Reproduced (slightly abridged) from the Australian and New Zealand Journal of Public Health, 1998, VOL22 NO 1

A core part of Questioning the Solution is an in-depth critique of oral rehydration therapy (ORT) as a treatment for diarrhoeal disease in children. This seems a most appropriate choice, since diarrhoeal diseases are a major feature of child health and mortality in developing countries.

I enjoyed the choice of title. In Questioning the Solution, the authors not only question the use of western models of selective health care practices in attempting to provide solutions to Third World health problems, they also—in using packaged ORT as an example—question the very content of the packages: i.e. the ORT solution. The authors question the promotion, distribution and marketing of pre-packaged ORT solution, when other less expensive and more appropriate oral rehydration methods, such as home made solutions of salt and sugar, or cereal-based drinks, are available and are proving to be more suitable.

Using specific examples and case studies, the authors provide a comprehensive explanation of how and why—in spite of the 1978 Alma Ata Declaration on primary health care (PHC) and goal of achieving “Health for all by the year 2000”— the world’s population is getting sicker and more poverty stricken by the day. The social, economic, political and environmental factors which are the root causes of disease are discussed. Detailed descriptions of PHC programs which have worked in spite of these negative forces are provided.

After briefly detailing the evidence that “global programs have failed to adequately reduce the continuing high rates of malnutrition, illness and death among third world children,” the book introduces us to the tragedy of the cycle of poverty, illness and death with ‘Rakku’s Story.’ This is an abridged version of a story by Sheila Zurbrigg, based on events in rural India: a mother’s struggle to save the life of her child, who has severe diarrhoea. Rakku has other children to feed, and her sole income is from working long hours in the fields for the local land owner. She is therefore not able to breast-feed her baby, and must leave it all day in the care of her young daughter. When the baby becomes really ill, she decides to take it to the city to the hospital. In doing this, she loses a day’s wages (all she has with which to feed herself and her other children) and she also risks losing her job. She sells the last of her possessions to pay for the bus fare. On seeing the doctor, she is scolded for not bringing the baby earlier, and is given advice about the importance of breast-feeding. She is also given a prescription for medicine, which she obviously cannot afford. After the baby receives intravenous fluids, she is sent home. The baby’s condition worsens on the way home, and by the time Rakku gets home, the baby is dead.

Werner and Sander’s book poses the question: “What caused Rakku’s baby’s death?” Working on the premise that “the way we define the causes of human ills often determines the solutions we seek,” the authors show that the real causes of ill health are not being addressed on a global scale and how primary health care and the ideals of Alma Ata have been undermined internationally.

While few dared say publicly that the Alma Ata model of primary health care was subversive, almost from the time of its conception there were choruses of important voices proclaiming that it would not, could not, and did not work.

The first part of the book covers the background to PHC in 3 aptly named chapters: “The historical failures and accomplishments of the western medical model in the third world;” “Alma Ata and the institutionalization of primary health care;” and “The demise of primary health care and the rise of the child survival revolution.” The latter describes the shift in the 1980s from comprehensive to selective primary health care, and the role of UNICEF in promoting this change.

This period is further dealt with in chapter 13, which discusses the role of the World Bank and the International Monetary Fund in undermining the development of primary health care. [We see how] the structural adjustment policies of the World Bank and the role of multinational corporations contributed to the demise of the ideals of primary health care. The history, however, is still in the making. The final chapters give the reader some excellent and detailed examples of programs where primary health care principles have been applied. These are examples of equity-oriented initiatives which have been able to make improvements in the health of communities [often] in spite of fierce opposition from local vested interests, repressive governments, and multinational corporations. Health status gains have been made as a result of programs such as Project Piaxtla in western Mexico, where the root causes of disease, such as landlessness, lack of political power, and poverty have been addressed.

It is easy to become disheartened at the lack of progress towards the “health for all” goals espoused by the Alma Ata Declaration, and one might feel even more despondent after reading this book. The information and descriptive detail which is presented helps the reader to come to grips with the forces which lie behind the international scandal of preventable poverty and disease.

This reader was left with the conviction that the principles of primary health care are intact, and with a better understanding of the reasons why they are often thought of as being unworkable. If primary health care is not working, it is not because the idea is not a good one; it is because it is dangerous to the interests of those who control most of the world’s wealth, and thereby most of the world’s access to good health.

It is easy to agree wholeheartedly with Albert Einstein (quoted in the frontispiece):

Not until the creation and maintenance of decent conditions of life for all people are recognized and accepted as a common obligation of all people and all countries—not until then shall we, with a certain degree of justification, be able to speak of mankind as civilized (p. iii).

The final chapter calls for a “grassroots united front for world health,” stresses the need for a “child quality of life revolution,” and suggests ways in which health workers and ordinary citizens can contribute to these movements.

This is a very readable, well produced text. The information and ideas presented are both thought provoking and action provoking. It is well referenced for those who wish to read further, and well chosen illustrations help to highlight the main points throughout the text.