mothers and peripheral health personnel. Unfortunately, there is no easy way of achieving this.
The genesis of RAP
In addition to the development of GOBI there was another important outcome of the 1983 meeting at UNICEF headquarters, in which both WHO and the United Nations University participated. This was approval of the UNU-UNICEF joint research programme to use anthropologists and sociologists for the evaluation of the impact of programmes of nutrition and primary health care. The first phase of this study examined the impact of government nutrition and health-care programmes on the knowledge. and, more importantly, on the health-related behaviour of family members. The methodology was an adaptation of classical anthropological techniques of participant observation, direct observation, and guided questioning, all designed for obtaining limited, specific information. "Focus groups" in which individuals meet to discuss a specific issue were also found useful. When these technologies are limited to nutrition and health-related issues, they permit more rapid appraisal of conditions than is possible with traditional surveys.
The guidelines themselves, which represent anthropological approaches to improving the effectiveness of programmes of nutrition and primary health care, have since been extended to the evaluation of the behaviour of health providers. Rapid assessment procedures, identified by the acronym RAP, have been developed for this project and have been published in English [11] and will appear also in Spanish and French. Not only should the information obtained from these investigations contribute to improving the effectiveness of primary health care and GOBI programmes, but the techniques themselves can be used for continuing programme evaluation.
Current problems with programmes of nutrition and primary health care
This multi-country RAP research has revealed a series of common problems that in most countries have prevented the primary health care programmes from achieving the effectiveness anticipated. They include the lack of proper training and motivation of health personnel, the lack of interest by recipients in preventive programmes, the failure of health care providers to consider the beliefs and attitudes of their patients, and the lack of understanding of the financial and time constraints of recipients.
Health personnel are not properly trained
With rare exceptions, physicians are generally trained and interested only in curative medicine. The result is that, when they are assigned to peripheral health services, they soon become immersed in curative tasks to the neglect of the Alma Ata concept of primary health care. Unfortunately, the rest of the health personnel follow their example. Although they are responsible for providing individuals and the community with the knowledge to make their own health decisions, this task is either totally neglected or done so badly as to be useless.
Thus, not only the physicians but also the nurses and auxiliary nurses in the public health systems of most developing countries spend most of their time and effort dealing superficially and generally ineffectually with complaints of illness. The second problem can only be fully appreciated from actual field experience with the promotion of preventive medicine at the primary level. This is the fact that individuals, unless well-informed, come to the health worker only when they are sick and want to be cured. They are not at all interested in the kind of preventive measures called for in the Alma Ada declaration.
I have been in country after country in which there are antenatal clinics to which mothers do not come, well-baby clinics to which babies are not brought, and immunizations that are offered and not accepted. In order to implement the nutrition and preventive medicine components of primary health care, the resistance of both providers and recipients must be overcome .
The first step in applying the principles of Alma Ada is a reorientation of the training of health workers toward preventive roles that include communication of health promotion concepts to people and gaining the confidence of communities. The public health nutritionist must provide the appropriate training and supervision for the nutrition component of this task.
In Guatemala an ambitious system of rural health posts staffed by doctors has proved too costly to maintain when health expenditures were cut 60% in the past decade as the result of economic adjustment policies. As I observed the functioning of the system, however, this will make less difference than conventionally assumed, The doctors manning these posts were mainly recent medical graduates forced into a period of rural service without adequate training or logistic support. Most were interested in obtaining money from private practice on the side and returning to a major city as soon as permitted. They were frequently absent from their posts and rarely did more than respond superficially to patient complaints. No time was devoted to preventing disease. As inadequate as their behaviour may have been, they were only reflecting their training and the priorities inherent in the system. Moreover, the demand from individuals and the community was for medical treatment, with no felt need for preventive health measures.
Twenty-five years ago an American physician, Dr. Caroll Behrhorst, came to Guatemala to open a clinic in the highland area of Chimaltenango [12]. It soon became apparent to him that the sophisticated training and skill of a physician are neither affordable nor essential for primary health care. (In fact, from my own experience, they are virtually useless [1].) He began recruiting and training assistants from local communities and gradually incorporated preventive services, including the encouragement of breastfeeding and proper supplementary feeding, family planning, tuberculosis control, and sanitation. The one or two physicians assisting him were used as organizers and teachers, not as primary health care providers.
Because of its assistance to the indigenous population, the programme has encountered suspicion and hostility from recent governments in Guatemala, and one of its physicians and several of its village workers have been killed or disappeared. Nevertheless, more than 100 village workers have been trained, and most are still working successfully in the area. The village programme is self-sustaining. It covers only a small proportion of the Mayan Indian population, but it does demonstrate what is possible.
A somewhat similar programme with minute monthly payments by villagers was established in Solo, and later in other areas of Indonesia by a dedicated physician, Gunawan Nugroho, after participating in the INCAP summer field course in clinical and public-health nutrition and observing the Behrhorst programme. The current highly acclaimed national nutrition and primary health care programme in Indonesia benefited from this demonstration.
The Indonesia programme is also similar in principle to the outstanding national primary health care programme in Thailand initiated by Amorn Nondasuta as Director of Public Health, which is serving as a model for other developing countries. The original "barefoot doctor,, programme of mainland China was established on similar principles and dramatically improved China's health statistics.
Constraints and beliefs of the recipients are ignored
Health workers cannot hope to influence health practices without understanding both the constraints on their clients and their beliefs [13]. Social scientists observing them are often shocked by the extent to which the economic and time constraints of the people are not understood or are ignored. All too often, health personnel assume that the greater their need, the more time poor people will have available to wait in clinics, bring children to health centres, make repeated visits, or attend lectures and demonstrations.
Health programmes are often ineffective because the populations they are supposed to serve cannot afford the economic losses and additional cost of using them or feel unable to neglect other crushing family responsibilities to seek the services, For example, a woman on a Guatemalan coastal plantation begins her day at five o'clock in the morning by taking lime soaked corn to the village mill to be ground and bringing it back home to prepare tortillas for breakfast and lunch. She must then get the children off to school, wash clothes and diapers in a nearby stream and leave them to dry, and then go to the field to pick coffee, taking her preschool children with her.
After carrying her heavy sack of coffee to be weighed, she may return to feed the children, chickens, and a pig; clean the house and wash dishes; take corn to be ground for supper; boil the next day's supply in lime-water; and make several trips for water carrying a heavy jar on her head. She has also been breast-feeding her infant on demand and changing innumerable diapers (especially when the child has diarrhoea), and doing other necessary chores, possibly including some work in her home garden.
If she breaks this unending routine to go to the health centre an hour away by bus, she will not only lose a day's wages but spend an equal amount on bus fare. At the clinic she may have to wait for hours or may not be seen at all. Even if she is seen at the clinic, it is likely that they will be out of medicine and will give her a prescription which she has no money to fill. Moreover, the hasty diagnosis and treatment she receives may be of little value. She may take a desperately sick child to the clinic, but she is not likely to go back for purely preventive services on still another day.
Lack of knowledge and consideration of the beliefs and constraints of health-care recipients engenders much misunderstanding and distrust. All populations have their own system of indigenous beliefs and practices pertaining to illness, and most make use of a variety of indigenous practitioners, often using the government health system as only one resort. Cosminsky and Scrimshaw [14] have described the way in which a mother with a sick child on a Guatemalan coastal plantation may try a local healer (curandero), or a spiritualist, or an injectionist, or ask for medicine at the pharmacy and usually will take the child to the government clinic only if the child fails to improve.
Such medical pluralism has also been described by anthropologists Pamela Hunte and Farhat Sultana for Baluchistan, Pakistan [15], and David Nyamwaya for northern Kenya [16], to mention only two more examples. In fact, medical pluralism is characteristic of developing-country populations, who often go back and forth between traditional and Western medical practitioners. Primary health care personnel must understand this behaviour and compete by showing the same concern for the feelings of their clients as the successful traditional practitioners. Health workers also need to understand and to respect folk medical beliefs and treatments and to recognize the gap between Western and folk medicine that primary health care must bridge. This obligation should be included at appropriate levels in the training of all health workers [17, 18, 19].
Evaluation as a guide to programme improvement
One of the most important ways of judging the effectiveness of programmes and improving them is formal evaluation. However, conventional nutrition and health surveys are expensive and time-consuming and collect large amounts of data requiring lengthy analysis. Furthermore, they are often not acceptable to the responsible health authorities or to the population to be studied because their scope and invasiveness are so threatening. The RAP methodology is, in contrast, able to provide information in a few weeks for a few thousand dollars without necessarily involving the health authorities at all.
Conventional nutrition surveys may reveal dietary habits and nutrition and health status, but they usually do not indicate whether or not a programme is having any significant effect, unless there have been good baseline studies or an appropriate control population. The RAP approach does not attempt to determine nutrition or health status. However, at a comparatively low cost and in a short period of time, it can provide information on the influence a programme is having, if any, on the knowledge and behaviour of the intended beneficiaries. Even more important, it can tell a great deal about why a programme is succeeding or failing. This information can serve as an immediate guide to programme improvement. Moreover, the RAP approach can be conducted at the local level without elaborate top-down planning.
In the UNU/UNICEF-sponsored RAP evaluations of primary health care in sixteen developing countries, it was apparent that the factors that made for relative success or failure were remarkably similar in all these different countries and cultures. Among the major problems most often identified by health-care recipients as reasons for not going to the health centre were the lack of adequate supplies and medicine, inconvenient scheduling of services, and abusive, rude, arrogant, or inconsiderate treatment by health providers. It was apparent that routines were most often established for the benefit of the physician and health personnel. The patients were expected to be able to leave their daily responsibilities at the convenience of the health centre, and no effort was made to schedule different services in the same visit.
Mothers often were asked to come on different days for the well-baby clinic and for immunizations, with long waits each time. Separate days for sick children and well children may prevent the mother with more than one preschool child from bringing them both on the same day. Some patients felt that no one listened adequately to their complaints or examined them properly. A review by Messer cites numerous additional examples [20]. Such flawed health services, with few or no preventive services, are a poor use of a nation's health resources. The RAP methodology offers a practical and affordable means of determining the effectiveness of existing primary health care programmes and how they can be improved.
It had been assumed that the RAP methodology required social scientists with training and experience in anthropological methodology, but it turns out that this is not necessarily the case. Peripheral health workers in Panama acquired a new sense of understanding and control of programme effectiveness when they used the RAP methodology, and it is already being utilized for the evaluation of specific health activities, such as those for the control of epilepsy. It is now clear that nutritionists who are already experienced in field work can take advantage of the RAP methodology for the qualitative evaluation of nutrition intervention programmes.
There will always be a need for nutrition surveys to determine nutritional status, dietary habits, and nutrient intakes and to measure directly the biological impact of nutrition programmes, but nutritionists will benefit from adding the RAP methodology to their skills.
The role of nutrition in primary health care
Finally, it should be mentioned again that there is no single element of primary health care that is as important as nutrition, because it is such a critical factor in the high morbidity and mortality of the underprivileged of developing countries. In their studies of the causes of child mortality in Latin America, Puffer and Serrano found that nutrition was responsible for 57% of all deaths of children under five years of age as either a primary or underlying cause [21].
The health of an infant depends to a great extent on the adequacy of the mother's nutrition during pregnancy, on the initial breast-feeding of the infant, and on timely and appropriate complementary feeding. The burden of diarrhoea! and respiratory diseases will be lessened if good nutrition is maintained. Although it will not prevent the common communicable diseases of childhood, good nutrition will practically eliminate mortality from them.
The most effective way of determining the adequacy of a child's nutrition is to monitor growth. However, as already emphasized, growth monitoring is useful only if it enables the mother to know when her child is failing to gain weight and what is the proper action to take. She must then be motivated to improve the child's food intake and, if the trend is not reversed, to bring the child to the health centre. The rapport necessary to communicate this information and to motivate the mother is also important for the promotion of family planning and prenatal care.
It is highly appropriate for this lecture to be given before the Society for Nutrition Education, because nutrition education of the community, particularly the mother, is essential to the success of the nutrition and primary health care strategy. The Alma Ata conference considered community and individual involvement to be fundamental to programmes of nutrition and primary health care. For people to be effectively engaged in caring for their own nutritional and health status, they must have the opportunity to understand what leads to health and what endangers it.
While this understanding requires education, conventional nutrition and health education in health programmes has generally been a failure. Lecturing at people without interacting with them or understanding their doubts and the problems of implementation does not work. The same is true of educational materials that fail to take into account beliefs and constraints. Health educators need to use the findings of medical and nutritional anthropologists. They also need to adopt some of the methods of anthropology in order better to interact with individual households.
It is not fair to blame the lack of appreciation of the importance of preventing disease on the victims. Preventive measures introduced by sympathetic and well-oriented health personnel who have the patience and motivation to explain and promote them are generally accepted. The problem, therefore, lies not so much with the lack of formal education and the perversity of the underprivileged, but with failures of current nutrition- and health-education practices. This is the challenge.
Prospects for the future
I would like to end on an encouraging note, because real progress is being made. Most countries in the world have signed the WHO resolution on "Health for all by the year 2000,,, although not many have yet demonstrated the political will to provide the necessary and appropriate health services. However, some elements of the UNICEF/WHO child-survival strategy, particularly immunization and oral rehydration, are being widely adopted. Seventy-seven developing countries have declared their intention to immunize the majority of their children UNICEF estimates that one million children's lives are being saved annually by immunization alone and that, without the introduction of oral rehydration in 1984 [22], three million more children would have died. Growth monitoring is more difficult to introduce effectively, but here too, good progress is being made in an increasing number of countries.
The rapid improvement in nutrition and health achieved by two small Latin American countries with very different political systems but a common decision to shift resources to education and health, Costa Rica and Cuba, is particularly encouraging [23]. In both countries there was a rapid fall in infant and preschool mortality once the decision was put into effect. Although both are poor countries, their current mortality and life-expectancy figures are closer to those of Europe and the United States than to other developing countries of the region except Chile [24, 23]. Chile has a long tradition of effective health care and supplementary-feeding programmes, which no recent government has dared to reverse. These three countries in the Western hemisphere and others in Asia are striking proof that political priorities and decisions determine health statistics, not gross national product .
There is, thus, ample additional evidence that developing countries that are strongly committed to promoting health as an integral part of social equity and provide for community participation in preventive services can achieve rapid improvement in infant, preschool, and overall mortality rates. Unfortunately, the continuing high death rates in most developing countries bear evidence to the sad fact that the health services are ineffective for the great majority. Nevertheless, more and more countries are implementing child-survival strategies. Moreover, the concepts of Alma Ata are making their way into the training of developing-country physicians and other health personnel, often in programmes identified as community medicine, rural medicine, or family medicine.
Wherever a new generation of health workers has been oriented toward preventive as well as curative medicine and this approach is supported by strong national health policies, as in the examples cited, rapid declines in morbidity and mortality have followed. Nutritionists must not allow themselves to be left out of this health revolution.
Summary and conclusions
The separation of nutrition programmes from other health activities is no longer acceptable. Since the WHO Alma Ata Conference on Primary Health Care in 1978, WHO and UNICEF have led a global effort to make nutrition a major component of primary health care. However, most nutritionists, whether medical or non-medical, have not been trained in this concept. Neither have most physicians and other workers who are responsible for health promotion and health maintenance at the community level. Yet community understanding, motivation, and involvement are each essential for the success of primary health care. As an approach to health for all it is neither an empty slogan nor an unrealistic ideal, but it does face many obstacles. The most important of these are the lack of a strong national commitment to health equity and the lack of training and commitment of health workers in the primary health care approach. As public health nutritionists, we must adjust our thinking and actions and the training of future nutrition and health workers to view nutrition education as an interactive community process and to recognize that the prevention of malnutrition must involve interaction with other public health disciplines as well.
Acknowledgement
The substantive and editorial contributions of Karen Mitzner and Mary Scrimshaw are gratefully acknowledged .
Reference
