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PROSPECTS FOR BETTER NUTRITION THROUGH PRIMARY HEALTH CARE Halfdan Mahler The governments of the world decided in 1977 that a main social target in the coming decades should be the attainment, by all the people of the world by the year 2000, of a level of health that will permit them to lead socially and economically productive lives. This goal has become known as "health for all"--an approach in which health is considered in the context of its contribution to, and promotion by, social and economic development. In the Declaration of Alma-Ata in 1978, the same governments proclaimed that the key to achieving that target was primary health care. That is, essential health care should be made accessible at an affordable cost with methods that are practical, scientifically sound, and socially acceptable and that involve other sectors in addition to the health sector. Those last few words--t'sectors in addition to the health sector"--are essential to an understanding of the reorientation of the health system, and not just the health care system, that is required if health for all is to become a reality. "Health for all" embodies the basic objective of the World Health Organization (WHO) defined in its consti- tution as "the attainment by all peoples of the highest possible level of health." It means accessibility for all persons to all levels of the health system. As a _ ~ ~ , ~ , . . . . . . . . pLOU~SS, 1C demands one reaucclon wltnln and Between countries of the unacceptable differences in health status and in allocation of health resources. But let me not place undue emphasis on "levels," ''processes," and "systems." Health for all refers most of all to people and therefore starts far from the hospital and clinic. It begins in homes, in communities, in schools, in fields, and in factories, where people live and work. It includes what people themselves can do to shape their lives and those of their families, to be free of the preventable burden of disease and disability, and to make the most of their social, economic, intellectual, and cultural potential. It is the fulfillment of that poten- tial that leads to socially and economically productive lives.

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6 NUTRITION AND PRIMARY HEALTH CARE It is within this broad definition of the goal of health for all, and of primary health care as the key to attaining it, that WHO is promoting proper nutrition and wrestling with the consequences of malnutrition. The ~ practical implications of this approach are best summed up in the two vital roles that the health sector plays in preventing and managing malnutrition. The first is a direct role in implementing health interventions that have an impact on the nutritional status of individuals, families, and communities, including the application of specific nutritional concepts at all levels of the health system. Monitoring the growth of infants and young children is a good example of a core primary health care activity that promotes health and prevents malnutrition. Growth and development are reliable indicators not only of overall child well-being, but also of the quality of the environment in which children live. At the same time, meeting the special nutritional needs of women is essen- tial to ensuring their health and the health of their offspring. Malnutrition, including anemia, is a major underlying cause of maternal morbidity and mortality and a particularly serious problem for women who start their pregnancies too early in life or who have too many pregnancies too closely spaced. Moreover, the nutri- tional status of women influences their chances of having normal pregnancies and deliveries and of giving birth to children with adequate weight, as well as their ability to breast-feed without detriment to their own health. Because periodic checks of the health and nutritional status of children and their mothers imply regular con- tact with health services, they also provide ideal opportunities for imparting health-improving and health- preserving messages about appropriate nutrition. Such contact could expose those in need to a full range of preventive, diagnostic, therapeutic, and rehabilitative services--whether at the first point of contact between individuals and the health system, where primary health care starts, or, after referral, through intermediate and central levels, where more complex problems can be dealt with.

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7 The second vital role of the health sector is an indirect one and has to do with the multiple external causes and contributing factors of malnutrition. It includes advocating sound nutritional policies by advising those in the nonhealth sectors on the probable consequences of their actions for nutrition and health and by undertaking joint action with them to improve nutritional status. The best example of this indirect role concerns agriculture. To say that agriculture has an impact on nutrition and health, with respect both to the food produced and to the livelihood provided for most of the world's people, is to flirt with the obvious. Yet, I wonder how often agriculture and health sit down at the same table to discuss the impact of the policies and programs of the former on the priorities and plans of the latter. We are keenly aware of the contribution that the right choice of agricultural policy can make to human health, especially by providing cheap calorie sources for people whose main problem is getting enough to eat. However, the main impact of agricultural policies and programs on nutrition and health occurs via the employ- ment and income of laborers, who constitute most of the rural poor. Choices affecting employment in agricul- ture--including pricing decisions, cultivation of food crops vs. nonfood cash crops, land use and land reform policies, and selection of capital-intensive vs. labor-intensive technology--are thus critical in determining appropriate nutrition and the preservation of health. How often are these choices taken seriously into account? Health professionals have an important responsibility to make clear to agricultural professionals the health consequences of their decisions. To do so, however, we must first make certain that the message of health that ~ .~ ~ ~ accurate, and timely. That is why effective, efficient food and nutrition surveillance schemes are critical for generating the kind of data that will permit health professionals to convey clear and convincing messages about the probable outcomes of agricultural policies and programs. we sent to agriculture IS relevant,

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8 PROMOTING INIERSECTORAL ACTION FOR HEALTH Nutritional status is the result of complex interactions of many individual, household, community, national, and international factors. Food must be produced and procured, whether directly or through cash payment, in exchange for labor, or by some other means. It must then be stored, prepared, cooked, distributed, and consumed. Dependent persons--the very young, the very old, and the infirm--must be fed and cared for. Finally, ingested food must be digested, absorbed, and used by the body. To return to my earlier observation about the reorientation of the health system and the involvement of nonhealth sectors in achieving health for all: The major health policy declarations of the last decade, including the Declaration of Alma-Ata in 1978 and global and regional strategies and plans of action for health for all, have all stressed that health is a social goal that has to be integrated into overall development strategies and that a wide range of actions must contribute to its achievement. Thus, WHO uses the comprehensive term "health system" to signify all the interrelated elements that contribute to health in homes, educational insti- tutions, workplaces, public places, communities, and the physical and psychosocial environment. There is no need to belabor the importance of intersectoral action for health, central as it is to national, regional, and international health policy. What is necessary is to define, in operational terms, what kind of collaboration is required, with which sectors, and through what social, economic, political, and administrative mechanisms, if the consensus con- cerning the approach is to be translated into effective action. Moreover, it is essential that common goals be agreed on and that all concerned contribute actively to their realization. THE ROLE OF NUTRITION IN HEALTH AND THE HEALTH SECTOR'S INVESTMENT IN NUTRITION Malnutrition can be defined in many ways. What I would call a "health equilibrium model" describes it as a

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9 state of imbalance (whether deficiency or excess) at the cellular level between the supply of nutrients and energy and the body's need for them to ensure maintenance, function, growth, and reproduction. If viewed from this perspective, malnutrition is a major public health problem the world over, not only in developing countries, where wasting and stunting are but its most conspicuous signs. Malnutrition is rampant in. industrial countries, where obesity ranks first in importance with its allied conditions--hypertension, cardiovascular disorders, and (the circumstantial evidence continues to mount) some kinds of cancer. The industrial countries face the deadly combination of faulty dietary habits and inappro- priate life styles, including the uses of tobacco and too much alcohol and the lack of sufficient exercise or even genuine relaxation. The result is nutritional disequi- librium having just as disastrous consequences for health, even if they are not as dramatic, as the stereotypical skin-and-bones image at the other end of the malnutrition spectrum. We are only beginning to appreciate the irony of the coexistence of ill health from nutritional deficiency and ill health from nutritional excess. A Haitian creole proverb that I find delightful in its simplicity and directness says a great deal about the interrelationship between nutrition and health in the part of the world that concerns us here: Sak vice pa kampe--"An empty sack cannot stand on its own." A block at any stage of the normal flow of nutrients and energy from the external environment to body cells, starting with food availability and ending with metabolism, can prevent our sack from standing, malnutrition and ill health. In general, three important factors regulate the way a person strikes a balance between demand for energy and nutrients and their supply: quantity and quality of available food, health and physiological status, and behavior, including psychosocial state. For example, most malnutrition seen during periods of natural or man-made disaster is due to a temporary, acute deficiency of food intake. Malnutrition in developing countries generally results from the combination of a chronically marginal food intake with a high frequency and duration - that is, can produce

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10 of illness. Moreover, malnutrition in industrialized countries has its roots mainly in behavioral factors. The underlying causes of malnutrition in each of these environments are closely linked to such circumstances within and between families, regions, and countries as availability and distribution of food, purchasing power and production possibilities, information and education, and access to health and other social services. Broadly speaking, in developed countries and among minority elites in developing countries, the amount and variety of available food poses no particular problem, and the main role of the health sector is to influence knowledge and behavior regarding healthy life styles. But the situation is dramatically different for the majority in developing countries. Food availability itself (apart from choice in relation to quality) is a A major focus of the health sector in serious problem. this environment must be to keep the body as free from disease as possible to permit maximal benefit of whatever food is available. We have begun to understand that the disastrous nutritional status of so many of the world's poor is due to a large extent to the presence of infec- tion and disease, as well as to the absence of food. The high incidence and severity of many diseases in the developing world are due to an unbroken cycle of infection and malnutrition, each reinforcing and capable of initiating the other. Children in particular often have defense mechanisms compromised from the start by low birth weight and are further assailed by a series of stresses that include measles, whooping cough, and repeated episodes of diarrhea and malaria. Each event sets back a child's growth and development; if the interval between events is too short, a spiral leading to death all too often results. The primary health care approach to community health problems is particularly well suited to break this cycle of infection and malnutrition, because it can bring so many essential elements to bear simultaneously. For example, individual, family, and community involvement is the key to ensuring that necessary, but simple and inex- pensive, preventive action is taken. Information and education help mothers and other family members to understand how to keep their children healthy, why their children might not be growing properly, and how to treat

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11 infection. Proper nutrition is important both as a preventive measure and as part of treatment. Safe water and basic sanitation, with personal hygiene and food safety, are essential to preserving health. Oral Dehydration salts are an important essential dz~ that can be made available to all. Immunization prevents infectious diseases that can precipitate malnutrition. And maternal and child health care, including family planning, has a mutually reinforcing effect on the health and nutritional status of mothers and children. THE LESSONS HE ARE LEARNING Eight years after the unanimous adoption of health for all as our main social target, can we say that our high expectations about primary health care's con- tribution to better nutrition are being justified? Information coming in from around the world gives rise to legitimate optimism in this regard. It shows that properly designed and implemented routine primary health care is having an impact on nutritional status in environments as varied as Botswana, China, Colombia, Egypt, E1 Salvador, Kenya, Lesotho, Nicaragua, Sri Lanka. and Thailand. The varied degrees in these and other countries have In common: of success registered at least four features The primary health care activities being pursued in each have explicit nutritional objectives as measures of their successful outcome. Health care components are carefully selected to match identified problems, and their implementation is sustained at an adequate level and for an adequate period to be effective. Monitoring and evaluation are built-in facets of service delivery and allow flexibility for swift correc- tive action where necessary. Community involvement is considered a prere- quisite, not only in making use of services, but in developing suitable mechanisms for the planning, opera- tion, and control of community health care programs.

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12 Not long ago, I visited an African country in the least-developed category that offers a striking example of a system of primary health care that, odds, is coping admirably with threats to the nutritional and health status of its entire population. The coun- try's essentially agrarian economy has been badly shaken by a severe drought that has afflicted the country for almost 4 years. But its national coordinator of rural development has been able to announce that no one has died as a result. How is it that drought has brought only hardship to this country but spelled disaster in so many others? One reason is that it was able to prepare _ against enormous . itself, thanks to a long-term commitment to the setting in place of a permanent, simplified, and highly effective primary health care infrastructure. The country has long had an operational food and nutrition "early-warning system," including some 500 small health posts that conduct regular surveys to monitor nutritional status. People have survived the drought, because there were timely responses to it, including the organization of supplementary feeding programs through the health care system. CONCLUSION The universal acceptance of primary health care as the means for achieving health for all is a milestone in the prevention and control of malnutrition. There are many examples of families, communities, and nations of widely varied degrees of wealth, stages of economic development, and geographical location that are managing to protect and improve nutritional and health status by applying the principles of primary health care. Many others will do so in the near future. The problem of malnutrition, for all its devastating seriousness, is reasonably well understood, and ways of dealing with its underlying causes are sufficiently developed for us to _ make progress on this front, provided that we have the necessary political commitment. We are engaged in nothing less than the slow, sometimes discouraging, but ultimately moral struggle to break the vicious circle of poverty, malnutrition, disease, and despair. Let us exploit to the fullest the

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13 finely crafted tools that we have at our disposal--health for all as our objective and primary health care as our means to achieve it--in preventing and tackling the problems associated with hunger and malnutrition. We have every reason to believe that our long-term i~.rest- ment in health and development will ultimately succeed. DISCUSSION OF DR. MAHLER'S PAPER DR. BENTLEY: It seems to me that there are no simple solutions. There is a lack of understanding on the biological side. What will be the motivation for and role of behavioral research? DR. MAHLER: Not until I worked in India did I manage a program that used both economists and social scien- tists. Ever since, it has been very difficult to con- vince the directors at WHO that it is worth investing in social or behavioral research. I think the WHO member states are beginning to see that if you want to translate laboratory knowledge from clinical trial or epidemiologi cal studies into reality, there is a huge gap which requires behavioral research. Nothing is more humil- iating than the case of tuberculosis control efforts. Despite the revolutionary introduction of standard chemotherapy 25 years ago, with reductions in the cost of treatment and diagnosis to a hundredth of what it was, compliance with required treatment is no more than 15 or 20%. This is because the kind of behavioral research that is needed has not been done. I believe that in nutrition there is an important need for such research. DR. NESHEIM: Some have argued that the solutions to the problems of malnutrition in the world were only to be achieved through economic development, and I think I understood from your discussion of a primary health care system that the interventions that can be undertaken in primary health care have a role to play in immediately alleviating problems of malnutrition. Perhaps these two views can be integrated. DR. MAHLER: In Asia, for example, if the health sector comes together with the agricultural sector, there

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14 are many avenues for making more calories available and thereby preventing and ameliorating malnutrition. Given that health is part of the soft social sector, compared with the harsh realities of economic growth, I believe that one can do much to ensure that the nutrient value will be more appropriate and better used and that nutritional interventions will be supported through the primary health care approach. Even in countries where economic growth has been limited, it is still possible to have a useful discussion of the relationships of productivity and consumption.