Black, PREVENTION IN DEVELOPINGCOUNTRIES
$13~,
Finally, and needing an even higher priority, there must be a parallel effort to r e m e d y the underlying causes of ill health in the environment and in socioecon o m i c structures. Together, the p o p u l a t i o n and the clinical approaches will achieve greater success than either by itself c o u l d h o p e for.
5. 6. 7.
REFERENCES 8.
1. U.S. Preventive Services Task Force. Guide to clinical preventive services: an assessment of the effectiveness of 169 interventions. Baltimore: Williams and Wilkins, 1989. 2. Mann AH. The psychological effect of a screening programme and clinical trial for hypertension upon the participants. Psychol Med. 1977;7:431-8. 3. Rose G. The strategy of prevention: lessons from cardiovascular disease. Br MedJ. 1981;282:1847-51. 4. Hypertension Detection and Follow-up Program Cooperative Group. Five-year findings of the Hypertension Detection and
9. I0.
l l.
Follow-up Program. 1. Reduction in mortality of persons with high blood pressure, including mild hypertension. JAMA. 1979;242:2562-71. Medical Research Council Working Party on Mild to Moderate Hypertension. MRC trial of treatment of mild hypertension: principal results. Br MedJ. 1985;291:97-104. Lipid Research Clinics Program. The Lipid Research Clinics coronary primary prevention trial results. JAMA. 1984 ;251:351-74. Kornitzer M, Rose G. WHO European collaborative trial of multifactorial prevention of coronary heart disease. Prev Med. 1985;14:272-8. Rose G. European collaborative trial of multifactorial prevention of coronary heart disease. Lancet. 1987;i:685. Rose G. Sick individuals and sick populations. Int J Epidemiol. 1985;14:32-8. Intersalt Cooperative Research Group. Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24-hour urinary sodium and potassium excretion. Br Med J. 1988;297:319-28. Kreitman N. Alcohol consumption and the preventive paradox. Br J Addict. 1986;81:353-63.
Prevention in Developing Countries ROBERT E. BLACK, MD, MPH Developing countries have i m p l e m e n t e d p r i m a r y health care p r o g r a m s directed p r i m a r i l y a t p r e v e n t i o n a n d mana g e m e n t o f i m p o r t a n t infectious a n d n u t r i t i o n a l p r o b l e m s o f children. Successful p r o g r a m s have e m p h a s i z e d the n e e d f o r i n d i v i d u a l a n d c o m m u n i t y i n v o l v e m e n t a n d have been c h a r a c t e r i z e d by responsible g o v e r n m e n t p o l i c i e s f o r equitable i m p l e m e n t a t i o n o f efficacious a n d cost-effective health interventions. Unfortunately, detmloping c o u n t r i e s m u s t also f a c e increases i n the c h r o n i c disease a n d social p r o b l e m s c o m m o n l y associated with i n d u s t r i a l i z e d countries. P r e v e n t i o n efforts, f o r example, to reduce tobacco s m o k i n ~ to m o d i f y the dieg to reduce injuries, o r to a v e r t e n v i r o n m e n t a l c o n t a m i n a t i o n , a r e n e e d e d to c o n t a i n f u ture m o r b i d i t y a n d rapidly i n c r e a s i n g medical c a r e costs. Developing c o u n t r i e s c a n build o n t h e i r successful app r o a c h e s to p r o g r a m i m p l e m e n t a t i o n a n d a d d o t h e r measures directed a t p r e s e r v a t i o n o f health a n d p r e v e n t i o n o f disease in adult a s well as child p o p u l a t i o n s . K e y words: injuries; developing countries; mortality; lOex,t m n t i o ~ smoking. J GEN IN't'vatN MED 1 9 9 0 ; 5 ( s u p p l ) : S 1 3 2 - 8 1 3 5 . PREVENTION IN DEVELOPING COUNTRIES is a broad, a n d somewhat daunting, topic. One may approach it by considering two questions: "Can we in the United States learn from developing-country experiences, both successes and failures, in health care?" and "Can d e v e l o p i n g c o u n t r i e s l e a r n f r o m o u r s u c c e s s e s a n d failures in health care?"
Received from the Department of International Health, The Johns Hopkins University School of Hygiene and Public Health, 615 North Wolfe Street, Baltimore, Maryland 21205. Presented at the conference, Frontiers in Disease Prevention, The Johns Hopkins University, June 5 - 6, 1989. Address correspondence and reprint requests to Dr. Black.
LESSONS FROM DEVELOPING COUNTRIES To begin with developing-country lessons, it is necessary to trace some trends internationally. Health sector efforts have evolved substantially in the last 40 years. Until the 1940s, the emphasis was on curative or palliative care delivered at hospitals or health centers by doctors. Nurses and auxiliaries were aides to the doctor, rather than providers of care. Beginning in the 1940s, there was some shift from the attention to individuals to the focus on communities. This included an emphasis on preventive programs, such as environmental sanitation or health education. These efforts were (and are, since this is still a c o m m o n health sector orientation in some developing countries) often delivered from health facilities or by selective outreach activities. The services were delivered at one level by doctors and nurses and at a second level by auxiliaries w h o staffed small dispensaries or mobile teams. This a p p r o a c h improved availability of services, but access was uneven, utilization was low, and the impact on health was modest. An important reorientation in health sector strategy was that toward a c o n c e r n for the entire population, i.e., the goal of "health for all." This objective was included in the constitution of the World Health Organization in 1948, but it took several decades to begin to see real action. The international meeting in Alma-Ata in 1978 declared the goal of "Health for All by the Year 2 0 0 0 . " This goal of universal coverage required greater stress on equity in health care and health outcomes. There was recognition that services were not
JOURNALOFGENERALINTERNALMEDICINE, Volume5 (September/OctoberSupplement), 1990
reaching the segments of the p o p u l a t i o n that had the greatest p r o b l e m s , and that health programs had to be rethought. In this reformulation, several i m p o r t a n t needs w e r e considered: 1. Need for individual and c o m m u n i t y self-reliance, responsibility, and participation. This requires a shift in thinking from seeing p e o p l e as the passive recipients of medical services to seeing t h e m as the active p r o d u c e r s of health, w h o n e e d to be provided with the means of production. 2. Need for a p p r o a c h e s to be efficacious and costeffective in dealing with current and e m e r g i n g health p r o b l e m s of the population. This requires an understanding of the health p r o b l e m s and their consequences, an a p p r e c i a t i o n of high-risk groups, and a continuous critical evaluation of the control strategies. 3. Need for a b r o a d e r c o n c e p t of the health t e a m to include various health professionals and c o m m u n i t y health workers, as well as experts in e p i d e m i o l o g y to assess health p r o b l e m s and control approaches, in social sciences to understand the determinants of health-related behaviors, in c o m m u n i c a t i o n s to inform and motivate the p o p u l a t i o n , and in m a n a g e m e n t sciences to operate and i m p r o v e the health programs. 4. Need for a c o m m i t m e n t to equity in the delivery of services and in the o u t c o m e s achieved. It is clear that p o o r d e v e l o p i n g countries still have severe p r o b l e m s with infectious diseases and malnutrition in childhood. It should be no surprise that for the entire p o p u l a t i o n of a c o u n t r y such as Ghana, malaria, measles, p n e u m o n i a , malnutrition, diarrhea, and tuberculosis are a m o n g the top ten causes of healthy days of life lost. 1 These c h i l d h o o d diseases have received priority attention in d e v e l o p i n g - c o u n t r y health programs. To confront these problems, major current child health p r o g r a m efforts involve: 1) monitoring of growth and nutritional support, 2) fluid and dietary therapy of diarrhea at the h o u s e h o l d level to p r e v e n t dehydration and malnutrition, 3) breastfeeding to prevent diarrhea and other infectious diseases and to supp o r t growth, 4) w a t e r and sanitation to prevent a variety of infectious diseases, and 5) immunizations to p r e v e n t c h i l d h o o d infectious diseases. Thus, the emphasis is on prevention of disease at the p o p u l a t i o n level. Primary health care projects have d e m o n s t r a t e d a substantial reduction, u p to 6 0 - 7 0 % , in infant and child mortality at a cost of less than $2.00 per capita, z There is recognition that the potential i m p a c t of these cost-effective technologies can be realized on a larger
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scale, if cultural, sociopolitical, and e c o n o m i c constraints can be overcome. There is also recognition that the determinants of health include poverty and social injustice and that these are part of the health agenda. Surely, the focus of d e v e l o p i n g - c o u n t r y programs on p r e v e n t i o n of disease at the p o p u l a t i o n level, on improving the delivery of cost-effective interventions, on fostering individual and c o m m u n i t y i n v o l v e m e n t w i t h health, and on equity serve as lessons from w h i c h the m o r e w e a l t h y d e v e l o p e d countries can learn.
LESSONS FROM DEVELOPED COUNTRIES To turn to the lessons for d e v e l o p i n g countries based on the e x p e r i e n c e of the m o r e d e v e l o p e d countries, it is important to note that the United States of 50 - 100 years ago had a health picture similar to those of some of the worst d e v e l o p i n g countries today. Further, one must note that the shift from the c h i l d h o o d infectious and nutritional p r o b l e m s of d e v e l o p i n g countries to the chronic disease and social p r o b l e m s of industrialized countries, the so-called " e p i d e m i o l o g i c transition", does not h a p p e n along a s m o o t h continuum. In fact, m a n y countries today face b o t h sets of p r o b l e m s simultaneously, in large part because of social inequity and e p i d e m i o l o g i c variability within the country. It is c o m m o n in countries such as Brazil or even in cities such as Mexico City for the two sets of p r o b l e m s to exist simultaneously. This presents severe challenges and strains on the health budget, imposing even m o r e difficult decisions in regard to priorities and allocation of resources. Before going on to consider specific health conditions and the implications for prevention, it is necessary to review certain d e m o g r a p h i c trendsP Special note will be given to some of these trends in Brazil, since health p r o b l e m s of this country will be considered in m o r e detail later. First, mortality rates have b e e n declining and life expectancies increasing in developing countries, primarily because of the p r e v e n t i o n of c h i l d h o o d deaths. In 20 - 30 years, life e x p e c t a n c i e s in Latin America are e x p e c t e d to be only slightly less than those in the United States. Second, birth rates c o n t i n u e to be high in most countries, resulting in p o p u l a t i o n growth rates of 2 - 4%. Third, the age structures of dev e l o p i n g countries are changing, with a trend towards aging of the population. While the United States currently has a m u c h larger fraction of its p o p u l a t i o n over 65 years old, this age g r o u p is increasing in Brazil at a faster rate, anticipated to be a 50% increase b e t w e e n 1980 and 2000. And fourth, m a n y d e v e l o p i n g countries are increasing their urban populations, often because of migration, and project a stable or decreasing rural population. Brazil will be considered as a case study. Life exp e c t a n c y increased from 41 years in 1940 to 59 years in 1980. Infectious and parasitic diseases a c c o u n t e d for 80% of deaths in 1940 and only 8% in 1980, p r e d o m i -
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Black, PREVENTION IN DEVELOPINGCOUNTRIE.5
nantly as a result of real changes in age-specific death rates and, to a lesser degree, changes in the age structure of the population. Mortality rates from heart disease, neoplasms, and cerebrovascular disease have remained constant or have increased in the last 40 years. The current three leading causes of potential years o f life lost after infancy are very similar to those in the United States. In Brazil, these are injuries, heart disease, and cerebrovascular disease.3 Neoplasms are also of importance, with rapid increases in lung cancer among others) Deaths due to injuries (including traffic accidents, homicide, suicide, industrial accidents, and other injuries) have a large impact on calculations of years of p r o d u c t i v e life lost since they o c c u r often in the young adult age group. Traffic accidents account for the largest n u m b e r of deaths due to injuries, with rates (approximately 20 per 1 0 0 , 0 0 0 per year) that are similar to those in the United States.4 When considered in terms of mortality p e r vehicle or per mile driven, rates in Brazil are substantially higher. Judging from experience in other countries, ensuring the use of motorcycle helmets and automobile seat belts through legal and educational means w o u l d be e x p e c t e d to r e d u c e traffic fatalities. The high p r o p o r t i o n (43%) o f Brazilian traffic fatalities that o c c u r among pedestrians, however, suggests that other changes in driving patterns and road crossing safety will be n e e d e d ) Since high proportions of b o t h vehicle and pedestrian deaths in Brazil seem to be related to excessive c o n s u m p t i o n of alcohol, other educational and legal interventions will also be necessary. The United States has made some progress in controlling traffic fatalities through these means and this e x p e r i e n c e should be instructive to developing countries. Risk factors for n o n c o m m u n i c a b l e diseases such as heart disease, cerebrovascular disease, and cancer are complex, but it is clear that there are important identifiable individual behaviors and environmental exposures. Of these, one might consider the case of tobacco smoking, w h i c h has b e e n shown to have a causal role for many important n o n c o m m u n i c a b l e diseases, such as some cancers, vascular disease, and obstructive pulmonary disease. In Brazil, cigarette c o n s u m p t i o n per capita increased rapidly for several decades until the late 1970s. 4 Beginning at that time and continuing in the 1980s, anti-smoking campaigns attempted to reverse the trend. These efforts to raise prices and provide education in order to r e d u c e smoking are considered well managed and successful, resulting in a 20% decline in per-capita consumption. 4 However, observations that 63% of Brazilian men continue to smoke and that smoking has c o n t i n u e d to increase to 33% among Brazilian w o m e n indicate that increased efforts are needed. Since it appears that cigarette c o n s u m p t i o n is highly elastic to price changes, especially among the p o o r and among young adults, higher cigarette taxes
may help r e d u c e s m o k i n g ) Furthermore, additional efforts to limit advertising and to provide education, particularly targeted to young w o m e n , are needed. Since the costs of anti-smoking efforts are small (and may be self-financed through cigarette taxes) and the benefits in terms of health or costs for health care are large, smoking prevention efforts w o u l d appear to be strongly indicated. The dramatic decreases in cigarette consumption in the United States as a result of anti-smoking efforts in the last several decades should provide optimism that countries such as Brazil can control this serious public health problem. In Brazil, other behavioral determinants of nonc o m m u n i c a b l e diseases, such as p o o r diet with high levels of salt and fat and low levels of fiber, are increasing, especially among the middle class. Likewise, in this group inadequate exercise and obesity are growing problems. Furthermore, occupational and environmental exposures to harmful substances present serious health risks and environmental p r o t e c t i o n efforts have only just b e g u n ) The experiences of d e v e l o p e d countries, including their difficulties in motivating individual behavior change and in developing sufficient public consensus for environmental protection, should also provide important lessons to developing countries that are increasingly facing these serious threats to health. O f course, AIDS poses a serious health threat to the populations of developing countries. However, it also presents potentially serious problems for the health systems of developing countries. The cost of treating an AIDS patient in Brazil is n o w e x t r e m e l y high and nearly all of this care occurs in public hospitals. The n u m b e r of HIV-infected persons in Brazil may n o w approach a half-million, and this n u m b e r may be doubling every year. The implications for the demand on public sector health resources are ominous and the projections for indirect costs to society and human suffering are even most disturbing. Brazil is already feeling the effects of this epidemiologic transition. The percentage of public sector resources allocated for individual illness treatment (vs. preventive services) has risen from 36% in 1965 to 85% in 1982. The proportion of the gross national p r o d u c t devoted to health has increased from 1% in 1950 to about 6% currently. 5 If Brazil wants to see what is coming, it could look to the United States, w h i c h devotes 12% of its gross national p r o d u c t to health, a p r o p o r t i o n that has been rapidly increasing in recent years. Yet many of the cost-effective preventive programs necessary to meet these challenges have not b e e n d e v e l o p e d or have been ineffective. What must developing countries do? Learning from the e x p e r i e n c e of d e v e l o p e d countries, the developing and transitional countries must consider ways to contain the costs of illness treatment and to place more emphasis on preventive approaches to improving
JOURNALOF GENERALINTERNALMEDICINE, Volume5 (September/OctoberSupplement), 1990
health. Cost containment, to some extent, can be done by shifting from expensive inpatient care to lower-cost ambulatory services. The a p p r o a c h should also include taking greater advantage of all of the members of the health care team and reducing the treatment cost per patient. Unfortunately, with constrained budgets in developing countries, even more difficult choices will need to be made. Rationing of resources for medical care, especially for expensive, potentially life-prolonging technology, is never comfortable, but is and will be necessary. Heavy reliance on the public sector for medical care in developing countries will make these decisions about allocation of resources critical, since without them it is likely that the resources will c o m e at the expense of other essential c o m p o n e n t s of the health system, such as the prevention of acute and c h r o n i c diseases. It is n o w accepted that there are many preventive approaches that are more cost-effective than late curative or palliative care. Primary prevention efforts, for example, to reduce tobacco smoking, to modify the diet, to reduce injuries, or to avert environmental contamination, are essentially nonexistent in most develo p i n g countries. The result is that the risks are increasing. Secondary prevention efforts, for example, hypertension or cancer screening, have been inconsistent and ineffective. Insufficient attention and resources have been brought to bear on these increasing problems. As w e k n o w from our experience in the United States, the task is difficult, but progress can be made. Developing countries have the o p p o r t u n i t y to establish their policies before the d e v e l o p m e n t of a high-cost medical infrastructure and of limitless expectations for medical services. The choices will not be easy, and some p e o p l e lament that developing countries cannot
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afford to implement the legal controls and populationbased preventive approaches. However, one might consider that they cannot afford to make the mistake of choosing high-cost illness management over preservation of health and prevention of disease. Developing countries must also recognize that this has to be an active choice and that a passive stance is, in fact, a choice of high rates of chronic disease and expensive illness management, w h i c h is against their longer-term interests. We need to be challenged by the cry of Mahatma Ghandi near the end of his life, "I am hard-hearted e n o u g h to let the sick die if you c o u l d tell me h o w to prevent others from b e c o m i n g sick." Acting sooner rather than later can only lessen the pain of these difficult decisions. Accomplishing this strategy of prevention will need to draw u p o n the necessary elements of individual self-reliance, c o m m u n i t y involvement, and responsible government, with an interest in equity and human development. Developing countries can build on their success and learn from the mistakes of the industrialized countries. They can make different choices, if they have the foresight and the courage.
REFERENCES 1. Ghana Health Assessment Project Team. A quantitative method of assessing the health impact of different diseases in less developed countries. IntJ Epidemiol. 1981;10:73-80. 2. Evans,JR, Hall KL,WarfordJ. Shattucklecture-- health care in the developing world: problems of scarcity and choice. N EnglJ Med. 1981;305:1117-27. 3. Health conditions in the Americas-- 1981 - 1984; vol 1; no 500. Washington, DC: Pan American Health Organization, 1986. 4. World Bank. Adult health in Brazil: adjusting to new challenges. Report no 7807-BR. Washington, DC: World Bank, 1989:133. 5. Briscoe J, Birdsall N, Echeverri O, McGreeveyW, Saxenian H. Financing health services in developing countries, with special reference to Brazil. In: Proceedings of Seminario sobre Financiamemo do SistemaUnico e Descentralizado de Saude, Secretariat of Health, Sao Paulo, 1988.
$13~,
Finally, and needing an even higher priority, there must be a parallel effort to r e m e d y the underlying causes of ill health in the environment and in socioecon o m i c structures. Together, the p o p u l a t i o n and the clinical approaches will achieve greater success than either by itself c o u l d h o p e for.
5. 6. 7.
REFERENCES 8.
1. U.S. Preventive Services Task Force. Guide to clinical preventive services: an assessment of the effectiveness of 169 interventions. Baltimore: Williams and Wilkins, 1989. 2. Mann AH. The psychological effect of a screening programme and clinical trial for hypertension upon the participants. Psychol Med. 1977;7:431-8. 3. Rose G. The strategy of prevention: lessons from cardiovascular disease. Br MedJ. 1981;282:1847-51. 4. Hypertension Detection and Follow-up Program Cooperative Group. Five-year findings of the Hypertension Detection and
9. I0.
l l.
Follow-up Program. 1. Reduction in mortality of persons with high blood pressure, including mild hypertension. JAMA. 1979;242:2562-71. Medical Research Council Working Party on Mild to Moderate Hypertension. MRC trial of treatment of mild hypertension: principal results. Br MedJ. 1985;291:97-104. Lipid Research Clinics Program. The Lipid Research Clinics coronary primary prevention trial results. JAMA. 1984 ;251:351-74. Kornitzer M, Rose G. WHO European collaborative trial of multifactorial prevention of coronary heart disease. Prev Med. 1985;14:272-8. Rose G. European collaborative trial of multifactorial prevention of coronary heart disease. Lancet. 1987;i:685. Rose G. Sick individuals and sick populations. Int J Epidemiol. 1985;14:32-8. Intersalt Cooperative Research Group. Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24-hour urinary sodium and potassium excretion. Br Med J. 1988;297:319-28. Kreitman N. Alcohol consumption and the preventive paradox. Br J Addict. 1986;81:353-63.
Prevention in Developing Countries ROBERT E. BLACK, MD, MPH Developing countries have i m p l e m e n t e d p r i m a r y health care p r o g r a m s directed p r i m a r i l y a t p r e v e n t i o n a n d mana g e m e n t o f i m p o r t a n t infectious a n d n u t r i t i o n a l p r o b l e m s o f children. Successful p r o g r a m s have e m p h a s i z e d the n e e d f o r i n d i v i d u a l a n d c o m m u n i t y i n v o l v e m e n t a n d have been c h a r a c t e r i z e d by responsible g o v e r n m e n t p o l i c i e s f o r equitable i m p l e m e n t a t i o n o f efficacious a n d cost-effective health interventions. Unfortunately, detmloping c o u n t r i e s m u s t also f a c e increases i n the c h r o n i c disease a n d social p r o b l e m s c o m m o n l y associated with i n d u s t r i a l i z e d countries. P r e v e n t i o n efforts, f o r example, to reduce tobacco s m o k i n ~ to m o d i f y the dieg to reduce injuries, o r to a v e r t e n v i r o n m e n t a l c o n t a m i n a t i o n , a r e n e e d e d to c o n t a i n f u ture m o r b i d i t y a n d rapidly i n c r e a s i n g medical c a r e costs. Developing c o u n t r i e s c a n build o n t h e i r successful app r o a c h e s to p r o g r a m i m p l e m e n t a t i o n a n d a d d o t h e r measures directed a t p r e s e r v a t i o n o f health a n d p r e v e n t i o n o f disease in adult a s well as child p o p u l a t i o n s . K e y words: injuries; developing countries; mortality; lOex,t m n t i o ~ smoking. J GEN IN't'vatN MED 1 9 9 0 ; 5 ( s u p p l ) : S 1 3 2 - 8 1 3 5 . PREVENTION IN DEVELOPING COUNTRIES is a broad, a n d somewhat daunting, topic. One may approach it by considering two questions: "Can we in the United States learn from developing-country experiences, both successes and failures, in health care?" and "Can d e v e l o p i n g c o u n t r i e s l e a r n f r o m o u r s u c c e s s e s a n d failures in health care?"
Received from the Department of International Health, The Johns Hopkins University School of Hygiene and Public Health, 615 North Wolfe Street, Baltimore, Maryland 21205. Presented at the conference, Frontiers in Disease Prevention, The Johns Hopkins University, June 5 - 6, 1989. Address correspondence and reprint requests to Dr. Black.
LESSONS FROM DEVELOPING COUNTRIES To begin with developing-country lessons, it is necessary to trace some trends internationally. Health sector efforts have evolved substantially in the last 40 years. Until the 1940s, the emphasis was on curative or palliative care delivered at hospitals or health centers by doctors. Nurses and auxiliaries were aides to the doctor, rather than providers of care. Beginning in the 1940s, there was some shift from the attention to individuals to the focus on communities. This included an emphasis on preventive programs, such as environmental sanitation or health education. These efforts were (and are, since this is still a c o m m o n health sector orientation in some developing countries) often delivered from health facilities or by selective outreach activities. The services were delivered at one level by doctors and nurses and at a second level by auxiliaries w h o staffed small dispensaries or mobile teams. This a p p r o a c h improved availability of services, but access was uneven, utilization was low, and the impact on health was modest. An important reorientation in health sector strategy was that toward a c o n c e r n for the entire population, i.e., the goal of "health for all." This objective was included in the constitution of the World Health Organization in 1948, but it took several decades to begin to see real action. The international meeting in Alma-Ata in 1978 declared the goal of "Health for All by the Year 2 0 0 0 . " This goal of universal coverage required greater stress on equity in health care and health outcomes. There was recognition that services were not
JOURNALOFGENERALINTERNALMEDICINE, Volume5 (September/OctoberSupplement), 1990
reaching the segments of the p o p u l a t i o n that had the greatest p r o b l e m s , and that health programs had to be rethought. In this reformulation, several i m p o r t a n t needs w e r e considered: 1. Need for individual and c o m m u n i t y self-reliance, responsibility, and participation. This requires a shift in thinking from seeing p e o p l e as the passive recipients of medical services to seeing t h e m as the active p r o d u c e r s of health, w h o n e e d to be provided with the means of production. 2. Need for a p p r o a c h e s to be efficacious and costeffective in dealing with current and e m e r g i n g health p r o b l e m s of the population. This requires an understanding of the health p r o b l e m s and their consequences, an a p p r e c i a t i o n of high-risk groups, and a continuous critical evaluation of the control strategies. 3. Need for a b r o a d e r c o n c e p t of the health t e a m to include various health professionals and c o m m u n i t y health workers, as well as experts in e p i d e m i o l o g y to assess health p r o b l e m s and control approaches, in social sciences to understand the determinants of health-related behaviors, in c o m m u n i c a t i o n s to inform and motivate the p o p u l a t i o n , and in m a n a g e m e n t sciences to operate and i m p r o v e the health programs. 4. Need for a c o m m i t m e n t to equity in the delivery of services and in the o u t c o m e s achieved. It is clear that p o o r d e v e l o p i n g countries still have severe p r o b l e m s with infectious diseases and malnutrition in childhood. It should be no surprise that for the entire p o p u l a t i o n of a c o u n t r y such as Ghana, malaria, measles, p n e u m o n i a , malnutrition, diarrhea, and tuberculosis are a m o n g the top ten causes of healthy days of life lost. 1 These c h i l d h o o d diseases have received priority attention in d e v e l o p i n g - c o u n t r y health programs. To confront these problems, major current child health p r o g r a m efforts involve: 1) monitoring of growth and nutritional support, 2) fluid and dietary therapy of diarrhea at the h o u s e h o l d level to p r e v e n t dehydration and malnutrition, 3) breastfeeding to prevent diarrhea and other infectious diseases and to supp o r t growth, 4) w a t e r and sanitation to prevent a variety of infectious diseases, and 5) immunizations to p r e v e n t c h i l d h o o d infectious diseases. Thus, the emphasis is on prevention of disease at the p o p u l a t i o n level. Primary health care projects have d e m o n s t r a t e d a substantial reduction, u p to 6 0 - 7 0 % , in infant and child mortality at a cost of less than $2.00 per capita, z There is recognition that the potential i m p a c t of these cost-effective technologies can be realized on a larger
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scale, if cultural, sociopolitical, and e c o n o m i c constraints can be overcome. There is also recognition that the determinants of health include poverty and social injustice and that these are part of the health agenda. Surely, the focus of d e v e l o p i n g - c o u n t r y programs on p r e v e n t i o n of disease at the p o p u l a t i o n level, on improving the delivery of cost-effective interventions, on fostering individual and c o m m u n i t y i n v o l v e m e n t w i t h health, and on equity serve as lessons from w h i c h the m o r e w e a l t h y d e v e l o p e d countries can learn.
LESSONS FROM DEVELOPED COUNTRIES To turn to the lessons for d e v e l o p i n g countries based on the e x p e r i e n c e of the m o r e d e v e l o p e d countries, it is important to note that the United States of 50 - 100 years ago had a health picture similar to those of some of the worst d e v e l o p i n g countries today. Further, one must note that the shift from the c h i l d h o o d infectious and nutritional p r o b l e m s of d e v e l o p i n g countries to the chronic disease and social p r o b l e m s of industrialized countries, the so-called " e p i d e m i o l o g i c transition", does not h a p p e n along a s m o o t h continuum. In fact, m a n y countries today face b o t h sets of p r o b l e m s simultaneously, in large part because of social inequity and e p i d e m i o l o g i c variability within the country. It is c o m m o n in countries such as Brazil or even in cities such as Mexico City for the two sets of p r o b l e m s to exist simultaneously. This presents severe challenges and strains on the health budget, imposing even m o r e difficult decisions in regard to priorities and allocation of resources. Before going on to consider specific health conditions and the implications for prevention, it is necessary to review certain d e m o g r a p h i c trendsP Special note will be given to some of these trends in Brazil, since health p r o b l e m s of this country will be considered in m o r e detail later. First, mortality rates have b e e n declining and life expectancies increasing in developing countries, primarily because of the p r e v e n t i o n of c h i l d h o o d deaths. In 20 - 30 years, life e x p e c t a n c i e s in Latin America are e x p e c t e d to be only slightly less than those in the United States. Second, birth rates c o n t i n u e to be high in most countries, resulting in p o p u l a t i o n growth rates of 2 - 4%. Third, the age structures of dev e l o p i n g countries are changing, with a trend towards aging of the population. While the United States currently has a m u c h larger fraction of its p o p u l a t i o n over 65 years old, this age g r o u p is increasing in Brazil at a faster rate, anticipated to be a 50% increase b e t w e e n 1980 and 2000. And fourth, m a n y d e v e l o p i n g countries are increasing their urban populations, often because of migration, and project a stable or decreasing rural population. Brazil will be considered as a case study. Life exp e c t a n c y increased from 41 years in 1940 to 59 years in 1980. Infectious and parasitic diseases a c c o u n t e d for 80% of deaths in 1940 and only 8% in 1980, p r e d o m i -
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nantly as a result of real changes in age-specific death rates and, to a lesser degree, changes in the age structure of the population. Mortality rates from heart disease, neoplasms, and cerebrovascular disease have remained constant or have increased in the last 40 years. The current three leading causes of potential years o f life lost after infancy are very similar to those in the United States. In Brazil, these are injuries, heart disease, and cerebrovascular disease.3 Neoplasms are also of importance, with rapid increases in lung cancer among others) Deaths due to injuries (including traffic accidents, homicide, suicide, industrial accidents, and other injuries) have a large impact on calculations of years of p r o d u c t i v e life lost since they o c c u r often in the young adult age group. Traffic accidents account for the largest n u m b e r of deaths due to injuries, with rates (approximately 20 per 1 0 0 , 0 0 0 per year) that are similar to those in the United States.4 When considered in terms of mortality p e r vehicle or per mile driven, rates in Brazil are substantially higher. Judging from experience in other countries, ensuring the use of motorcycle helmets and automobile seat belts through legal and educational means w o u l d be e x p e c t e d to r e d u c e traffic fatalities. The high p r o p o r t i o n (43%) o f Brazilian traffic fatalities that o c c u r among pedestrians, however, suggests that other changes in driving patterns and road crossing safety will be n e e d e d ) Since high proportions of b o t h vehicle and pedestrian deaths in Brazil seem to be related to excessive c o n s u m p t i o n of alcohol, other educational and legal interventions will also be necessary. The United States has made some progress in controlling traffic fatalities through these means and this e x p e r i e n c e should be instructive to developing countries. Risk factors for n o n c o m m u n i c a b l e diseases such as heart disease, cerebrovascular disease, and cancer are complex, but it is clear that there are important identifiable individual behaviors and environmental exposures. Of these, one might consider the case of tobacco smoking, w h i c h has b e e n shown to have a causal role for many important n o n c o m m u n i c a b l e diseases, such as some cancers, vascular disease, and obstructive pulmonary disease. In Brazil, cigarette c o n s u m p t i o n per capita increased rapidly for several decades until the late 1970s. 4 Beginning at that time and continuing in the 1980s, anti-smoking campaigns attempted to reverse the trend. These efforts to raise prices and provide education in order to r e d u c e smoking are considered well managed and successful, resulting in a 20% decline in per-capita consumption. 4 However, observations that 63% of Brazilian men continue to smoke and that smoking has c o n t i n u e d to increase to 33% among Brazilian w o m e n indicate that increased efforts are needed. Since it appears that cigarette c o n s u m p t i o n is highly elastic to price changes, especially among the p o o r and among young adults, higher cigarette taxes
may help r e d u c e s m o k i n g ) Furthermore, additional efforts to limit advertising and to provide education, particularly targeted to young w o m e n , are needed. Since the costs of anti-smoking efforts are small (and may be self-financed through cigarette taxes) and the benefits in terms of health or costs for health care are large, smoking prevention efforts w o u l d appear to be strongly indicated. The dramatic decreases in cigarette consumption in the United States as a result of anti-smoking efforts in the last several decades should provide optimism that countries such as Brazil can control this serious public health problem. In Brazil, other behavioral determinants of nonc o m m u n i c a b l e diseases, such as p o o r diet with high levels of salt and fat and low levels of fiber, are increasing, especially among the middle class. Likewise, in this group inadequate exercise and obesity are growing problems. Furthermore, occupational and environmental exposures to harmful substances present serious health risks and environmental p r o t e c t i o n efforts have only just b e g u n ) The experiences of d e v e l o p e d countries, including their difficulties in motivating individual behavior change and in developing sufficient public consensus for environmental protection, should also provide important lessons to developing countries that are increasingly facing these serious threats to health. O f course, AIDS poses a serious health threat to the populations of developing countries. However, it also presents potentially serious problems for the health systems of developing countries. The cost of treating an AIDS patient in Brazil is n o w e x t r e m e l y high and nearly all of this care occurs in public hospitals. The n u m b e r of HIV-infected persons in Brazil may n o w approach a half-million, and this n u m b e r may be doubling every year. The implications for the demand on public sector health resources are ominous and the projections for indirect costs to society and human suffering are even most disturbing. Brazil is already feeling the effects of this epidemiologic transition. The percentage of public sector resources allocated for individual illness treatment (vs. preventive services) has risen from 36% in 1965 to 85% in 1982. The proportion of the gross national p r o d u c t devoted to health has increased from 1% in 1950 to about 6% currently. 5 If Brazil wants to see what is coming, it could look to the United States, w h i c h devotes 12% of its gross national p r o d u c t to health, a p r o p o r t i o n that has been rapidly increasing in recent years. Yet many of the cost-effective preventive programs necessary to meet these challenges have not b e e n d e v e l o p e d or have been ineffective. What must developing countries do? Learning from the e x p e r i e n c e of d e v e l o p e d countries, the developing and transitional countries must consider ways to contain the costs of illness treatment and to place more emphasis on preventive approaches to improving
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health. Cost containment, to some extent, can be done by shifting from expensive inpatient care to lower-cost ambulatory services. The a p p r o a c h should also include taking greater advantage of all of the members of the health care team and reducing the treatment cost per patient. Unfortunately, with constrained budgets in developing countries, even more difficult choices will need to be made. Rationing of resources for medical care, especially for expensive, potentially life-prolonging technology, is never comfortable, but is and will be necessary. Heavy reliance on the public sector for medical care in developing countries will make these decisions about allocation of resources critical, since without them it is likely that the resources will c o m e at the expense of other essential c o m p o n e n t s of the health system, such as the prevention of acute and c h r o n i c diseases. It is n o w accepted that there are many preventive approaches that are more cost-effective than late curative or palliative care. Primary prevention efforts, for example, to reduce tobacco smoking, to modify the diet, to reduce injuries, or to avert environmental contamination, are essentially nonexistent in most develo p i n g countries. The result is that the risks are increasing. Secondary prevention efforts, for example, hypertension or cancer screening, have been inconsistent and ineffective. Insufficient attention and resources have been brought to bear on these increasing problems. As w e k n o w from our experience in the United States, the task is difficult, but progress can be made. Developing countries have the o p p o r t u n i t y to establish their policies before the d e v e l o p m e n t of a high-cost medical infrastructure and of limitless expectations for medical services. The choices will not be easy, and some p e o p l e lament that developing countries cannot
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afford to implement the legal controls and populationbased preventive approaches. However, one might consider that they cannot afford to make the mistake of choosing high-cost illness management over preservation of health and prevention of disease. Developing countries must also recognize that this has to be an active choice and that a passive stance is, in fact, a choice of high rates of chronic disease and expensive illness management, w h i c h is against their longer-term interests. We need to be challenged by the cry of Mahatma Ghandi near the end of his life, "I am hard-hearted e n o u g h to let the sick die if you c o u l d tell me h o w to prevent others from b e c o m i n g sick." Acting sooner rather than later can only lessen the pain of these difficult decisions. Accomplishing this strategy of prevention will need to draw u p o n the necessary elements of individual self-reliance, c o m m u n i t y involvement, and responsible government, with an interest in equity and human development. Developing countries can build on their success and learn from the mistakes of the industrialized countries. They can make different choices, if they have the foresight and the courage.
REFERENCES 1. Ghana Health Assessment Project Team. A quantitative method of assessing the health impact of different diseases in less developed countries. IntJ Epidemiol. 1981;10:73-80. 2. Evans,JR, Hall KL,WarfordJ. Shattucklecture-- health care in the developing world: problems of scarcity and choice. N EnglJ Med. 1981;305:1117-27. 3. Health conditions in the Americas-- 1981 - 1984; vol 1; no 500. Washington, DC: Pan American Health Organization, 1986. 4. World Bank. Adult health in Brazil: adjusting to new challenges. Report no 7807-BR. Washington, DC: World Bank, 1989:133. 5. Briscoe J, Birdsall N, Echeverri O, McGreeveyW, Saxenian H. Financing health services in developing countries, with special reference to Brazil. In: Proceedings of Seminario sobre Financiamemo do SistemaUnico e Descentralizado de Saude, Secretariat of Health, Sao Paulo, 1988.
