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World Health and Technical Assistance
312
and their method of pharmaceutical preparation are correlated with the bioavailability of their contained digoxin in man. From the results of such an investigation new official standards for the formulation and preparation of digoxin tablets could be introduced. Doctors must be able to rely on the predictable potency, in terms of bioavailability, of the preparations they use. The vagaries of patient variability are difficult enough to cope with, without the added problem of different pharmaceutical potency. It seems extraordinary that none of this might have come to light without the advent of methods of measuring the concentration of digoxin in plasma.
This
experience highlights another problem. Many investigations on the bioavailability of drugs and their pharmacokinetics-particularly those carried out with radioactive isotopic derivatives-have involved oral administration of solutions and tablets whose physical characteristics were not stated. If such investigations are to be relevant to everyday therapeutics, these variables will have to be taken into consideration more carefully.
World Health and Technical Assistance INTERNATIONAL concern for the health of the world is comparatively recent in origin. It really began with the need for the Old World to protect itself from the scourges of the East and the unknown parts of Africa; the sanitary conventions beginning in 1851 were drawn up mainly for this purpose. These were followed by the establishment of the Paris Office, the League of Nations, and finally the World Health Organisation in 1948. Even then, the Third World was an indeterminate entity, largely the responsibility of colonial governments. As long as disease was contained within the boundaries of Africa and Asia, the concern of the well-to-do communities was minimal. The disappearance of most of the colonial empires has resulted in the emergence of new nations, clamouring for deliverance from ill-health and for the right to have the same living standards as the rest of the world. The expansion of communicationparticularly the introduction of television-confronts the people of the Old World with the plight of those less fortunate than themselves. The speed of international travel has revived threats long since forgotten. How improbable to have cholera in Huddersfield. We are told that, on balance, the world is a healthier place to live in today than it was fifty years ago, and this must of course be true in Europe and America. One can only be sceptical about the application of this view to the increasing millions in tropical and subtropical areas. Reports from the World Health Organisation confirm that there is less malaria, less smallpox, and less measles, yet there remain horrifying outbreaks of cholera and yellow fever. Still the common lot of those living in African jungles, the savannahs, and the semi-deserts of the world, is
birth, life, and death without help from the medical advances which benefit the sophisticated peoples of the world. Indeed, the director-general of the World Health Organisation doubts whether there will be much further improvement until certain serious endemic hazards-trypanosomiasis, schistosomiasis, filariasis-have been the subject of further fundamental research. If effective vaccines or chemotherapy could be applied to the communicable diseases, still the bane of tropical and subtropical areas, there would be much improvement. It must not be forgotten that the affluent world suffers comparatively few environmental disadvantages, since the sanitary era of the 19th and early 20th centuries removed the biggest killer of them all-" diarrhoeal disorders ". Endemic poverty is a thing of the past, and education universal. It is difficult to see how better knowledge of major endemic disease can overcome, by itself, the fundamental handicaps of relative poverty, lack of sanitation, and minimal education against a background of a heavily infected increasing population. Economists believe that the economic development of countries in the Third World will result, ipso facto, in an improvement of health. This can only be true if that economic development includes within its components investment in the health sector. Yet many of the Third World countries are simply incapable of realising the dream of development cherished by the economists. It is these " undeveloping " countries which require and demand the most international assistance to improve their health. The people of the Third World should not have to wait for long-term economic development when intelligent use of resources now being offered could benefit them today. Disease knows no barriers, but efforts so far to combat disease have seldom been successful on a regional basis. Most effort is made by nations striving to improve the health of the people within their own boundaries. World government is surely a long way off and a global health service not
yet contemplated.
Against this background of complexity and near despair, countries giving medical aid must make every effort to find out what is needed in real terms. They must realise that the mere provision of aid is no guarantee that it will be used to advantage, or indeed at all. There are many stages between the decision to provide aid and the effective application of it to the people for whom it is intended. Aid must be appropriate for the community and effectively applied. Without real concern for all the problemssocial, political, and scientific-all the aid programmes, research, individual work, and teamwork will just be so much wasted effort. With all this in mind, let us now take stock of Britain’s own medical-aid programme to developing countries, particularly since ten years have elapsed since Sir ARTHUR PORRITT’S working-party reported
313
medical aid to the developing world. It wass then envisaged-and these principles have beeni applied ever since-that there should be three majoir guidelines for aid, summarised below: on
1. However great the medical deficiencies of the developing countries may be, the advice and help which is given tc) them must be given in the form in which they request, 2. The best and most economical way of helping to improve their medical services is to raise the standard of teaching ai their own teaching centres and to train their own teachers, 3. That the Governments of developing countries should1 make some contribution towards the projects selected. -
.
,
The first of these principles seemed designed to) avoid an accusation that Britain might be making; attempts to interfere in the independence so recentlyr bestowed, and thus become guilty of neocolonialism. The second seems to have been interpreted so thatt the teaching of medically qualified personnel becomes; the major objective; and the third assumed that: Governments preferred, or could even afford, to. contribute towards the projects selected. Surelyr these principles should be re-examined. Britain is spending more than E5 million a year onIl medical aid (the latest published figure, E4’8 millionl for 1967). From time to time reports are publishedl on the amount of aid provided, but there is almost; complete failure to assess its value to the receiving. countries. Requests have most usually been to provide medical and auxiliary staff to undertake specific tasks with the stated objective of filling gaps in the health. systems of the developing countries. We do not knowr to what extent these gaps have been filled by suitablyr training local staff. We do know that there are large numbers, particularly of Commonwealth students, at our medical schools and that a large proportion of these are undertaking longer and longer postgraduate educational programmes. We are constantly being told by the Department of Health that a large proportion of our own hospital service is being supported by foreigners, most of these from India or Pakistan. Could this state of affairs have arisen because the aid-giving countries have avoided having any say at all in the form their aid should take ? It is well known that efforts are made unofficially to encourage developing countries to make reasonable requests, and indeed to refuse those which are patently unreasonable. On the other hand, it is politically unacceptable to refuse too often. Technical assistance has been given for expatriate staff to undertake jobs that do not exist, or to run hospitals that are not opened. The excellent idea of introducing the Porritt lectureships has to some extent been nullified because of the provision that a contribution is expected from the receiving Government. It failed utterly to recognise that in many countries, particularly in Africa, the health budgets have remained static in size and in some cases have diminished. In 1971 there was a unique meeting of some representatives from Africa and the Far East concerned with medical education, medical care, and .
’
’
’
research, to examine with interested and experienced medical men and administrators from this country the effects of Britain’s medical aid programme. This meeting reiterated things which have been said on other occasions, but it must have left the representatives from the Third World with an uncomfortable feeling that they were banging their heads against a brick wall, and those from this country with the view that they were doing the best they could under difficult circumstances. It was clear that the three principles of the British aid programme were out of date, that it was time to take more positive action, and that much the same principles could be applied to medical aid whether it took the form of education, research, or medical care. As a result of this meeting it becomes possible to suggest a series of alternative principles which might be applied to aid. They are as follows: 1. There should be closer consultation between Governconcerning medical-aid programmes. 2. All donating countries should relate their aid programmes to national health plans. 3. Donating countries should make specific offers of aid following a study of national plans. 4. There should be coordination of international and bilateral aid in each receiving country. 5. Capital loans should be free from " tied aid ", and other assistance freed from the " contribution " element. 6. The imposition of aid should be avoided by consultation with local expert technical opinion. 7. Managerial skills should be introduced into medical-care programmes at all levels. 8. The development of systems of medical care on a wide scale, particularly in rural areas, should be encouraged. 9. Pilot projects should be pursued to identify the best method of application of basic health services. 10. The requirements of the basic health services for auxiliary personnel should be recognised and comprehensive training programmes integrated with professional education. ments
Some mechanisms exist already for the channelling of aid on a rational basis from Britain to the developing areas. In terms of research, the M.R.C. has long established the Tropical Medicine Research Board, which constantly maintains a contact with research progress, at least in Africa and the Caribbean. Support for academic institutions is directed by the Interuniversity Council, and many links have been forged between individual universities in the United Kingdom and in the Commonwealth. There is even a panel for one disease-trypanosomiasis. There does not appear to be the same type of mechanism for determining the needs for medical care applied to the community. If the Third World is positively to improve its health, this can only be achieved on a community basis, and it is here that community medicine has its greatest part to play. The greatest lack of all lies in the application of knowledge to the people. This can only be accomplished by adopting and implementing a stern and imaginative realism. Is there not room, therefore, for a community-medicine panel to assist the Civil Service and the politicians of Britain negotiating with the Third World the type of aid it needs in regard to this fundamental part of living ?
and their method of pharmaceutical preparation are correlated with the bioavailability of their contained digoxin in man. From the results of such an investigation new official standards for the formulation and preparation of digoxin tablets could be introduced. Doctors must be able to rely on the predictable potency, in terms of bioavailability, of the preparations they use. The vagaries of patient variability are difficult enough to cope with, without the added problem of different pharmaceutical potency. It seems extraordinary that none of this might have come to light without the advent of methods of measuring the concentration of digoxin in plasma.
This
experience highlights another problem. Many investigations on the bioavailability of drugs and their pharmacokinetics-particularly those carried out with radioactive isotopic derivatives-have involved oral administration of solutions and tablets whose physical characteristics were not stated. If such investigations are to be relevant to everyday therapeutics, these variables will have to be taken into consideration more carefully.
World Health and Technical Assistance INTERNATIONAL concern for the health of the world is comparatively recent in origin. It really began with the need for the Old World to protect itself from the scourges of the East and the unknown parts of Africa; the sanitary conventions beginning in 1851 were drawn up mainly for this purpose. These were followed by the establishment of the Paris Office, the League of Nations, and finally the World Health Organisation in 1948. Even then, the Third World was an indeterminate entity, largely the responsibility of colonial governments. As long as disease was contained within the boundaries of Africa and Asia, the concern of the well-to-do communities was minimal. The disappearance of most of the colonial empires has resulted in the emergence of new nations, clamouring for deliverance from ill-health and for the right to have the same living standards as the rest of the world. The expansion of communicationparticularly the introduction of television-confronts the people of the Old World with the plight of those less fortunate than themselves. The speed of international travel has revived threats long since forgotten. How improbable to have cholera in Huddersfield. We are told that, on balance, the world is a healthier place to live in today than it was fifty years ago, and this must of course be true in Europe and America. One can only be sceptical about the application of this view to the increasing millions in tropical and subtropical areas. Reports from the World Health Organisation confirm that there is less malaria, less smallpox, and less measles, yet there remain horrifying outbreaks of cholera and yellow fever. Still the common lot of those living in African jungles, the savannahs, and the semi-deserts of the world, is
birth, life, and death without help from the medical advances which benefit the sophisticated peoples of the world. Indeed, the director-general of the World Health Organisation doubts whether there will be much further improvement until certain serious endemic hazards-trypanosomiasis, schistosomiasis, filariasis-have been the subject of further fundamental research. If effective vaccines or chemotherapy could be applied to the communicable diseases, still the bane of tropical and subtropical areas, there would be much improvement. It must not be forgotten that the affluent world suffers comparatively few environmental disadvantages, since the sanitary era of the 19th and early 20th centuries removed the biggest killer of them all-" diarrhoeal disorders ". Endemic poverty is a thing of the past, and education universal. It is difficult to see how better knowledge of major endemic disease can overcome, by itself, the fundamental handicaps of relative poverty, lack of sanitation, and minimal education against a background of a heavily infected increasing population. Economists believe that the economic development of countries in the Third World will result, ipso facto, in an improvement of health. This can only be true if that economic development includes within its components investment in the health sector. Yet many of the Third World countries are simply incapable of realising the dream of development cherished by the economists. It is these " undeveloping " countries which require and demand the most international assistance to improve their health. The people of the Third World should not have to wait for long-term economic development when intelligent use of resources now being offered could benefit them today. Disease knows no barriers, but efforts so far to combat disease have seldom been successful on a regional basis. Most effort is made by nations striving to improve the health of the people within their own boundaries. World government is surely a long way off and a global health service not
yet contemplated.
Against this background of complexity and near despair, countries giving medical aid must make every effort to find out what is needed in real terms. They must realise that the mere provision of aid is no guarantee that it will be used to advantage, or indeed at all. There are many stages between the decision to provide aid and the effective application of it to the people for whom it is intended. Aid must be appropriate for the community and effectively applied. Without real concern for all the problemssocial, political, and scientific-all the aid programmes, research, individual work, and teamwork will just be so much wasted effort. With all this in mind, let us now take stock of Britain’s own medical-aid programme to developing countries, particularly since ten years have elapsed since Sir ARTHUR PORRITT’S working-party reported
313
medical aid to the developing world. It wass then envisaged-and these principles have beeni applied ever since-that there should be three majoir guidelines for aid, summarised below: on
1. However great the medical deficiencies of the developing countries may be, the advice and help which is given tc) them must be given in the form in which they request, 2. The best and most economical way of helping to improve their medical services is to raise the standard of teaching ai their own teaching centres and to train their own teachers, 3. That the Governments of developing countries should1 make some contribution towards the projects selected. -
.
,
The first of these principles seemed designed to) avoid an accusation that Britain might be making; attempts to interfere in the independence so recentlyr bestowed, and thus become guilty of neocolonialism. The second seems to have been interpreted so thatt the teaching of medically qualified personnel becomes; the major objective; and the third assumed that: Governments preferred, or could even afford, to. contribute towards the projects selected. Surelyr these principles should be re-examined. Britain is spending more than E5 million a year onIl medical aid (the latest published figure, E4’8 millionl for 1967). From time to time reports are publishedl on the amount of aid provided, but there is almost; complete failure to assess its value to the receiving. countries. Requests have most usually been to provide medical and auxiliary staff to undertake specific tasks with the stated objective of filling gaps in the health. systems of the developing countries. We do not knowr to what extent these gaps have been filled by suitablyr training local staff. We do know that there are large numbers, particularly of Commonwealth students, at our medical schools and that a large proportion of these are undertaking longer and longer postgraduate educational programmes. We are constantly being told by the Department of Health that a large proportion of our own hospital service is being supported by foreigners, most of these from India or Pakistan. Could this state of affairs have arisen because the aid-giving countries have avoided having any say at all in the form their aid should take ? It is well known that efforts are made unofficially to encourage developing countries to make reasonable requests, and indeed to refuse those which are patently unreasonable. On the other hand, it is politically unacceptable to refuse too often. Technical assistance has been given for expatriate staff to undertake jobs that do not exist, or to run hospitals that are not opened. The excellent idea of introducing the Porritt lectureships has to some extent been nullified because of the provision that a contribution is expected from the receiving Government. It failed utterly to recognise that in many countries, particularly in Africa, the health budgets have remained static in size and in some cases have diminished. In 1971 there was a unique meeting of some representatives from Africa and the Far East concerned with medical education, medical care, and .
’
’
’
research, to examine with interested and experienced medical men and administrators from this country the effects of Britain’s medical aid programme. This meeting reiterated things which have been said on other occasions, but it must have left the representatives from the Third World with an uncomfortable feeling that they were banging their heads against a brick wall, and those from this country with the view that they were doing the best they could under difficult circumstances. It was clear that the three principles of the British aid programme were out of date, that it was time to take more positive action, and that much the same principles could be applied to medical aid whether it took the form of education, research, or medical care. As a result of this meeting it becomes possible to suggest a series of alternative principles which might be applied to aid. They are as follows: 1. There should be closer consultation between Governconcerning medical-aid programmes. 2. All donating countries should relate their aid programmes to national health plans. 3. Donating countries should make specific offers of aid following a study of national plans. 4. There should be coordination of international and bilateral aid in each receiving country. 5. Capital loans should be free from " tied aid ", and other assistance freed from the " contribution " element. 6. The imposition of aid should be avoided by consultation with local expert technical opinion. 7. Managerial skills should be introduced into medical-care programmes at all levels. 8. The development of systems of medical care on a wide scale, particularly in rural areas, should be encouraged. 9. Pilot projects should be pursued to identify the best method of application of basic health services. 10. The requirements of the basic health services for auxiliary personnel should be recognised and comprehensive training programmes integrated with professional education. ments
Some mechanisms exist already for the channelling of aid on a rational basis from Britain to the developing areas. In terms of research, the M.R.C. has long established the Tropical Medicine Research Board, which constantly maintains a contact with research progress, at least in Africa and the Caribbean. Support for academic institutions is directed by the Interuniversity Council, and many links have been forged between individual universities in the United Kingdom and in the Commonwealth. There is even a panel for one disease-trypanosomiasis. There does not appear to be the same type of mechanism for determining the needs for medical care applied to the community. If the Third World is positively to improve its health, this can only be achieved on a community basis, and it is here that community medicine has its greatest part to play. The greatest lack of all lies in the application of knowledge to the people. This can only be accomplished by adopting and implementing a stern and imaginative realism. Is there not room, therefore, for a community-medicine panel to assist the Civil Service and the politicians of Britain negotiating with the Third World the type of aid it needs in regard to this fundamental part of living ?