Publications

Questioning the Solution. The Politics of Primary Health Care and Child Survival with an in-depth critique of Oral Rehydration Therapy (1997)

By David Werner and David Sanders with Jason Weston, Steve Babb and Bill Rodriguez

Review by Claudio Schuftan, MD

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, based on their respective long experience in the field.

The book makes a passionate call for rectifying what the authors see as being terribly wrong with PHC in the mid-nineties. It calls for a strengthening of 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 poor people, 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, 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 the ultimate determinants of 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 capital 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.

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.

In closing, the authors recap 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 therefore, is 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.

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.

All in all, this is a one-of-a-kind book that reminds us of the groundbreaking 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 oversimplistic, sometimes using sweeping one-liners. Nevertheless, even people 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.

A HealthWrights Paperback, 1997, 207 pp., HealthWrights, P.O. Box 1344, Palo Alto, CA 94302, USA, $30 airmail postage paid. Tel: 650 325 7500 Fax: 650 325 1080 Email: healthwrights@igc.org Web: www.healthwrights.org.

Reviewed by Claudio Schuftan, MD. I. P.O. Box 24 - Hanoi, Vietnam. Tel/Fax: (84-4) 823-6401 Email: aviva@netnam.org.vn, Hanoi, September, 1997

Human Nutrition in the Developing World (1997)

By Michael C. Latham (FAO Food and Nutrition Series No. 29)

Human Nutrition in the Developing World provides a comprehensive introduction to nutritional problems in developing countries. It is a useful reference for workers in agriculture, health, education and other fields who are seeking to promote simple, practical and affordable actions to solve nutritional problems in developing countries.

In this book, Michael Latham, Professor of International Nutrition at Cornell University, draws upon his far-reaching experience in the field of international nutrition to provide a rich source of sound science-based information on food, nutrition, the causes of malnutrition, nutritional disorders and their prevention, and nutrition policies and programmes. The book focuses on the nutritional and health consequences of poor food consumption. Each major nutritional disorder is described and factors contributing to malnutrition such as low food production, food insecurity, poor health status and social and cultural factors are reviewed. Finally, policies and programmes to alleviate malnutrition are discussed, based on the framework set by the 1992 FAO/WHO International Conference on Nutrition and endorsed by the 1996 World Food Summit.

The book emphasizes three prerequisites of good nutrition: food security, good health and adequate care, however fails to display UNICEF's conceptual framework of child survival and development of the triple A process (contrary to the wishes of the author). Special stress is given to applied and multidisciplinary approaches for the alleviation of malnutrition, with food-based approaches emphasized as the only sustainable way to improve the nutritional status of all.

The book has five annexes including tables of recommended intakes of nutrients, anthropometric tables, tables of nutrient content for selected foods, and tables of reference nutrient densities relevant for developing and evaluating food-based dietary guidelines.

Published by the FAO. 526 pp. US $52.00. Further information about ordering this book can be obtained from the FAO Bookshop, Viale delle Terme di Caracalla, 00100 Roma, Italy. Tel: 39 6 5705 5727 Fax: 39 6 5705 3152 E-mail: Publications-sales@fao.org. Web: http://www.fao.org/CATALOG/giphome.htm. Sources include the fly leaf cover to the book and the FAO new publication webpage (http:// www.fao.org/CATALOG/interact/inter-e.htm).

Sight and Life Manual on Vitamin A Deficiency Disorders (VADD) (1997)

By Donald S. McLaren and Martin Frigg First Edition

Established by F. Hoffmann-La Roche Ltd in 1986, the Sight and Life Task Force is a humanitarian programme dedicated to fighting vitamin A deficiency in developing countries. Sight and Life provides free vitamin A and technical know-how, funds study and research grants and participates in educational campaigns to promote sound nutrition. Since 1986, the Task Force Sight and Life has supported over 600 projects in more than 70 countries, and distributed 25 million vitamin A capsules to children between 6m and 5y. The Task Force consists of one full-time manager and specialists drawn from many Roche departments. Doctors, nutritionalists, researchers from various disciplines and specialists in communications take part in its activities. Dr Andres Leuenberger, Vice-Chairman of the Board, Roche Holding Ltd, is at present the chairperson of Sight and Life. Task Force Sight and Life is financed entirely by F. Hoffmann-La Roche Ltd. It publishes regular free newsletters, an annual report giving an outline of activities and projects receiving support, and posters, brochures and video films in various languages providing additional information on xerophthalmia and the Task Force.

The 'Sight and Life Manual on Vitamin A Deficiency Disorders' is intended to be a guide to those interested in and working in the field of vitamin A deficiency. It is an information tool that presents the complexities of this subject in a clear and understandable fashion without trivializing or oversimplifying the issues. The manual takes a very practical approach, dealing with those problems that are of concern to health and nutrition workers, especially those in the fields of child survival and protection of vision. Its primary aim is to present current knowledge in a form that practitioners can put to direct use.

The manual may be used as a reference text, however it is not the intention of the authors that the information provided be exhaustive. For those readers who wish to learn more about the subject, key references and a short list of publications for further reading are provided.

The first two chapters consider the role of vitamin A and its precursor carotenoids in nature, the food sources of vitamin A and the various factors that may influence the concentration of nutrients and their availability in the diet. Chapter 3 describes what happens to vitamin A once it has been ingested, and includes a review of its various functions at the molecular level. This leads to a discussion on human requirements of vitamin A and a summary of current recommended dietary allowances (RDA). There then follows an account of the existing methodologies for the assessment of vitamin A status and their application for drawing up guidelines, in particular, for assessing subclinical vitamin A deficiency. The ocular manifestations of vitamin A deficiency are described, followed by discussion of epidemiological issues and presentation of global prevalence estimates. The final section is devoted to the subject of control of vitamin A deficiency. This is considered under seven headings - treatment, prophylaxis, prevention and management of infectious diseases, fortification, dietary modification, plant breeding and disaster relief. To aid the reader a glossary of terms is also provided.

A slide collection and accompanying notes have also been prepared for Sight and Life. When used together with the slide set, this handbook will serve well as an aid to further education and in prevention campaigns.

138 pp. For more information about this book and the slide set, please contact Task Force Sight and Life, P.O. Box 2116,4002 Basel, Switzerland. Tel: 41 61 691 2253 / 41 61 688 7494 Fax: 41 61 688 1910 Email: basel.sight_and_life@roche.com Web: http://www.sightandlife.org. Source: forward and preface of the book, Sight and Life website.

Vitamin A Supplements. A Guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia (1997)

Prepared by a WHO/UNICEF/IVACG Task Force Second edition

Recent years have seen a steady increase in the number of programmes distributing high-dose vitamin A supplements to treat or prevent vitamin A deficiency and its consequences. Health care workers are sometimes in doubt about how much vitamin A should be given to different age and population groups, how often, and in what form. WHO, UNICEF, and the International Vitamin A Consultative Group (IVACG) have therefore prepared the guidelines contained in this publication, which update and extend those published by WHO in 1988.

New information derived from scientific investigations and practical experience has warranted this revision. Recommendations are based on the best current evidence. Easy-to-follow treatment and prevention schedules are given, and a chapter on operational issues makes suggestions for the integration of vitamin A distribution into a variety of primary health care services. A list of selected further reading is given along with four annexes detailing the members of the WHO/UNICEF/IVACG task force; countries categorized by degree of public health importance of vitamin A deficiency; the rationale for vitamin A supplementation; and the stability of common vitamin A preparations.

Those concerned with the prevention and treatment of vitamin A deficiency and its consequences are invited to consider these guidelines, adapt them as necessary to local conditions, and carefully monitor their application and impact.

Published by WHO. 28 pp. CHF 14.- (CHF 9.80 in developing countries). To order this publication, please contact Distribution and Sales, World Health Organization, 1211 Geneva 27, Switzerland. Tel: 41 22 791 24 76 Fax: 41 22 791 48 57 Email: publications@who.ch Web: http://www-pll.who.ch/programmes/pll/pll_index_frames.html. A catalogue of WHO publications on Nutrition (including an order form) is also available on request. Source: back cover.

Health, Nutrition, and Population (1997)

The World Bank (Sector Strategy Studies)

This report presents the World Bank's corporate strategy in the area of health, nutrition, and population (HNP). It is divided into three main sections, with supportive statistical annexes. Section 1 provides a worldwide overview of recent achievements, development challenges, and the emerging consensus on reform strategies in the HNP sector. Section II reviews current Bank trends in policy dialogue, analysis, lending, and quality assurance. The final section provides a discussion of the Bank's objectives in the HNP sector, new strategic policy directions, ways of achieving greater impact, staff development and enhancement of partnerships.

Published by the World Bank. 112 pp. US $20. To order this report please contact The World Bank, Box 7247-8619, Philadelphia, PA 19170-8619, U.S.A. Tel: 703 661 1580 Fax: 703 661 1501 Email: books@worldbank.org Web: http://www.worldbank.org/html/extpb/HowToOrder.html. Source: world bank publications webpage.

Breastfeeding and Child Spacing Country Profiles (1997)

By Miram H. Labbok, Rafael Pérez-Escamilla, Anne Peterson & Shirley Coly

The purpose of this report is to highlight the complementary aspects of breast-feeding and nutrition, health, child spacing, and maternal and infant survival. The book presents the relationships between these different components of public health, and summarizes the issues and recommendations most relevant to decision and policy makers.

Twenty-seven separate country profiles are presented. For each, the purpose of the analysis is to explore breast-feeding patterns, the transition from lactational amenorrhea to the acceptance of a complementary family planning method, and the potential for the use of the Lactational Amenorrhea Method (LAM) to achieve healthy child spacing. Four figures are presented for each country: the percent breastfeeding as a function of number of months postpartum; the percent breastfeeding in the first six months by sociodemographic variables; lactational amenorrhea, family planning use and risk of pregnancy; and fertility-inhibiting effect of the intermediate fertility variables. The data sources and survey techniques, and the methodology applied to each figure and the definitions used are fully explained in Chapter 2. Each country profile concludes with a brief interpretive comment on breast-feeding and family planning-related issues that may be amenable to program and policy change. A summary of the analysis and recommendations for all 27 countries is presented at the end of the report, with breastfeeding, fertility and family planning information for all countries summarized in a table.

Published by Washington DC: Institute for Reproductive Health. 98 pp. For details of how to obtain copies of this report, please contact Dr Rafael Pérez-Escamilla, Assistant Professor and Extension Nutrition Specialist, Department of Nutritional Sciences, University of Connecticut, 3624 Horsebarn Rd Ext, Storrs, CT 06269-4017, USA. Tel: 860 486 5073 Fax: 860 486 3674 Email: rperez@canr1.cag.uconn.edu. Source: introduction and preface to the book.

Care and Nutrition. Concepts and Measurement (1997)

Edited by Patrice L. Engle, Purnima Menton & Lawrence Haddad

This paper is intended to provide an effective introduction to the concept of "care" as a determinant of child nutrition and to offer a useful summary of attempts to develop care indicators and measurements of care in different cultures.

Care is the provision in the household and the community of time, attention, and support to meet the physical, mental, and social needs of the growing child and other household members. The links between food availability, care practices, and nutrition of the child are well established but hard to measure. The significance of care has best been articulated within the framework developed by UNICEF. This paper extends the UNICEF model in two ways: it defines resources needed by the caregiver and specific care practices, and it presents an argument that the child's own characteristics play a role in the kind of care that he or she receives. That is, the way that the child and the caregiver interact can affect the health and nutritional status of the child.

The paper discusses is detail two of the least studied care practices: feeding practices and psychosocial care. It also discusses measurement of care and suggests appropriate tools for measuring resources for care and the two care practices, based on a summary of recent literature. A substantial bibliography is included.

Published by IFPRI. 50 pp. To order a copy of this paper, please contact IFPRI, 1200 Seventeenth Street, N.W. Washington D.C. 20036-3006, U.S.A. Fax: 202 467 4439, or send an email to IFPRI-info@cgnet.com. Further information on IFPRI publications can be found on the Web at http://www.cgiar.org/ifpri/pubs/pubs.htm. Single copies are sent free of charge; additional copies may be purchased for US $7.50 each. Source: summary of paper.

Height Census and Its Uses: Technical Report (1997)

A joint publication by the Pan American Health Organization and UNICEF

Height censuses of schoolchildren have been used by several countries in Latin America to gauge nutritional status in the population. This report summarizes the main results of a joint UNICEF / PAHO/WHO technical meeting held from 18-20 October, 1994, to evaluate experiences with height censuses in the Americas. The report presents a critical analysis of the uses of height censuses and sets forth the theoretical bases for their use and interpretation. After reviewing the causes of stunting and its biological and social consequences, the publication describes a series of potential uses of height censuses related to policy planning or program evaluation. For each of the potential uses, the advantages, disadvantages, conditions for successful application, and alternative activities are described. To aid the reader, this information is summarized in a table at the end of the report. Also included are the conclusions and recommendation stemming from the expert meeting and an extensive list of references. Poliymakers and program planners will benefit from this concise yet comprehensive explanation of height censuses and how they can be put to optimum use.

This publication is also available in Spanish 'Los censos de talla y sus usos. Infrome technico'.

PAHO Technical Paper No. 45. 16 pp. US $8. Copies of this report are available from PAHO, World Health Organization, 525 Twenty-third Street, N.W. Washington, D.C. 20037, U.S.A. Fax: 202 338 0869. Further information about PAHO publications, including order forms, can be found on the Web: http://www.paho.org/english/publicat.htm. Sources: PAHO publication web page and introduction to the report.

WHO Programme of Food Safety and Food Aid: New Documents (1997)

The following new documents are now available from the Programme of Food Safety and Food Aid, WHO:

· HACCP: Introducing the Hazard Analysis and Critical Control Point System (WHO/FSF/FOS/97.2). This document explains the international status of the HACCP system and provides guidance for the implementation of HACCP by industry and government agencies. Annexed to the document is "Hazard Analysis and Critical Control Point (HACCP) System and Guidelines for its Application", adopted by the 22nd Session of the Codex Alimentarius Commission (Geneva, 1997).

· Food Safety and Globalization of Trade in Food (WHO/FSF/FOS/97.8). This document was prepared in cooperation with the WTO. The document explains the implications of the WTO Agreements to the public health sector and provides advice to the decision-makers of health authorities on how the national food control system needs to be strengthened to comply with the WTO Agreement on the Application of Sanitary and Phytosanitary Measures (SPS Agreement).

· Surveillance of foodborne diseases: what are the options? (WHO/FSF/FOS/97.3). This document explains the need for the collection of the epidemiological data and reviews the advantages and disadvantages of various objectives and needs.

Copies of these documents can be obtained from the Programme of Food Safety, World Health Organization, 20 Avenue Appia, CH-1211, Geneva 27, Switzerland. Tel: 41 22 791 2555 Fax: 41 22 791 4807 Email: foodsafety@who.ch. Web: http://www.who.ch/programmes/fsf/publist.htm Source: Programme of Food Safety, WHO.

GTZ Guidelines for Nutrition Baseline Surveys in Communities (Version 1.2,1997)

By Rainer Gross, Am fried Kielmann, Rolf Korte, Hans Schoeneberger & Werner Schultink

The purpose of this book is to provide guidelines for nutrition surveys. The guidelines serve to:

· initialize the assessment of the nutritional situation of communities;
· assist in planning and implementing surveys;
· standardize survey methods and techniques;
· be used for training of nutrition and public health workers and specialists;
· help bring about an improvement of the nutritional situation of target groups.

The guidelines can be ordered at the following address: SEAMEO-TROPENMED Network, Central Office, 420/6 Rajvithi Road, Bangkok 10400, Thailand. Fax: +66 2 2477721 or +66 2 6444331

Rapid Assessment Procedures (RAP) Ethnographic Methods to Investigate Women's Health (1997/1998)

By Joel Gittelsohn, Pertti J. Pelto, Margaret E. Bentley, Karabi Bhattacharyya, and Joan L. Jensen

This book contains guidelines and procedures for carrying out a community-based ethnographic study of women's health in general, rather than on a specific disease or cluster of related illnesses. The main goal of the protocol is to provide techniques for the generation and analysis of data that will facilitate programme development and implementation in organization's working in women's health. The results of the ethnographic study are intended to help identify women's health problems as perceived by women, to develop recommendations for appropriate communication with women, and to enhance development of effective health care advice through description of ethnomedical models of women's health problems. They also aim to identify constraints to improving the conditions of women's health and suggest appropriate strategies to deal with them, to prepare an ethnographic report and to improve surveys that examine patterns of morbidity and mortality in women by suggesting ways of adapting questions to consider/acknowledge community perceptions and practices. The first part of the protocol is centered on an intensive training period in ethnographic methods, during which preliminary data on women's health are collected. The main body of the protocol focuses on a series of data collection exercises that will permit an organization to develop a sizeable body of data on local perceptions and practices regarding women's health in the study area. The final section presents several ways to apply the data to programmes and future research activities.

Published by Boston, MA, USA: International Nutrition Foundation, Inc. To be published late 1997 or early 1998. Further information can be obtained from the International Nutrition Foundation, Inc., Charles St. Sta, P.O. Box 500, Boston, MA 02114-0500, USA, Tel: (617)-227-8747 Fax: (617) 227-9405 Email: unucpo@zork.tiac.net. Information including an order form is also available on the World Wide Web: http://oz.plymouth.edu/~food/orderform.html. Source: Nevin Scrimshaw, UNU.

Many thanks to all those who contributed to this issue!