This month we review a study finding out how primary health care programmes can be made to reach the people who need them; and two books showing why people still go hungry though farmers grow more food every year.
Editor: Anuradha Vittachi
Practising Health for All
by David Morley, Jon Rohde, and Glen Williams
OUP (pbk) £3.50/$6.00 (inc. p. & p.)
If health for all could be achieved through the implementation of health technologies alone, it would be a relatively straightforward process - since effective and affordable technologies are available. The major obstacles to the implementation of primary health care are not technical but political and organisational.
Few authors have attempted to look at how attempts to implement primary health care around the world have battled on in spite of political problems, how these problems have been overcome in some places, and also at the value of primary health care initiatives that can only exist at a local level because of political obstacles at the national level.
Through well-illustrated case studies, Practising Health for All considers the lessons to be learnt from national primary health care programmes such as those in China and Cuba. It also looks at countries where a national strategy has been implemented but where, nevertheless, small pilot projects have carried on despite political obstacles. In some places the influence of these small projects has spread far beyond their starting point.
Not all the examples given are success stories. The authors question what the criteria should be for evaluating the success of primary health care programmes. Should we consider their medical effectiveness, or their social impact, or the extent to which they are implemented throughout a country?
The first two are suggested as valid criteria. But these are still very difficult to assess. There is still no internationally accepted set of quantifiable indicators of community health status. Assessment of social impact is even more difficult. In some countries, as in the example given in the book from the Dominican Republic, it is based on observing the changes in the health, social status and responsibilities of women in society.
China, Cuba and, more recently, the People’s Democratic Republic of North Yemen are often considered the only countries where primary health care has been truly successful because it has been adopted as part of a national political commitment. However, various examples in the book, especially from South East Asia and Latin America, describe small primary health care initiatives within a state or a district that have had considerable impact on the community despite an unfavourable national political climate.
Health is a function of the political process. It therefore reflects the best and the worst of that process in each country. The establishment of health as a universal right is obviously dependent on the development of more equitable societies. Nevertheless, it would be shortsighted to undervalue the efforts in many countries without a national commitment to primary health care to implement small scale projects. As Emmanuel de Kadt (of the Institute of Development Studies, UK) comments: ‘the seeds of change may need to be sown in unfavourable circumstances and the results may surprise even the most sceptical observer’. The roots of future equitable societies may lie in some of the seemingly isolated primary health care initiatives struggling to develop in repressive political climates.
Denise Ayres is Executive Editor of ‘Diarrhoea
Dialogue’, published by the Appropriate Health
Resources & Technologies Action Group (AHRTAG).
SPECIAL OFFER: Currency restrictions make it difficult to market this book in many developing countries. But if you will pay for two copies forfriends who live in the Third World, you will receive a free copy from Teaching Aids at Low Cost, P.O. Box 49, St Albans, Herts, U.K.
More Than We Can Chew:
the crazy world of food and farming
by Charlie Clutterbuck and Tim Lang
Pluto Press (pbk) £2.50
Food, Poverty & Power
by Anne Buchanan
Spokesman (pbk) £3.50
More Than We Can Chew describes,in the words of its subtitle, ‘the crazy world of food and farming’. The authors are of course right to inveigh against our present agricultural policies which are both ecologically and socially damaging. The blurb sets the scene enticingly:
Under the Common Agricultural Policy, Europe has become a landscape of butter mountains and wine lakes. Farmers produce morefood every year. But much of it fails to reach those who need it, a situation that breeds ingenious schemes for dumping and recycling foodstocks.
More Than We Can Chew examines the power struggles and crazy contradictions of the modem world food economy and shows their impact on nutrition, food adulteration and factory conditions.
‘The harsh reality is that the world elite have convened to stalk the progress of the rural masses, not to seek ways to alleviate their sorry plight.’ The Lesotho Agriculture Minister, speaking at a world conference on agrarian reform, 1979.
Alas, the title and the blurb tum out to be the best parts of the book. The rest, while making many good points, does so in a superficial and stereotyped manner that will convince only the converted. ‘Food does affect our health,’ write the authors, adding that there are wide differences in life expectancy between the classes in Britain:
This is, at least in part, due to different diets. The purple, gout-ridden upper-class faces of politicians, seen on the box every day, eat rich well-prepared food. The anaemic faces of workingclass people, on the streets every day, eat stodgy, mass-prepared, fatty carbohydrates. There are no prizes for guessing who dies earliest.’
Only two paragraphs are devoted to how the Common Agricultural Policy actually works, while the crucial issue of subsidies from the taxpayer to the farming industry merely merits the odd mention now and again.
All this is a great pity. The authors have one of the most vital international topics of our times in their sights but they miss their aim completely. They have simply bitten off more than they can chew.
Much more serious in tone and convincing in treatment is a thoughtful study, Food, Poverty and Power, which uses a wide range of sources to document many of the political and social causes of hunger. There are short, succinct chapters on all the main aspects of poverty: colonialism, ‘dependent’ development, myths about hunger, and the Third World connection from the Green Revolution to trade, export cropping to aid. There is also a very useful annotated list of references. While the overall analysis will be familiar to readers of How the Other Half Dies or Food First, the clear writing, well-chosen quotations and drawings make this book a very good introduction to the issue.