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Low-technology approaches
THE LANCET
Low-technology approaches David Morley
Water can be rendered safer to drink simply by exposing it to sunlight in a transparent container. Oral rehydration can be achieved by using prepacked sachets but a lot can be done by giving child or adult a diluted pap such as rice water (50g/L) instead of glucose or sugar. The volume of diarrhoeal stool can be halved. These are examples of so-called "low tech" (meaning practicable and affordable) responses to disease in the poorer regions of the world. Two others, relating to mosquito-borne illnesses, are summarised in accompanying vignettes recording experiences in Tanzania and The Gambia. I am going to focus on children (and their mothers), showing what can be done at community level without the relative complexities of vertical programmes. Rekindling
Alma Ata
The 1960s and 1970s saw great improvements in child health and infant mortality worldwide. This was achieved through vertical programmes, such as the GOBI (growth monitoring, oral rehydration, breast feeding, and immunisation) initiatives, in which the late Jim Grant of U N I C E F played a major part. In the 1980s and 1990s the decline in child mortality has slowed or even gone into reverse as a consequence of the adverse economic climate. There have been some attempts to return to the spirit of the Alma Ata Declaration and involve the community more in their own health care. The new concepts include ideas such as "participatory rural (or social) appraisal" and "participatory social learning", drawn from lessons learned in the disciplines of agricultural and community development. There are some exemplary small programmes, largely dependent on charismatic leaders. In Jamkhed, a very poor district in Maharashta State, India, Dr Raj Arole and Dr Mabelle Arole have shown that it is possible to reduce infant mortality while at the same time creating in a population of roughly 250000 a stable economy and overcoming the problems of the caste system. 2 Progress has also been achieved by intersectoral approaches, notably between health and education. Primary health care and primary education are heavily interdependent (figure 1).
Figure 1: Primary health care and primary education: shared responsibility
recent directory. 3 T h e original concept has moved on, widening to involve children as communicators with their peers, with adults, and with the community rather than simply as receivers of instruction. Children can be powerful communicators, and not just in developing countries. In Africa, if children start to wash their hands, parents will take note, while in Europe the person most likely to stop a man smoking is his young daughter. During a recent visit to Canada I heard an account of a child-to-child project in a disadvantaged North American Indian community. The children (aged 10-12) were asked to identify the most pressing health problem in their area. Prostitution, they decided. Adult advisers thought this an inappropriate problem for them to tackle but the children were adamant. In the end the city council arranged 24 hour police cover and the prostitutes moved from the area. With Child-to-Child success is difficult to measure though the children involved in the earliest programmes
Child-to-Child
In many developing countries small children are, for half of every day, cared for by older brothers and sisters. The "Child-to-Child" concept arose during the International Year of the Child in 1979. The idea was that these siblings could be taught, both in and outside school, how to care better for young children. Descriptions of such programmes from over 60 countries and information on seven national and regional resource centres is given in a
Lancet 1997; 3 4 9 (suppl III): 24-25 Centre for International Child Health, Institute of Child Health, London WCIN 1EH~UK (Prof D Morley FRCP)
SIII24
Figure 2: Citizens as health workers, at any age
Vol 3 4 9 • June • 1 9 9 7
THE LANCET
Figure 3: Direct recording scale in India have themselves t u r n e d out to be excellent parents. In 1990 the W o r l d S u m m i t for C h i l d r e n m a r k e d a n e w o r d e r (figure 2): the b a n n e r b o r n e by the adults represents the spirit of Alma Ata while the c h i l d r e n ' s placard declares " w e ' r e citizens too".
Health care and numeracy In i m p r o v i n g adult literacy it is i m p o r t a n t to use w o r d s that are significant to those learning to read. T h e same principle applies to n u m e r a c y and to m e a s u r e m e n t s o f i m p o r t a n c e to m o t h e r s in developing countries. G r o w t h m o n i t o r i n g with weight-for-age graphs b e g a n in the late 1950s a n d s o o n spread worldwide. However, w h e n in the 1980s cost-benefit analysis was called into play it b e c a m e clear that growth monitoring, to p r e v e n t malnutrition, was effective only in small p r o g r a m m e s , usually t h o s e r u n
Tanzania:
by n o n - g o v e r n m e n t a l organisations. In national health p r o g r a m m e s it did n o t w o r k - - a n d the explanation e m e r g e d only w h e n those c o n c e r n e d with primary e d u c a t i o n were consulted. T h e e d u c a t i o n guru Jean Piaget (1896-1980) h a d s h o w n that the linear graph is a very difficult c o n c e p t to grasp. I n the developing world schools do n o t have graph paper; few primary teachers can tackle graphs; a n d even h e a l t h workers have difficulty making decisions on the basis o f graphical weight-for-age information. T h e answer m a y lie in simple technology, the direct r e c o r d i n g scale (figure 3). T h e m o t h e r sees the spring stretching up h e r child's chart; she can m a r k the next p o i n t by inserting a ballpoint p e n t h r o u g h a hole in the p o i n t e r and can i m m e d i a t e l y see h o w the weight has changed. 3'4 O t h e r m o t h e r s b e c o m e involved, including the in-laws w h o are so i m p o r t a n t in d e c i s i o n - m a k i n g Y
References 1 ConroyRM, Meegan ME, JoyceT, McGuigen KG, Barnes J, Solar disinfectionof drinking water and diarrhoea in Maasai children: a controlled trial. Lancet 1996: 348:1695-97. 2 AroleM, Arole R. Jamkhed: a comprehensiverural health project. London: Macmillan, 1994. 3 Directory of child-to-childactivitiesworldwide.Obtainable from Child-to-Child Trust, Institute of Education, Universityof London, 20 Bedford Way, London WC1H 0AJ, UK. 4 MorleyD, Nickson P, Brown R. TALC direct recording scales. Lancet 1990; 336: 1600. 5 MeeganM, Morley DC, Brown R. Child weighingby the unschooled: a report of a controlled study of growth monitoring over 12 months of Masaai children using the direct recording scale. Trans Roy Soc Trop MedHyg 199?; 88:635 37.
c o n t r o l o f Culex v e c t o r s o f f i l a r i a s i s
The construction of pit latrines or septic tank/cesspit but the chances of reinfection were kept very low by sanitation systems frequently leads to an upsurge of periodic checks for, and treatment of, new breeding Culex quinquefasciatus mosquitoes, which breed in places in pit latrines. organically polluted water. These are Unfortunately, checks have not been the main nuisance mosquitoes and kept up in the past four years and vectors of filariasis (which leads to people are once again complaining of elephantiasis and hydrocele) in tropical mosquito nuisance. A check of night urbanised areas. Mosquito larvae and bloods was done in 1997 (results not pupae breath air through the water yet in). Arrangements are in hand to surface and, as originally suggested by send a new supply of expandable Paul Reiter, a floating layer of polystyrene and to revive the system expanded polystyrene beads suffocates of checking and where necessary the larvae and pupae and is very treatment of newly wet pit latrines. durable. Makunduchi is exceptional in having no drains and almost no marshes in The town of Makunduchi, Zanzibar, which mosquito breeding can occur Tanzania (population 12000) was (and for which polystyrene beads are notorious for its mosquitoes and not applicable). However, in many filariasis until 1988 when, with a team tropical towns and refugee camps of three local malaria agents, we long-term prevention of mosquito located all 550 wet pit latrines, breeding in the pits with polystyrene expanded enough polystyrene from beads would give control teams the imported granules in boiling water time to concentrate their effort on (figure) and treated all the pits with a repeated treatment, with chemical or layer 1-2 cm thick. This brought down Expanding polystyrene granules to bacterial agents, of more open sites. the density of mosquitoes in bedrooms make 2 mm diameter beads by 98%. 1 Almost simultaneously we Two bucketsfulof beadsare enoughto C F Curtis, C A Maxwell arranged mass treatment of the people deal with one mosquito-infestedpit latrine. LondonSchoolof HygieneandTropicalMedicine,London WClE7HT,UK with the antifilarial drug diethylcarbamazine. The percentage of people with microfilariae in night blood samples declined from 49% before treatment to 10% soon after it and then to 3% over the next five years. During this time there was no further drug treatment, Vo1349 • June • 1997
1 MaxwellCA, Curtis CF, Hamadi Haji, Shaban Kisumku, Abdul Issa Thalib, Salum All Yahya. Control of bancroftian filariasisby integrating therapy with vector control using polystyrenebeads in wet pit latrines. Trans R Soc Trop Med Hyg 1990; 84: 709-14.
sIII25
Low-technology approaches David Morley
Water can be rendered safer to drink simply by exposing it to sunlight in a transparent container. Oral rehydration can be achieved by using prepacked sachets but a lot can be done by giving child or adult a diluted pap such as rice water (50g/L) instead of glucose or sugar. The volume of diarrhoeal stool can be halved. These are examples of so-called "low tech" (meaning practicable and affordable) responses to disease in the poorer regions of the world. Two others, relating to mosquito-borne illnesses, are summarised in accompanying vignettes recording experiences in Tanzania and The Gambia. I am going to focus on children (and their mothers), showing what can be done at community level without the relative complexities of vertical programmes. Rekindling
Alma Ata
The 1960s and 1970s saw great improvements in child health and infant mortality worldwide. This was achieved through vertical programmes, such as the GOBI (growth monitoring, oral rehydration, breast feeding, and immunisation) initiatives, in which the late Jim Grant of U N I C E F played a major part. In the 1980s and 1990s the decline in child mortality has slowed or even gone into reverse as a consequence of the adverse economic climate. There have been some attempts to return to the spirit of the Alma Ata Declaration and involve the community more in their own health care. The new concepts include ideas such as "participatory rural (or social) appraisal" and "participatory social learning", drawn from lessons learned in the disciplines of agricultural and community development. There are some exemplary small programmes, largely dependent on charismatic leaders. In Jamkhed, a very poor district in Maharashta State, India, Dr Raj Arole and Dr Mabelle Arole have shown that it is possible to reduce infant mortality while at the same time creating in a population of roughly 250000 a stable economy and overcoming the problems of the caste system. 2 Progress has also been achieved by intersectoral approaches, notably between health and education. Primary health care and primary education are heavily interdependent (figure 1).
Figure 1: Primary health care and primary education: shared responsibility
recent directory. 3 T h e original concept has moved on, widening to involve children as communicators with their peers, with adults, and with the community rather than simply as receivers of instruction. Children can be powerful communicators, and not just in developing countries. In Africa, if children start to wash their hands, parents will take note, while in Europe the person most likely to stop a man smoking is his young daughter. During a recent visit to Canada I heard an account of a child-to-child project in a disadvantaged North American Indian community. The children (aged 10-12) were asked to identify the most pressing health problem in their area. Prostitution, they decided. Adult advisers thought this an inappropriate problem for them to tackle but the children were adamant. In the end the city council arranged 24 hour police cover and the prostitutes moved from the area. With Child-to-Child success is difficult to measure though the children involved in the earliest programmes
Child-to-Child
In many developing countries small children are, for half of every day, cared for by older brothers and sisters. The "Child-to-Child" concept arose during the International Year of the Child in 1979. The idea was that these siblings could be taught, both in and outside school, how to care better for young children. Descriptions of such programmes from over 60 countries and information on seven national and regional resource centres is given in a
Lancet 1997; 3 4 9 (suppl III): 24-25 Centre for International Child Health, Institute of Child Health, London WCIN 1EH~UK (Prof D Morley FRCP)
SIII24
Figure 2: Citizens as health workers, at any age
Vol 3 4 9 • June • 1 9 9 7
THE LANCET
Figure 3: Direct recording scale in India have themselves t u r n e d out to be excellent parents. In 1990 the W o r l d S u m m i t for C h i l d r e n m a r k e d a n e w o r d e r (figure 2): the b a n n e r b o r n e by the adults represents the spirit of Alma Ata while the c h i l d r e n ' s placard declares " w e ' r e citizens too".
Health care and numeracy In i m p r o v i n g adult literacy it is i m p o r t a n t to use w o r d s that are significant to those learning to read. T h e same principle applies to n u m e r a c y and to m e a s u r e m e n t s o f i m p o r t a n c e to m o t h e r s in developing countries. G r o w t h m o n i t o r i n g with weight-for-age graphs b e g a n in the late 1950s a n d s o o n spread worldwide. However, w h e n in the 1980s cost-benefit analysis was called into play it b e c a m e clear that growth monitoring, to p r e v e n t malnutrition, was effective only in small p r o g r a m m e s , usually t h o s e r u n
Tanzania:
by n o n - g o v e r n m e n t a l organisations. In national health p r o g r a m m e s it did n o t w o r k - - a n d the explanation e m e r g e d only w h e n those c o n c e r n e d with primary e d u c a t i o n were consulted. T h e e d u c a t i o n guru Jean Piaget (1896-1980) h a d s h o w n that the linear graph is a very difficult c o n c e p t to grasp. I n the developing world schools do n o t have graph paper; few primary teachers can tackle graphs; a n d even h e a l t h workers have difficulty making decisions on the basis o f graphical weight-for-age information. T h e answer m a y lie in simple technology, the direct r e c o r d i n g scale (figure 3). T h e m o t h e r sees the spring stretching up h e r child's chart; she can m a r k the next p o i n t by inserting a ballpoint p e n t h r o u g h a hole in the p o i n t e r and can i m m e d i a t e l y see h o w the weight has changed. 3'4 O t h e r m o t h e r s b e c o m e involved, including the in-laws w h o are so i m p o r t a n t in d e c i s i o n - m a k i n g Y
References 1 ConroyRM, Meegan ME, JoyceT, McGuigen KG, Barnes J, Solar disinfectionof drinking water and diarrhoea in Maasai children: a controlled trial. Lancet 1996: 348:1695-97. 2 AroleM, Arole R. Jamkhed: a comprehensiverural health project. London: Macmillan, 1994. 3 Directory of child-to-childactivitiesworldwide.Obtainable from Child-to-Child Trust, Institute of Education, Universityof London, 20 Bedford Way, London WC1H 0AJ, UK. 4 MorleyD, Nickson P, Brown R. TALC direct recording scales. Lancet 1990; 336: 1600. 5 MeeganM, Morley DC, Brown R. Child weighingby the unschooled: a report of a controlled study of growth monitoring over 12 months of Masaai children using the direct recording scale. Trans Roy Soc Trop MedHyg 199?; 88:635 37.
c o n t r o l o f Culex v e c t o r s o f f i l a r i a s i s
The construction of pit latrines or septic tank/cesspit but the chances of reinfection were kept very low by sanitation systems frequently leads to an upsurge of periodic checks for, and treatment of, new breeding Culex quinquefasciatus mosquitoes, which breed in places in pit latrines. organically polluted water. These are Unfortunately, checks have not been the main nuisance mosquitoes and kept up in the past four years and vectors of filariasis (which leads to people are once again complaining of elephantiasis and hydrocele) in tropical mosquito nuisance. A check of night urbanised areas. Mosquito larvae and bloods was done in 1997 (results not pupae breath air through the water yet in). Arrangements are in hand to surface and, as originally suggested by send a new supply of expandable Paul Reiter, a floating layer of polystyrene and to revive the system expanded polystyrene beads suffocates of checking and where necessary the larvae and pupae and is very treatment of newly wet pit latrines. durable. Makunduchi is exceptional in having no drains and almost no marshes in The town of Makunduchi, Zanzibar, which mosquito breeding can occur Tanzania (population 12000) was (and for which polystyrene beads are notorious for its mosquitoes and not applicable). However, in many filariasis until 1988 when, with a team tropical towns and refugee camps of three local malaria agents, we long-term prevention of mosquito located all 550 wet pit latrines, breeding in the pits with polystyrene expanded enough polystyrene from beads would give control teams the imported granules in boiling water time to concentrate their effort on (figure) and treated all the pits with a repeated treatment, with chemical or layer 1-2 cm thick. This brought down Expanding polystyrene granules to bacterial agents, of more open sites. the density of mosquitoes in bedrooms make 2 mm diameter beads by 98%. 1 Almost simultaneously we Two bucketsfulof beadsare enoughto C F Curtis, C A Maxwell arranged mass treatment of the people deal with one mosquito-infestedpit latrine. LondonSchoolof HygieneandTropicalMedicine,London WClE7HT,UK with the antifilarial drug diethylcarbamazine. The percentage of people with microfilariae in night blood samples declined from 49% before treatment to 10% soon after it and then to 3% over the next five years. During this time there was no further drug treatment, Vo1349 • June • 1997
1 MaxwellCA, Curtis CF, Hamadi Haji, Shaban Kisumku, Abdul Issa Thalib, Salum All Yahya. Control of bancroftian filariasisby integrating therapy with vector control using polystyrenebeads in wet pit latrines. Trans R Soc Trop Med Hyg 1990; 84: 709-14.
sIII25