…IT IS INCREASINGLY CLEAR that a world in which there are such enormous differences between the “haves” and the “have nots,” between the overfed and underfed, a world in which the rising expectations of peoples previously silent are not being met, a world in which increased economic output threatens to be outpaced by increasing populations is not a safe, a healthy world for anyone anywhere… .
Our country, parts of Europe, and a few other places, constitute islands of relative health and plenty in a world of people who are sick, poor, undernourished, and whose outlook is one of despair.
From the Pacific Ocean, through the Orient, and into the Arab countries swings a terrible scythe of sickness; of malaria, of leprosy, of malnutrition, of diarrheal disease. To the south of us in Latin America, millions are ailing and ill-housed and ill-fed. In Africa the struggle to establish stable governments takes place against a tapestry of disease and want, and those who jockey for political advantage do so amid the smell of death.
Seven years ago some 250 million people in our world were attacked by malaria–140 million still are. It drains their lives and energies, cutting down the production of the food and goods they badly need. Another quarter of a billion people are infected with filariasis. Hookworm attacks upwards of 750 million people, including many in Latin America and Africa… .There are still about ten million persons with leprosy… .
The figures are so enormous that they almost obscure the picture. So let me focus on one small village of 464 persons in the Near East.
The people are Arabs–farmers, herdsmen, and charcoal burners. They keep camels, buffalo, horses, sheep, goats, donkeys, and smaller animals. There is no veterinary service. There are 92 houses in the village. There is plenty of water, but it is polluted. There is no bathhouse and there are no latrines and no toilets. There is no school of any kind, governmental or religious. There is no health officer, nor in fact any government office of any kind. There is no doctor, no nurse… .
The survey listed the village as moderately clean, and the population as cooperative. Ninety-four per cent of the inhabitants were examined. Trachoma was so general it was simply listed as widespread. Twenty-nine per cent of the people had schistosomiasis… .
In other words, most everyone was sick–and most of the time. There was work to do but no one felt like doing it–and there was no leadership, no organization that could make a dent in the status quo. When I think of the efforts we are making in the world, I often think of this village… .
It is the established policy of the United States to work for the alleviation of sickness in other countries. Written into our federal laws are bold statements of purpose–to add to research on an international front, to add to our own protection and to social and economic development elsewhere through development of better health outside our borders… .
…As you know, the U. S. Public Health Service has officers serving with the Peace Corps, with the World Health Organization, and with the Agency for International Development (called AID) which is now the chief agency of our government concerned with the economic and human development of the less affluent countries. AID acts through bilateral agreements with other governments and international agencies. It makes loans and distributes food and materials. It sends American experts of all kinds abroad and brings some 6,500 foreign students here to study. This year it will spend about 50 million dollars directly on health programs, but much that the agency does in helping raise the general standard of living also improves health… .
Private and voluntary organizations, including the American Public Health Association, have long aided international health programs. The great, quiet work of the Rockefeller Foundation in the health field has become a legend… .
There is no doubt that the spirit behind our overseas health effort is now changing. As one looks back over what has been done, one finds a lot of aid that was given as a result of charitable impulse–contributions following catastrophes such as earthquakes, floods, and typhoons. Some efforts, although conducted by people with humanitarian feelings, have been to solve immediate practical problems, such as making more productive the employees of a commercial concern, or cleaning up a community to protect members of the American armed forces as well as the local population. Other programs–those conducted by religious groups–aimed at preventing or alleviating disease, but tied to this was the objective of spreading particular religious beliefs.
There is no doubt that now our objectives are becoming much broader and that we are aiding in overseas health projects because we believe they are necessary to the physical and mental health of the whole world. We are convinced that they are an essential adjunct to social and economic progress. Such progress can be viewed as an end in itself or as important to our own interest. Inevitably it is both… .
… .Those who believe that aiding in health programs in other countries is simply taking what we know and flying over there with it, to be received with open arms, are doomed to sharp disappointment. Many of the people we will be dealing with know that they are right and we are wrong… .
These are 5 points of view that may be useful in overseas work. They constitute an attitude we may carry with us and which seems to me we will need.
1. In working in another country, understand what is already there, both physically and in people's minds and mores and build on this foundation—
Different as remote cultures may seem, they have their own strengths and resources… . The local citizen is quite likely to feel that what he is doing is right, and he is unlikely to revise his opinion unless he is given impressive reasons to the contrary… .
Many local customs are practical and sensible reactions to existing conditions. In parts of Greece, for example, outside experts spent a lot of time and money trying to introduce the mortarboard plow in place of the old and traditional scratch plow. It turned out, finally, that the scratch plow was exactly right for the thin soil of the region and that the mortarboard plow turned up far too much subsoil. The local people had been right all along. The outside experts, dragging their cultures behind them, were wrong, at least for this particular region… .
Leona Baumgartner
Source. Photo courtesy of the Prints and Photographs Collection, History of Medicine Division, National Library of Medicine.
It is wise to build on existing personnel, training as need be to develop a cadre as the nucleus of a future health staff. It is also wise to train within the region, when feasible, for then the training takes place against a background of actual needs and potentialities.
We must shift our thinking about personnel and how to use them, and in particular we must get rid of the idea that everything in medicine must be done by doctors and nurses… . In some of the areas overseas that we are concerned with, a villager who has never been to school at all, given brief training and today's drugs, can achieve a greater reduction in sickness in his area than the best doctor could 25 years ago… .
2. Consider and recognize the relationship between the health programs and other developments in the region—
…Many of the emerging countries are now involved in their own industrial revolutions. These revolutions are similar to those the now affluent countries once went through, but they are occurring much faster, with even greater building up of tensions. At the same time that we, with our health programs, are seeking to change traditional ways of doing things, cultural patterns are already being bent by the forces of economic and social development… .
3. Handle the problems the people themselves consider most important—
…We have had scientific backgrounds. It is natural for us to survey the situations we find and to suggest what should be done in terms of what our facts show… . If we do not help people where they believe they need help, we may never gain their confidence, or cooperation… .
4. Realize that transplants of whole technologies from one culture to another are not necessarily viable—
We pride ourselves on the success western medicine and public health have enjoyed. There is a natural temptation to attempt transplanting our know-how and technology, item by item, to the countries in which we will serve. This often will not work. What is done in health in these less affluent lands must be tailored to local needs, local conditions. Just because it was good back home does not mean it is good somewhere else… .
The wise man does not transplant the succulent flowers of deserts to the soggy banks of streams; neither does he seek to move our health procedures unchanged to other areas. He remembers, too, that it is often easier to modify the technology than to change the culture to which the transplant is carried. At best the transplant will need careful watching, loving care, lest it wither on the vine… .
5. Let us recognize that technical assistance is a 2-way street—
First of all, above all, let us be humble. Remember that we do not know it all. We have been wrong, and the people we seek to help have been right.
I wonder how many of you recall that after the First World War we sent maternal and child health teams to the Balkans. A lot that we taught was accepted, but one thing was not. We tried to teach the mothers to feed babies at specified times of the day. We gave them schedules and told them to follow the schedules. The mothers rebelled. They had the quaint idea that babies should be fed when they were hungry. It took us a long time to realize that they were being sensible and we were not… .
In conclusion, I wish to make two points. The first is that these problems of improving the health of all the people are being tackled on a scale woefully short of what the situation demands. This business of learning, of experimenting, of applying the magic of modern science and technology in other countries is a complicated affair. It demands the same imaginative, vigorous, critical scientific approach which has characterized the growth of Western science. It requires more–the sensitivity of the human spirit to, and respect for, the values other human beings hold dear… .
The second is that this adventure of world-wide health, world-wide social and economic development is perhaps the greatest adventure yet launched by man… . Our ability to go forward in this great new adventure is a sensitive indicator of our own moral, intellectual, scientific, social, and spiritual maturity. Let us move, confident that we are wise enough and strong enough to meet the challenges.