Care within Reach: Appropriate Health-Care Delivery in the Developing World
Authors: M K Nations, D S Shields, J G Araujo, M A de Sousa, R L Guerrant
Journal: New England Journal of Medicine (1984)

Despite recent advances in medical science the poor health of many in the developing world remains a reality; more than half of the worlds people do not have access to even basic health care.  Providing basic biomedical services requires financial and personal resources that are simply far beyond the capacities of most developing nations.  Hence cost-effective approaches are needed.  1 such proposed strategy would focus limited resources on high-priority diseases such as diarrhea measles whooping cough schistosomiasis and neonatal tetanus singled out because of high prevalence associated mortality and the existence of effective control measures.  Another approach gives priority to poor mothers and children living in rural and periurban areas because they are expected to have the greatest increase in life expectancy as a result of health investments.  Although these selective approaches have merit a number of obstacles still impede the provision of primary health care fashioned after the Western biomedical model--e.g. expensive and inappropriate technology uneven distribution of physicians excessive dependence on costly drugs inconsistent availability of medical supplies and high personal cost for physicians.  Clearly what is needed are creative low-cost health-care strategies that are socially and culturally appropriate to local communities.  In our 6 years of experience working on diarrheal illnesses in northeast Brazil we have learned that mobilization and the use of existing health resources--the indigenous medical system and its traditional healers--offer a promising medical system that promotes health for all.  The system uses the assistance of the traditional healer to deliver lifesaving oral rehydration solutions in the treatment of diarrheal illnesses which constitute the leading cause of death in most parts of the developing world.  As noted in Figure 1 traditional healers are uniformly consulted early in the course of an illness long before the aid of village health workers or physicians is sought and usually before complications or serious dehydration ensue.  It is obvious from these data that in order to provide the critical early management of potentially serious illnesses such as diarrhea in the community one must deal directly with the traditional healers or mothers rather than only with visiting nurses physicians or hospital-based personnel.  Healers are pragmatic; they see value in selected modern pharmaceuticals refer difficult cases to physicians and encourage such preventive measures as breastfeeding.  Furthermore healers accurately prepare oral rehydration solutions with safe sodium concentrations and their treatment is more acceptable to the villagers because it is given with the prestige and perceived power of the healers.  The articualtion of traditional and biomedical care can provide services that are both technically competent and culturally acceptable.  Implementing such innovative programs for health care delivery will require health professionals to come to grips with financial attitudinal social and political issues that hamper the full acceptance of alternative healers and their systems of medicine.  However to deal effectively with the major causes of morbidity and mortality on a global scale it is imperative that we bridge ethnological advances with existing widely sought respected indigenous healers.  (full text)