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Unformatted text preview: Default User ID: 29030002245953 SCHNEIDER,DONA Profile name: FACSTF... Request ID: REQ-786950 Request type: RU-REQUESZ Title: The New England journal of medicine. Item ID: 39030032678627 Call Number: XX(49i 56.47) V. 241 1949 Service Library: LSM Date replied: 6/12/2007 Status: RU-NEW Request Pickup/Delivery: ALEXANDER Article Author: Walsh and Warren Article Title: Selective primary health care: an interim strategy for disease control in developing countries Journal Volume: 301 Date: 1979 Pages: 967—74 Deposit Account 4-28999-88000 No.: Vol. 301 'No. 18 DISEASE CONTROL IN DEVELOPING COUNTRIES — WALSH AND WARREN 967 SPECIAL ARTICLE SELECTIVE PRIMARY HEALTH CARE An Interim Strategy for Disease Control in Developing Countries JULIA A. WALSH, M.D., AND KENNETH S. WARREN, MD. Abstract Priorities among the infectious diseases af- fecting the three billion people in the less developed world have been based on prevalence, morbidity, mor- tality and feasibility of control. With these priorities in mind a program of selective primary health care is compared with other approaches and suggest- ed as the most cost-effective form of medical inter- vention in the least developed countries. A flexi- ble program delivered by either fixed or mobile units might include measles and diphtheria—per- THE three billion people of the less developed world suffer from a plethora of infectious dis- eases. Because these infections tend to flourish at the poverty. level, they are important indicators of a vast state of collective ill health. The concomitant dis- ability has an adverse effect on agricultural and in- duStrial development, and the infant and child mor- tality inhibits attempts to control population growth. What can be done to help alleviate a nearly un- broken cycle of exposure, disability and death? The best solution, of course, is comprehensive primary health care, defined at the World Health Organiza- tion conference held at Alma Ata in 1978 as the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition, an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious dis- eases; prevention and control of locally endemic diseases; ap- propriate treatmentof common diseases and injuries; and provi- sion of essential drugs.‘ The goal set at- Alma Ata is above reproach, yet its very scope makes it unattainable because of the cost and numbers of trained personnel required. Indeed, the World Bank has estimated that it would cost bil- lions of dollars to provide minimal, basic (not com- prehensive) health services by the year 2000 to all the poor in developing countries. The bank’s president, Robert McNamara, offered this somber prognosis in his annual report in 1978: Even if the projected — and optimistic — growth rates in the developing world are achieved, some 600 million individuals at the end of the century will remain trapped in absolute poverty. From the Rockefeller Foundation, 1133 Avenue of the Americas. New York, NY 10036, where reprint requests may be addressed to Dr. Warren. Presented at a meeting on Health and Population in Developing Countries, cosponsored by the Ford Foundation, the International Develop- ment Research Center and the Rockefeller Foundation and held at the Bel- lagio Study and Conference Center, Lake Como. Italy, April, 1979. tussis—tetanus vaccination, treatment for febrile malaria and oral rehydration for diarrhea in chil- dren, and tetanus toxoid and encouragement of breast feeding in mothers. Other interventions might be added on the basis of regional needs and new de- velopments. For major diseases for which con- trol measures are inadequate. research is an inex- pensive approach onthe basis of cost per infect- ed person per year. (N Engl J Med 301:967-974, 1979) Absolute poverty is a condition of life so characterized by malnutrition, illiteracy, disease, high infant mortality and low life expectancy as to be beneath any reasonable definition of human decency.2 How then, in an age of diminishing resources, can the health and well-being of those “trapped at the bot- tom of the scale” be improved before the year 2000? A valid approach to this Overwhelming problem can be based on the realization that the state of collective ill health in many of the less developed countries is not a single problem. Traditional indicators, such as infant mortality or life expectancy, do not permit a grasp of the issues involved, since they are actually composites of many different health problems and disorders. Each of the many diseases endemic to the less developed countries (Table 1) has its own unique cause and its own complex societal and scientific facets; there may be several points in the process for Which interventions could be considered."5 Thus, a rationally conceived, best-data-based, selective attack on the most severe public-health problems facing a region might maximize improve- ment of health and medical care in less developed countries. In the discussion that follows, we try to show the rationale and need for instituting selective primary health care directed at preventing or treating the few diseases that are responsible for the greatest mortality and morbidity in less developed areas and for which interventions of preved efficacy exist. ESTABLISHING PRIORITIES FOR HEALTH CARE Faced with the vast number of health problems of mankind, one immediately becomes aware that all of them cannot be attacked simultaneously. In many regions priorities for instituting control measures must be assigned, and measures that use the limited human and financial resources available most effec- tively and efficiently must be chosen. Health planning for the developing world thus requires two essential steps: selection of diseases for control and evaluation of different levels of medical intervention from the most comprehensive to the most selective. 963 ' THE NEW ENGLAND JOURNAL OF MEDICINE SeleCtlng Diseases for Control i In selecting the health problems that should receive the highest priorities for prevention and treatment, four factors should be assessed for each disease: prevalence, morbidity, mortality and feasibility of control (including efficacy and cost). Table 2 incorporates these factors into an analysis of three representative illnesses of the less developed world. The newly discovered Lassa fever was as- sociated with a 30 to 66 per cent mortality rate in the few limited outbreaks recorded in Nigeria, Liberia and Sierra Leone. Those who survived recovered fully after an illness lasting seven to 21 days. Although this fatality rate seems to suggest giving Lassa fever high priority in a major health program, the prevalence of overt disease appears to be low. Furthermore, the only treatment available is injections of serum from patients who have recovered. Since its mode of trans- mission is unknown and there is no vaccine, Lassa fever is impossible to control at present.6 Therefore, concentration on preventing Lassa fever would be neither efficient nor efficacious. Ascaris, the giant intestinal roundworm, causes the most prevalent infection of man, with one billion cases throughout the world.7 Yet disability appears to be minor and death relatively rare.“ Treatment, howev- er, requires periodic Chemotherapy for an indefinite period.’-” Control may ultimately require massive, Nov. 1, 1979 long-term improvements in sanitary and agricultural practices to reduce reinfection. In view of the difficulty of eliminating exposure to the roundworm and the low morbidity associated with the infection, ascariasis deserves less attention than its ubiquity seems to sug- gest. ‘ Malaria is associated with a far smaller'mortality rate than that of Lassa fever and a far lower prevalence that that of ascariasis. Yet its mode of transmission is well known, and it produces much recurring illness and death; about one million children in Africa alone die annually from malaria.9 What also distinguishes malaria from Lassa fever and ascariasis is that it can be controlled through regular mosquito-spraying programs or chemoprophylairisfis9 Of these three infections, then, malaria would be as- signed the highest priority for prevention in the most effective approach to reducing morbidity and mor- tality. By means of the process outlined above for Lassa fever, ascariasis and malaria, the major infections endemic to the developing world (Table 1) were evaluated and assigned high (I), medium (II) or low (III) priorities. Within categories exact rank is not of major importance, and rank may change or items may be added or deleted, depending on the geographic area under consideration. For instance, schistos'omia- sis, to which a high priority was assigned, does not occur in many areas of the developing world. Our re- Table 1. Prevalence. Mortality and Morbidity of the Major Infectious Diseases of Africa. Asia and Latin America, 1977-1978! INFECTION lecrtons DEATHS DISEASE AVERAGE No. or RELATIVE (THOUSANDS/YR) (T HOUSANDS/Yl) (THOUSANDS or Bus or LIFE Losr PERSONAL CASES/YR) (PER Cass) DISABILITYT Diarrheas 3—5,000.000 540,000 3-5,000,000 3—5 2 Respiratory infections 4—5000 5-7 2-3 M alaria 800,000 1200 150,000 3—5 2 Measles 85,000 900 80,000 10—14 2 Schistosomissis 200.000 500—1000 20,000 600—1000 3—4 Whooping cough 70.000 250—450 20,000 21-28 2 Tuberculosis 1,000,000 400 7000 ZOO-400 3 Neonatal tetanus 120—180 100—150 120480 7—10 1 Diphtheria 40.000 50—60 700-900 . 7-10 3 Hookworm 7-900.000 50-60 1500 100 4 South American trypan- 12,000 60 1200 600 2 osomiasis Onchocerciasis Skin disease Low 2—5000 3000 3 30.000 River blindness 20—50 ZOO-500 3000 1—2 Meningitis 150 30 150 7—10 1 Amebiasis 400.000 30 1500 7-10 3 Ascarinsis 8000004000000 20 1000 7—10 3 Poliomyelitis 80,000 10—20 2000 3000+ 2 Typhoid 1000 25 500 14—28 2 Leishmaniasis 12.000 5 12,000 [00—200 3 African irypanosomiasis 1000 5 10 150 1 Leprosy Very low 12,000 500.3000 2_3 Trichuriasis 500,000 Low 100 7—10 3 Filnriasis 250,000 Low 2—3000 1000 3 Giardiasis 200,000 Very low 500 5-7 3 Dengue 3—4000 0.1 [—2000 5-7 2 2000 Malnutrition 'Bused on estimates from the World Health Organization and its Special Programme rm Research and Training in Tropical Diseases. confirmed or modified by extrapolations 1'1 denotes bedridden, 2 able to function on own to some extent. 3 ambulatory. & 4 minor. I Vol. 301 No. 18 DISEASE CONTROL IN DEVELOPING COUNTRIES — WALSH AND WARREN . 969 Table 2. An Approach to the Establishment of Priorities for Disease Control. Based on Prevalence. Mortality. Morbidity and Feasibility of Control of Three Representative Infections. W [uracnou Pasvmnca Monnu‘n' Lassa fever Unknown High (30-66%) (thought to be low) Ascariasis Extremely high Extremely low (thought to affect (approximately 1 billion people) 0.001%) Malaria High (more than Low (approxi- 300 million in- mately 0.1%) fected annually) " sults and rationale for the proposed hierarchy are list- , ed in Table 3. ' " Group I contains the infections causing the greatest amount of most readily preventable illness and death: “ diarrheal diseases, malaria, measles, whooping cough, chistosomiasis and neonatal tetanus. With the excep- tion of schistosomiasis, all the infections receiving ._ highest priority for health-care planning affect young children more than adults.‘°'“ Together with respira- ‘tory infections and malnutrition, they account for ‘ most of the morbidity and mortality among infants and young children.""5'17 Members of this age group ' (five years old or less) have a death rate many times greater than that of their counterparts in Western countries -- accounting for 40 to 60 per cent of all mortality in most less developed countries.“"7‘l9 If in- fant and child deaths from these infections are 7 reduced, a large decline in the overall death rate will result. Such a situation would be an optimal outcome of a selective disease-control program. Groups II and III contain health problems that are _ either less important or more difficult to control. Res— piratory infections, a major cause of disability and death, are not listed in Group I because of the dif- . ficulties involved in preventing and managing them. A wide variety. of viruses and bacteria are associated with pulmonary infections, and no specific causative agent has been found in most patients.“-20 As in the industrialized world, where pneumonia is frequently the terminal episode in elderly patients weakened by cancer or cardiovascular disease, lower-respiratory- tract infections affect children in developing countries who are already afflicted with chronic malnutrition and parasitic infections.“ Pneumococcal and in- fluenza vaccines prevent only a small percentage of cases, and influenza immunization must be given almost yearly because the virus changes antigenical- ly. When penicillin injections were given to all children with clinical signs of pneumonia in the Narangwal Project in India, the mortality rate decreased by 50 per cent,“ but this method must be evaluated more extensively before it can be regarded as a major improvement in prevention of respiratory disease. Mownrrv FEASIBILITY Paioam or Comm. Moderate Extremely poor . Low: prevalence (bedridden at present low, feasibility 7—21 days) of control poor Low (minor dis- Poor (continuous Low: mortality ability & drug treatment & morbidity often asymp— required) low, feasibility tomatic) of control poor High (severe, Good (chemoprophy- High: prevalence many compli- laxis available; high, morbidity cations, often regular spraying high. feasibility recurrent) programs for \ of control good vectors practical) A medium or low priority was assigned if control measures were inadequate. For example, there is no acceptable therapy for chronic Chagas’ disease}4 Only toxic drugs and procedures of unknown efficacy, such as nodulectomy, are available for treatment of enchocerciasis.“ Leprosy and tuberculosis require years of drug therapy and even longer follow-up Table 3. Priorities for Disease Control in the Developing World, Based on Prevalence, Mortality. Morbidity and Feasi- bility of Control. ‘ Paiom'v ‘ Gaour I High Diarrhea] diseases Measles Malaria Whooping cough Schistosomiasis Neonatal tetanus ll Medium Respiratory infections Poliomyelitis Tuberculosis Onchocerciasis Meningitis Typhoid Hookworm Malnutrition 111 Low South American trypanoso« miasis (Chagas’ disease) African trypanosomiasis Leprosy Ascariasis Diphtheria Amebiasis Leishmaniasis Giardiasis Filsriasis Dengue Reasons FOR ASSIGNMENT 10 THIS CATEGORY High prevalence. high mortality or high morbidity. effective control High prevalence. high mortality, no effective control High prevalence. low mortality, effective control High prevalence, high mortality. control difficult Medium prevalence, high morbidity. low mortality, control difficult Medium prevalence. high mortality. control difficult Medium prevalence, high mortality. control difficult High prevalence, low mortality. control difficult High prevalence, high morbidity, control complex Control difficult Low prevalence, control difficult Control difficult . Low mortality. low morbidity. control difficult Low mortality. low morbidity Control difficult Control difficult Control difficult Control difficult Control difficult 970 THE NEW ENGLAND JOURNAL OF MEDICINE periods to ensure cure.‘I"-23 Instead of attempting im- mediate, large-scale treatment programs for these in- fections, the most efficient approach may be to invest in research and development of less costly and more efficacious means of prevention and therapy. To reiterate, the most important factor in establishing priorities for endemic infections, even when evaluating diseases with high case rates, is a knowledge of which diseases contribute most to the burden of illness in an area and which are reasonably controllable. EVALUATING AND SELECTING MEDICAL INTERVENTIONS Once diseases are selected for prevention and treat- ment, the next step is to devise intervention programs of reasonable cost and practicability. The interven- tions relevant to the world’s developing areas that are considered below are comprehensive primary health care (which includes general development as well as all systems of disease control), basic primary health care, multiple disease-control measures (e.g., insec- , ticides, water supplies), selective primary health care, and research. Below is a discussion of each approach, with emphasis on the relative cost involved in under- taking and maintaining these programs and on the benefits that have accrued. This section of our analysis relies on reported results from individual studies conducted in various parts of the world. In addition, we have examined es- timates of cost and effectiveness in terms of expected deaths averted by each intervention for a model area in Africa. The model area is an agricultural, rural por- tion of Sub-Saharan tropical Africa with a population of about 500,000 (100,000 are five years old or less). For reference purposes, the average figures for Sub- Saharan Africa will be used: the birth rate is 46 per thousand total population, the crude death rate 19 per thousand total population, and the infant mortality rate 147 per thousand live births.“25 Comprehenslve versus Baslc Prlmary Health Care Comprehensive primary health care for everyone is the best available means of conquering global dis- ease, the humane and noble goal declared at Alma Ata. As defined by the World Health Organization, this system encompasses development of all segments of the economy, ready and universal access to curative care, prevention of endemic disease, proper sanitation and safe water supplies, immunization, nutrition, health education, maternal and child care and family planning. Since resources available for health pro- grams are usually limited, the provision of compre- hensive primary health care to everyone in the near fu- ture remains unlikely. Basic primary health-care systems are far more cir- cumscribed in their goals, which are to provide health workers and establish clinics for treating all illnesses within a population. Nevertheless, this approach is far from inexpensive. The World Bank has estimated that the cost of furnishing basic health services to all the Nov. 1, 1979 3 poor in developing countries by the year 2000 will be . 35.4 to $9.3 billion (in 1975 prices)“ This investment, :2 which includes only initial capital investment and ‘ training costs, would provide one community health worker or auxiliary nurse-midwife for every 1500 to ‘ 2000 people and one health facility for every 8000 to . 12,000 people or every 10 km“, whichever is greater. In 1 the model area in Africa, the World Bank estimated , that supplying the minimum care offered by building . one health post with one vehicle per 10,000 people and '_ training 125 auxiliary nurse-midwives and 250 com- :1 munity health workers would cost $2,500,000, or $5 in per capita. To this figure must be added the recurrent costs of salaries, drugs, supplies and maintenance. Other costs not included are for training facilities, continuing education, expansion of referral services ' and development of communication, transportation :1 and administrative networks to supply and manage the health facilities. Furthermore, the effectiveness of 5 this model program for averting deaths or applying such preventive measures as education in sanitation . and nutrition has not been clearly established. ‘ The pilot projects for providing basic health-care '7 services that have been evaluated vary in their effec- ;‘ tiveness in improving the general level of health ...
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