Medical Care for Developing Countries

THE American way is not necessarily the best way for all the people of the world. Drastic adaptation is necessary before our methods are transplanted to other cultures. The health center movement provides a good example of how Western practices have been and are continuing to be adapted to provide new organizational patterns for other countries.

The system of health and medical care that has been accepted as the long-range planning goal for most of the people of the world is a regional organization of rural and urban health centers around base hospitals. Considerable local adaptation is, of course, necessary in hospital administration and regional organization. Even more significant, however, are the major innovations required in developing health centers as the basic peripheral units serving groups of 20,000 to 100,000 people. The need for such a peripheral organization has been made more acute by repeated demonstrations in mass programs, such as malaria eradication, that the attack phase cannot be transformed into a maintenance phase unless there is a general health service to take over.

Early origins of the health center concept can be traced to the Temple of Asclepius and still-visible ruins of hospitals erected by the Emperor Asoka in India more than two thousand years ago. The modern health center idea started at the beginning of this century in a movement in Britain and the United States to combine under one roof previously scattered local health services. Several initial attempts to incorporate curative services for the poor were blocked by medical societies, especially since most hospitals had charity services. An artificial and unfortunate separation between curative and preventive services developed. When public health was concerned primarily with infectious diseases and sanitation, there was less urgency for health officials and practicing physicians to work closely together. As attention has shifted to chronic, noncommunicable disease, the ultimate medical goal of prevention depends increasingly on practicing doctors, because we do not have simple community-wide measures for mass diseases such as cancer. Conversely, there is a growing demand that public health services undertake mass diagnostic and therapeutic services for diseases such as tuberculosis and syphilis. The Dawson Report to His Majesty’s Government in 1920, a major landmark in health planning, made recommendations for regional integration of hospital and health services that were so novel that the report was shelved for many years.

It has been left for the newly developing countries to break with the traditional pattern of separated medical and health services which has become so firmly rooted in Western culture. In countries where minimum facilities exist, it is possible to plan logically without limitations imposed by the investment of bricks and sentiment in historically prestigious institutions or the even more restrictive personal involvements and ambitions of professional leaders. On the other hand, a common limitation in the developing nations is the tendency of local professional leaders to adopt without adapting the practices and norms of the Western system under which they were trained. The break with their own culture imposes a natural inclination to accept intact the new pattern as an almost sacred whole.

Much of the credit for the start of the health center movement in underdeveloped countries goes to the medical pioneers of the Rockefeller Foundation. As the ambitious worldwide program for eradicating hookworm failed in the early decades of this century, these doctors salvaged from the experience the idea that for basic changes in the people’s ways of life the long-term influence of health units would be necessary. On the basis of U.S. experience, they first insisted that these units should be purely preventive, partly because of the obvious impossibility of meeting the overwhelming curative needs. In the late 1920s a worldwide campaign of building and stalling demonstration health centers was started. Rural sites were selected in villages strategically located near the capitals or major cities of countries such as Ceylon and Chile, and in every province of countries such as India. Following a five-year period of intensive Rockefeller support, the financing and operation of the centers were taken over by the local government. Other major pioneering programs have been the Servicio program developed in Latin America as part of the wartime good-neighbor policy and the work of Kark in Negro reservations near Durban, South Africa, and of Hydrick in Java.

FOR several years it has been one of my hobbies to visit the old Rockefeller health centers for a thirtyyear follow-up. From my experience I would make certain generalizations.

The purely preventive approach imported from the United States has almost always been modified, and curative services have been added in response to popular demand. Many of the more isolated rural health centers now have twelve to sixty beds for patients. The original pattern of purely preventive health units was most widely developed in Ceylon, where an excellent island-wide network was for many years considered the outstanding example of the success of the original plan. Recently, however, the government has added dispensaries and other curative facilities.

In spite of the above generalization, we need to recognize, too, the inherent danger that doctors prefer curative work and often miss the challenge of preventing the diseases with which they are surrounded. On a visit to a rural health center in southern India I found an unhappy and discouraged young doctor. He was looking forward only to the time when he would finish his governmentrequired stint in the village and be free to do more interesting work than writing prescriptions for iron mixture. He had seen so much anemia that he thought he could tell the hemoglobin level from across the room. As we talked about the causes of anemia, he said the possibility of heavy hookworm infestation seemed worth investigating. He was critical of the health authorities for doing nothing about sanitation. I pointed out that he was the local health authority, and we discussed the long-range contributions he could make by looking for the cause of the anemia. I later heard that he had turned the routine dispensing of iron mixture over to his pharmacist. He had borrowed a microscope, conducted a stool survey, found heavy hookworm infestation, and launched an intensive program for treating hookworm and building latrines.

The staff of the Rockefeller-sponsored health units were carefully selected young doctors who had received one or more years of public health training at Harvard and Johns Hopkins. They were often the best-trained specialists in the country, and it was only logical for Ministers of Health to put them into more responsible administrative positions as soon as the operation of the health center became a government responsibility. Today, as one travels in various parts of the world, it is impressive to find that many key public health specialists obtained their start in this way.

Those who originally developed health unit programs were disappointed at the relatively narrow spread of better health practices from demonstration villages to neighboring areas. I have asked village people in several countries the reasons for this lag, and the general reaction has been that the neighboring villages were waiting for someone to start a health center for them, too. In one village in Yugoslavia they said that conditions improved so much as a result of the Rockefeller team’s efforts that local girls refused to marry outside the village and local boys insisted on marrying girls who had learned modern methods of homemaking, canning, and the like. General dispersion of health center activities is now occurring as governments are undertaking regionalized developments.

Health improvements which persisted were those accepted as the specific responsibility of individuals or families. Facilities such as pumps and latrines installed for community use quickly became disreputable because they were not maintained, or they were completely dismantled. Similar installations in homes are still serving well after more than thirty years’ use.

Of great value in several places were special short courses for training villagers to assume responsibility for their own health services. An outstanding example was the teaching health center of the All-India Institute of Hygiene in Singur, near Calcutta, which was developed by Dr. John Grant. In each village of the demonstration area, a health committee of six of the better-educated young men were assigned individual jobs which included malaria control and surveying for mosquitoes, vital statistics and epidemic reporting, maintenance of pumps, water supplies, and latrines, organizing maternal and child health clinics and vaccination programs. From each village in the health center area, the committee members for a particular job were brought into the health center for a two-week course each year. On a field trip with one of the volunteer malaria workers some fifteen years after his training, I was impressed with his technical knowledge of subjects such as the identification of Anopheles culicifacies larvae and the enthusiasm with which he followed malaria cases.

SPECIAL categories of auxiliary personnel are being trained for particular responsibilities in some countries. The programs range from threeto fouryear courses for rural doctors to elementary training for special assistants, such as vaccinators, midwives, and DDT sprayers for malaria control. There is general agreement about the desirability of training the latter group of specialized assistants with sharply limited responsibilities. Great arguments continue to arise, however, when the merits of medical assistants or rural practitioners are discussed. Qualified doctors resent the implication that their functions can be performed by practitioners with minimal training. But most countries, including the United States, need to increase drastically the number of practitioners. While many routine functions performed by doctors are relatively simple and could be handled by a well-trained auxiliary, it is important that those conditions requiring greater professional competence be screened out for special attention.

Study of experimental training programs in several countries reveals a general pattern for planning in countries such as the new nations of Africa. Popular demand in self-governing areas usually leads to insistence that medical-care needs be saturated even if the quality of care is not high. Eventually a normal drive toward excellence makes the basic training institutions progress to full professional medical education. In the United States up to fifty years ago, uncontrolled proliferation of proprietary medical schools produced many more doctors than were needed, until professional standards consistent with scientific medicine were imposed following the Flexner Report of 1908. In Russia, starting in the nineteenth century, separate categories of doctors were trained for urban and rural services; feldshers, or rural practitioners, are now gradually being replaced by fully qualified doctors. In Iran, Behdars were trained; in West and East Africa and the Pacific they were called medical assistants; and in India, licentiates. Licentiate training was introduced in India primarily to provide assistants for British civil surgeons. The term “licentiate” developed a stigma of colonial domination which contributed to hasty moves to abolish this category of professional training promptly after independence in 1947, even though the immediate medical-care needs of the country were far from saturated. Now there are recurring waves of discussion about the need for basically trained rural doctors, with political pressure for the modernization of the generally popular Ayurvedic, or ancient Hindu, system of medicine. More than 80 percent of the doctors compete for the limited amount of money to be made in city practice, while the 80 percent of the people who live in villages rely, for the most part, on indigenous practitioners.

It does no good for advisers from the West to decry the falling standards of professional education. On the one hand, it is important to work for the development of a few “lighthouse” institutions, where high standards are maintained, to provide teachers, researchers, and professional leaders. On the other, it is even more important to analyze carefully the lessons to be learned from past experiences in training auxiliaries and rural practitioners in order to devise adequate programs to meet quantitative needs.

In this quantitative-qualitative dilemma there are two ways of providing routine care by nonmedical personnel in order to fill the gap in health service. The common approach historically has been to train individuals who were almost doctors, frequently with provision for selected persons to go on to full medical training. Premature conversion or amalgamation of such programs into a regular system of medical education can be expected. This transition is natural and predictable because of normal nationalistic pride which leads new countries to strive for the labels of development even before the product is there to be labeled. In many of the more developed countries, too, the disparity in quality of education between the best and the poorest schools is almost as great as if there were two systems of education. It seems necessary, therefore, to accept these differences and to make the distinctions less invidious by giving all medically trained persons the same degree while efforts are made to apply minimum standards of professional preparation.

The alternative and more promising mechanism for meeting the mass health-care needs is to plan for categories of health assistants so far below the doctor that there can be no confusion as to the role that each must play in medical service. Whether routine and simple medical care is provided by women with some adaptation of nurse-midwifery training or by men with a modified pharmacy training then depends on local cultural preferences. Two important considerations must be emphasized. Supervision of both preventive and curative work by doctors is essential. The health assistants should screen the one to five hundred patients per day now being cared for by health center doctors to free their time for the sickest patients. If stationed in the more isolated rural subcenters, where fully qualified doctors should not be expected to go, the health assistants should be visited at least once a week by health center doctors, with an established mechanism for patient referral in the intervals. Secondly, much of the training and practice of the health assistants should be in disease prevention. It should be a matter of pride with them to keep their clinics free of readily preventable diseases, and success in prevention should be recognized by financial remuneration. In order to supervise such health assistants the doctors, too, must receive more training in prevention than they now do.

A CONTINUING problem is the need for health workers to understand the cultural blocks to health activities. Of particular value in understanding local attitudes toward sanitation in India is a threeyear intensive study by health workers and anthropologists under Ford Foundation sponsorship. General recognition and acceptance of the desirability of latrines were found to be offset by such negative considerations as odor, cost, difficulties in maintenance, and other deterrents. An efficient way of promoting latrine acceptance was the simple process of working first with the spontaneously interested families, who were often the village leaders. Latrines that were good enough for them were then more generally accepted.

Similar studies in Latin America demonstrated the importance of relating health activities to the ritualism of local folk medicine. Not only are certain practices important, but also the order in which they are done. An example was the use of the Latin belief in the power of the number “three,”so that three injections, or three pills for three days, have built-in acceptance. Ritual days are important in many parts of the world; in Indian villages we found a considerable difference in the numbers of people coming to clinics on Wednesdays versus Thursdays.

Redefinition of our traditional Western preconceptions about rural-urban distinctions is overdue. Many village areas in developing countries have population densities greater than urban areas in Western countries, and therefore many of the amenities of sanitation and other urban facilities can be directly supplied. These villages are still psychologically and socially rural, however, and have the characteristics of a stable agrarian society in which cultural blocks provide more resistance to change than in areas where social mobility is greater.

In trying to understand cultural variables before introducing new activities, I would suggest the value of focusing observations on indigenous practitioners of medicine. They represent in its purest form the culture’s orientation to health problems. The beliefs of the general public will be dilutions of attitudes of the indigenous practitioner. Many ancient cultures, for instance, have complicated dietary prohibitions, such as the subtle distinctions between “hot" and “cold" foods and the conditions under which each may be eaten. A Western-trained doctor who casually recommends a hot food for a patient with fever immediately loses the confidence of his patients, whereas he could just as readily have suggested a cold food with equivalent dietary value. The clearest categorization of foods can be obtained by going directly to the local practitioners.

Excessive population growth is the greatest health problem of countries such as India. Although the introduction of better health is often said to be the major cause of population increase, it also carries with it the best prospect of solving the population problem. As infant and childhood mortality drops, parents begin to realize that it is no longer necessary to have six children in order to raise three.

We know that because of the high proportion of young people, the population of the world will double in the next two generations, even if the average number of children per family is drastically reduced. We know, too, that technologically it is possible to increase food production and industrial development faster than projected population increases. The major limitations on both food production and economic development are organizational and political, and these limitations are most evident in the rapidly developing countries where excessive population growth clearly inhibits economic progress. Eventually, however, a balance between birth and death rates suited to modern, scientifically based civilization will have to be reached, with provision for parents to have some rational control over the number of children they will have.

It is at the level of the family that the crucial decision-making process occurs. With the somewhat haphazard contraceptive methods of the past, social influences were obviously primary; with better contraceptive techniques, the role of medical and health services in population control will probably increase. Various village studies in India have shown that 15 to 20 percent of village couples will readily accept simple contraceptive methods. Although this is not a large enough group to reduce the birth rate to levels desired by the National Planning Commission, it is at least a place to start. It seems reasonable to saturate this spontaneous need through the existing health services with the expectation that there will be spontaneous spread. This should be part of the routine activities of rural health centers.

A moot issue is the financing of health center activities. In most countries today it is accepted that health care is the right of every individual and should be paid for by society, just as public education is provided. Basic public health services universally come from tax funds. The total cost of medical care is, however, proving to be too great for the tax-supported health services in many developing countries. Senior health officials of several countries have indicated that they would welcome help in devising ways of getting communities to bear more of the cost of local health services.

Various modifications of health insurance are being experimented with. If health centers which integrate preventive and curative services are going to be financed by health insurance, such insurance must be broadly based and firmly financed. When I visited at Santiniketan, Rabindranath Tagore’s rural university in Bengal, I saw a dramatic example of the failure of a too-limited health-insurance program. Tagore started one of the first village development programs in India. A network of rural health centers was established in 1926. This self-supporting activity was financed through a widely subscribed voluntary health-insurance program. In addition to basic dispensary care, a certain amount of health education, immunization, and maternal and child health work was done. For thirty years the health centers flourished. When DDT became available after World War II, the Santiniketan staff was one of the first groups in India to start spraying throughout the heavily malarious villages. As malaria rates dropped, subscriptions to the health-insurance program were canceled. It became evident that much of the appeal of the health-insurance program had been based on the fact that this was a cheap way of getting the gallons of quinine people had needed to suppress their malaria. Now they no longer saw the need for paying their insurance subscriptions.

Both health personnel and villagers must have a clear idea of the health worker’s role and relationship to the local people. In community development circles there is much discussion about the extent to which the innovator from outside should conform to village life in order to gain acceptance. Obviously, the health worker should live in the village, but at what point in personal living should the line be drawn between what the health worker would like to do and what the villagers can afford? A night spent in a small village in northern India as the guest of a community development worker highlighted some of these problems for me. We were to sleep in an open space adjacent to the oneand-a-half-room mud-thatch hut in which the village worker lived with his wife and baby. Toward the end of our late evening discussion, around a smoky cow-dung fire, with some of the village elders, I asked for poles to support my mosquito net. The development worker looked around for a while; there was some conversation with neighbors, but no poles were produced. He finally told me that, although he used a mosquito net inside his house, he did not believe in putting one up outside because he did not want to seem different from the people, who could not afford nets. I assured him that I did not mind being different on this point, but eventually had to drop the matter and rely on insect repellent. The mosquitoes woke me every three or four hours to remind me it was time to put on more repellent. Next morning, when I found the ponds swarming with anopheline larvae and several cases of chills and fever in the village, I lost my enthusiasm for the policy of identification with village people.

Later, while chatting with a group of village elders, we discussed the difficulties of village life. They took the common fatalistic stand that village improvement is impossible because of the widespread poverty. “We have proof,” they said, “that it is impossible to improve the condition of villagers. Just look at our development worker. He has a B.S. in agriculture, and his wife is educated too; they work hard and are wonderful people. They lived for years in the city, but now they have come to the village, and he has become just like the rest of us. He lives in a mud house, wears our clothes, and takes the same health risks. If he can’t do any better, what hope is there for us?”

When our family lived in a model home in a village, we found that it was possible to protect the health of our children without losing contact with the village people. Our efforts to adapt village materials to modern health practices were enthusiastically received by the villagers. The village people expected us to show in our daily living a better way of doing things. It was enough for them that we were there living with them and showing through our way of working and speaking that we cared for them. Peace Corps workers, too, have learned that they need feel no hesitation about taking a better way of life into the villages.