Carl E. Taylor

Implications for the delivery of health care

Abstract Several international agencies have recently passed resolutions calling for increased comprehension of the interactions at the interface which links social organization of the community with systems of health care so as to make synergism possible. One of the bases on which more synergistic relationships can be built is by development and utilization of a comparative anthropology of health beliefs similar to the comparative epidemiological studies which have made such major contributions to the understanding of multiple causes of diseases. Another is the development of more centrifugal comprehensive care services reaching out to rural communities and integrating both traditional healers and local community leaders. A new partnership between official cosmopolitan medicine and local resources holds a promise of bringing back some of the human concern and hope that health systems need if they are really going to meet social needs.

Child growth as a community-surveillance indicator.

Growth monitoring has unique potential for the ability to correct malnutrition and other health problems at an early age. Monitoring must be a 2-stage process of screening and intervention. Field studies of individuals and communities need to be conducted in order to determine technological and program problems, casual factors, and epidemiology of the problems. Growth monitoring objectives include education, early detection, womens participation, and promotion of community awareness and organization. Workers must decide the priorities of program policy -- including questions of individual growth monitoring vs. monitoring of a population. Pilot programs tend to be more successful than mass implementation because they are more flexible and more open to learning. Field studies that are locally appropriate need to be conducted. These should survey and test the following areas: community situation analysis; objective and priority planning; community intervention; management of primary health care; political administration and public support; locally relevant training of personnel; and self-evaluation of the program. The individual and community-based approaches should be synthesized into 1 cohesive program. Eventually, the sequence of events within any growth monitoring program should be screening of babies, analysis of casual factors, definition of controls, and implementation of the most cost effective controls.

U.S. Medical Students in Nepal.

A formal course in Human Ecology in the Himalayas proved to be a powerful educational innovation partly because of its international setting. The six students in the medical part of this course experienced a profound affective impact on their career goals, a totally new orientation toward the problems of poverty in the United States, and a changed appreciation of the need for preventive measures and a community approach. The effect was far greater than that usually associated with individualized international experiences because of careful preparatory seminars, group activities which included surveys and research, and abundant opportunity for interpretive discussions as cultural and health care shock was being experienced. Clinical work was kept in perspective and provided opportunities for learning, not only about exotic diseases but also about what could be done under the simplest of conditions.

Myths of community-based health care

Editor – I am responding to Adnan Hyder (1), who says that ‘‘community-based health care has been plagued by principles which have become myths’’. It should be pointed out that his principles/myths were not part of Alma-Ata’s message (2, 3) and mostly emerged five years later in the debate which advocated a shift to selective primary health care. An unfortunate polarization between top-down and bottom-up approaches in scaling up programmes to national coverage since then has often stalled health care reform. The dichotomy is false, since we need both. Community-based primary health care brings together multiple approaches to rationalize the balance. I agreewithHyder in debunking the first myth: there is no ‘‘universal model’’, an idea arising from the common public health preference for a blueprint approach. The second myth of focusing ‘‘only on villages’’ was a claimmade in arguing against Alma-Ata but it was never a principle of the Health for All movement. The same applies to the claim that ‘‘governments are the problem’’, since everyone agrees that governments must be a full partner with communities. When he refutes the claim that communitybased programmes are ‘‘less expensive’’, with no indication of less expensive than what, I agree with him that rigorous analysis of real but invisible costs may help. However, to resolve the old polarization, studies of both governmental and community-based activities are needed which look for points of synergy and mutual facilitation. Most of all, I agree with Hyder when he turns from evaluation by costs alone to introduce transparency, equity and need. In the final paragraph he stresses recognition of ‘‘the value base upon which the notion of community-based health care stands’’. He focuses correctly on the values of equity, empowerment and respect, and emphasizes the overriding need for recognition of the plurality of pathways by which these values are put into practice — hopefully in government and village partnerships. A major problem remains: to change the attitudes of international experts who seem to want to prolong the appearance of an argument as part of academic competition. I hope Hyder’s letter will help each of us to clarify our own myths. n Carl E. Taylor, Professor Emeritus Department of International Health School of Hygiene and Public Health Johns Hopkins University 615 N. Wolfe Street, Suite E8132 Baltimore, MD 21205, USA email: Ctaylor@jhsph.edu

Leprosy of the large intestine and gall-bladder: Case report with review of the literature

Abstract The published discussions of intestinal leprosy are scanty and contradictory. There is some evidence for the belief that relatively benign leprous infiltration of the submucosa of the gastro-intestinal tract may take place. It is possible that rarely, particularly during a lepra reaction, this infiltration may undergo necrosis causing active ulceration which is aggravated by secondary infection with intestinal flora. In the case which has been described, the patient died during an active lepra reaction and had diarrhoea terminally. Autopsy revealed numerous necrotic ulcers along the entire large intestine; there was also oedema, necrosis, and haemorrhage in the wall of the gallbladder. The presence of leprosy bacilli in these lesions and the absence of other aetiological agents provide presumptive proof that they were due to leprosy. As far as I have been able to determine, Von Reisners is the only previously published case which can be considered to be ulcerative leprosy of the intestine; I have found no reports of leprous cholecystitis.