Questioning the Solution: The Politics of Primary Health Care and Child Survival

David Werner & David Sanders (1997)

What the book is about is not oral re-hydration: it is about power and duplicity, and the poor weapons that ordinary people have against the might and wealth of the powerful.
—Victor Nell, in the Journal of Primary Prevention

In this book we explore the problems of primary health care and child survival in underprivileged countries and communities. To do this, we must look into some of the most thorny issues of economic and social development. We have chosen diarrheal disease—one of the biggest killers of impoverished children—as a focus for exploring the complex determinants of child health and quality of life.

As the year 2000 approaches it is increasingly clear that the ambitious programs mounted by WHO, UNICEF, USAID, the World Bank, and other institutions to address problems of disease, hunger, and poverty in the Third World have fallen far short of their goals. In many countries progress toward health has stagnated during the last decade. In others, the living conditions and health status of growing numbers of impoverished people have actually been deteriorating. In particular, these global programs have failed to adequately reduce the continuing high rates of malnutrition, illness, and death among Third World children.

The substantial gains achieved by the narrowly focused “child survival” campaign (using technological interventions such as immunization) have, to a large extent, been offset by a worsening standard of living for much of humanity. According to UNICEF’s latest calculations, 12.5 million of the world’s children under age five still die each year. The agency asserts that without its Child Survival Revolution, the number of children dying yearly would have risen to 17.5 million by 1990 as a result of Third World population growth. Although the percentage of children dying has dropped, it is deeply disturbing that approximately the same number of children are dying today as were dying ten years ago.

Who we wrote this book for:

  • Students, health workers, activists, and everyone concerned about global issues, including health, development, nutrition, human rights, the environment, and quality of life—especially as these issues relate to children in difficult situations. We have tried to provide enough background so that readers relatively unfamiliar with international health questions can follow our discussion.
  • People working or interested in primary health care and allied fields, particularly in the Third World.
  • Health and development planners and policy-makers, especially those working or concerned with child survival and children’s quality of life, alternative development strategies, and oral rehydration therapy.

The four major parts of the book are:

  • Part 1: The Rise and Fall of Primary Health Care
  • Part 2: Oral Rehydration Therapy: A Solution to Death from Diarrhea?
  • Part 3: What Really Determines the Health of a Population
  • Part 4: Solutions That Empower the Poor: Examples of Equity-Oriented Initiatives


What the book is about is not oral re-hydration: it is about power and duplicity, and the poor weapons that ordinary people have against the might and wealth of the powerful.
But hope never goes away …. I would like nothing better than to believe, against the weight of history and reason, that a lucid and timely book may yet sow the seeds of a revolution. This volume is a strong candidate: it elegantly states the problem, and sketches the diversity of ways it has been addressed in a variety of settings over the past several decades. Whether or not it wins the battle against power and greed, this book is a powerful addition to the primary prevention library and to the teaching curriculum—for which I would strongly recommend it—across a range of courses, such as comprehensive community based health care in medical schools, community psychology, developmental studies, international politics, sociology, and macroeconomics.
—Victor Nell, Human Science Research Council of the University of South Africa Research Unit, in the Journal of Primary Prevention

Questioning the Solution cuts like a precision laser beam through the self-serving myths and misguided policies propagated by official aid bureaucracies and by profit-seeking corporations from the baby food and pharmaceutical industries. With extensive and authoritative documentation, Sanders and Werner pull no punches in their deeply troubling account of how greed and official complicity are spreading death and suffering in a human tragedy that need not be. Essential reading for every aid worker and responsible citizen.
—David C. Korten, President, People Centered Development Forum; Author, When Corporations Rule the World

David Werner and David Sanders are truth-tellers who force us to confront essential and difficult questions. They insist that technical solutions to illness must be insufficient if humans lack power to determine their own physical, emotional and spiritual destinies. Anyone who is not uncomfortable reading this book has simply missed the point.’
—Norbert Hirschhorn, MD, International consultant in Primary Health Care and diarrheal disease control

Questioning the Solution is a labour of love: a product of experience, research and decades of deep involvement of the authors with the health concerns of the poor. This powerful book inspires health action for change.
—Mira Shiva, MD, All India Drug Action Network

Diarrhoea still accounts for three million deaths a year. The international goal to make packets of Oral Rehydration Salts universally available could never be achieved. Questioning the Solution, I hope, will speed the involvement of communities to understand the problem and develop their own ‘solution.
—David Morley, MD, Emeritus Professor of Tropical Child Health, University of London

Questioning the Solution is a timely book. It shows the way ‘solutions’ are formulated by so-called experts and imposed not just on villages, but on entire countries. It helps us understand why even the World Bank can now talk about the relationship between poverty and ill health. ‘Poverty’ is a safe word, skirting the underlying gross inequities in power and access to resources. One word continues to be rare in most mainstream documents: justice.
—Michael Tan, Health Action Information Network, Philippines Author, Dying for Drugs

The Story of the Book’s Collaborative Origins

Editor’s Note: Out of curiosity I asked David about the behind-the-scenes process of writing and organizing Questioning the Solution: The Politics of Primary Health Care and Child Survival—with an In–depth Critique of Oral Rehydration Therapy, as it boasts two authors (the two Davids), and three additional collaborators (Steve Babb, Bill Rodriguez, and Jason Weston). Here are excerpts of our conversation.

David Sanders passed away in August 2019. Read David Werner’s memorial of his friend and collaborator here.

David Werner

First of all David Sanders and I decided to take it on together. And I actually got to know David Sanders becuse he was working with Oxfam England at that time—he grew up in Zimbabwe but was in exile during the struggle for liberation for Zimbabwe and he had to leave for his own life, and ended up working with Oxfam. And he came across Where There Is No Doctor and some of my papers like “Health Care and Human Dignity” and “Village Health Wroker: Lackey or Liberator?” and he got in touch with me. And on one of my visits to England, I met with him several times. We hit it off and became really good friends. And he invited me—after Rhodesia became Zimbabwe—he invited me there, because he was involved in the new health ministry, and wanted some of my input on the training of healthworkers and community based programs and those kinds of things. So we worked on that together. And he had written an excellent booklet called The Struggle for Health which actually it was sort of a pre-edition of Questioning the Solution, but we decided that a lot of these ideas needed to be developed more. So we took on Questioning the Solution, very similar focus to the Struggle for Health with a lot of examples of how—again—how a lot of the government sponsored programs tend to be hierarchical and often catering to the people with more voice and more votes and more money, and inadequate for the people at the bottom. And the whole focus of Struggle for Health and Nothing About Us was to work on ways of involving the people in greatest need, and having a voice and leadership in their own programs, [and for] Students to learn about this perspective on things, which is different from what you learn in medical school, or in much of public health.

The book, again it’s a book that should have had much wider distribution than it had[.] People still buy it, but it’s pretty much out of date now. And in fact the People’s Health Movement is doing a revised new edition for The Struggle for Health [David Sander’s 1985 work which Questioning the Solution updated].

Jason Weston

And what about Steve Babb and Bill Rodriguez?

David Werner

Steve Babb worked a lot on the Nicaragua chapter, because he spent time in Nicaragua. And that was pretty much was his contribution. [Searching his memory] I don’t even remember what Bill Rodriguez did, do you Jason?

Jason Weston

I remember before I got involved in the project that Steve had traveled to South Africa and worked with David Sanders. And then I came into the project—it had pretty much stalled it hasn’t moved in a year or two. And I got to work on it, and really doing a lot of editing and a lot of tracking down of sources. There were all sorts of things that—you especially David, were terrible about keeping track of sources. You’d say “Well, I read this somewhere… blah blah blah” and we’d track down who said those things. And we had the book pretty much in order by the time we had the meeting in the Philipines with the IPHC. And I think Bill Rodriguez was there, and he was a young medical student, and was totally gung-ho on this. And he offered to reorganize the book because he felt—not only he—but we felt like it needed a stronger organization than it had. So he took the book and did a pretty significant reorganization of things. And then I think after that you and I and David Sanders spent a summer in New Hampshire going over the book once again and really pulling it together and getting it ready to publish. It was a multi-year huge project.

David Werner

It has been and is used as a textbook in universities. It has been used in university classes as a textbook in a variaty of subjects.

Jason Weston

That book is interesting in that it has a lot of information about the history of primary health care, and a lot of information about how oral rehydration was used. And a lot of that information won’t go out of date, because it’s historical context for all that. And there’s a lot of analysis of what was going on in the 1990s that is a lot less relevant for people today.

David Werner

It documents the sort of division of attitudes on oral rehydration therapy. WHO and Unicef had promoted the use of these packets of oral rehydration salts for children with dehydration. But the problem of it was putting them in packets. Originally they were supposed to be given away in clinics, but then USAID said “No, this creates dependency. People have to pay for it.” So at 12 cents a packet—it doesn’t sound like much but when you consider that people in Bangladesh were making 17 cents a day [at that time] it isn’t really a solution for a family facing diahrea. So [we argued that] the home mix solution using things people already had made, at low cost with the local grain or whatever, in their house, was superior to the sugar-based rehydration. That’s the reason we called the book “Questioning the Solution.”


You’re a sucker for bad puns at HealthWrights.

David Werner


Jason Weston

Indeed. And it has the longest title of any book I have ever known.