Diseases of Children in the
Subtropics and Tropics
This book is licensed under a Creative Commons Attribution 3.0 License
Diseases of Children in the Subtropics and Tropics
Paget Stanfield Martin Brueton Michael Chan Michael Parkin Tony Waterston
Copyright © 2008 Paget Stanfield
For any questions about this text, please email: [email protected]
The Global Text Project is funded by the Jacobs Foundation, Zurich, Switzerland
This book is licensed under a Creative Commons Attribution 3.0 License
This edition was scanned and converted to text using Optical Character Recognition. We are in the process of converting this edition into the Global Text Project standard format. When this is complete, a new edition will be posted on the Global Text Project website and will be available in a variety of formats upon request.
This is the fourth edition of this book that was last published in 1991.
Diseases of Children in Subtropics and Tropics 2 A Global Text
Foreword
Paediatrics is often thought of as following two main routes. One is that of ultratechnology and ever- narrower specialization. The other is recognition of child health in a community context, related to family circumstances (especially the health and welfare of mothers) and influenced by the environment, social stresses, economic limitations, cultural attitudes and practices, and policy decisions and priorities based on the political system.
Neither is right, but rather a balance is needed.
Thus, preventive programmes, such as immunization, depend on refined technology to produce appropriate vaccines and devise workable equipment for effective 'cold-chains'. Curative paediatrics, especially simpli- fied methods in appropriate technology, has to be underpinned by science - both by necessity and to achieve acceptance by orthodox members of the Estab- lishment. Examples include the work of gastroentero- logists on the intestinal 'sodium pump' and how this can be 'primed' and made more effective by glucose.
In this way, essential scientific credence has been given to the seemingly simple methods of oral rehydra- tion, using prepared ORS packets or home-made mix- tures of sugar and salt or dilute rice (or other staple) gruels.
However, as always, it can be difficult to persuade physicians, including paediatricians, to acquire a com- munity perspective, understanding and, still more, a truly active role. This is often in part because of their training which frequently remains predominantly clinical - 'we teach what we have been taught'. How- ever, things are changing in some more enlightened training establishments, and the trend is certainly indicated in this Fourth Edition.
Sound clinical work, as in a hospital environment, is vital and will always remain a major need. This
approach alone cannot begin to touch the major issues of child health. Some of these may be beyond the scope of the paediatrician or of medical science. Nevertheless, an awareness of the need for an advocacy role has to be cultivated. In this way, advice and guidance may begin to move those in power towards policies which can improve community child health.
The 'complete' paediatrician anywhere, but espe- cially in less technically developed countries, often in tropical regions, needs to be much more than a blinkered 'vertical' /'horizontal' expert. Rather, there is a need for 'lateral' thinking, training and action. This implies realization of the wide range of factors needing consideration in child health work and also recog- nization of the value of a dove-tailed curative-pre- ventive approach, as part of a team including paedia- trIClanS, nurses, community health workers and (importantly) parents, particularly mothers, in the community itself.
The present edition of Diseases of Children in the Sub- tropics and Tropics moves in this direction and will most certainly be valuable not only as a clinical reference text. My hope is that it will also persuade its readers that a paediatrician should not only be clinically sound, but also able to recognize the wider community issues involved in the causation of problems and the need for imaginative interdisciplinary programes to improve the outlook for life and health of mothers and children in the Third World.
D.B. Jelliffe, MD, FRCP.
Professor of Public Health and Pediatrics, Director, International Health Program, School of Public Health, University of California, Los Angeles, USA
Preface
The fourth edition of this book incorporates significant advances in technical knowledge and also takes into account the widening role of paediatricians in the health care of children in developing countries. As in earlier editions, it seeks to provide paediatricians with an up- to-date review of the diseases of children encountered in the tropics, together with their diagnosis and treatment, with particular reference to the practical management of difficult problems facing the busy doctor. Technically there have been spectacular advances since the last edition, for example oral rehydration and drugs for the treatment of schistosomiasis, neonatal septicaemia and malignant diseases in childhood. There have also been setbacks, such as increasing drug resistance in malaria and leprosy. The mechanisms of many nutritional, genetic and metabolic disturbances have been considerably clarified and means of early detection of disease and the identification of risk to health factors have been developed even though many need yet to be adequately applied.
The vital relationship of the health of the mother to the well-being of the child has become a major concern in developing countries since the last edition was published. A new section has been added to focus on practical care for pregnant women, the management of labour and delivery, the care of the newborn infant, and the organization of perinatal care.
Doctors are becoming increasingly aware of the limitations of a largely hospital and curative based medical education in preparing practitioners to play a leading part in child health. This edition is intended to prepare its readers for the task of improving the health care of children in the developing world.
The environment remains the major determinant of child health. The balance of influence changes in favour of the child wherever there is stability, education, economic growth, more equitable distribution of resources and a political will to improve the health of mothers and children. In contrast, national and inter- national economic constraints and political conflicts
have profoundly damaging effects on child health, both through diminished government budgets available for services and through decreased parental employment and income. Likewise, the grim consequences of natural and man-made disasters have highlighted the vulnerability of mothers and children, for example, among refugees.
Increasingly efficient and penetrating communica- tion is also having its effects throughout the world. The shrinking globe has exposed traditional ways of life to the stimulus, advantages and distortions of other cultures. Extended family units, which have buffered the mother and child from severe physical and social deprivation, are tending to break up. There is a steady migration of people from country into city and agricul- ture to industry while urban unemployment continues to increase. The impact of modern, ecologically inappropriate advertising has adversely influenced many child-rearing practices such as breast-feeding, as well as the prescribing of drugs.
Alongside these potentially harmful developments there has been emerging a world-wide emphasis on the extension of primary health care to the community.
This has been accompanied by a growing sense of the importance of local participation in the provision of community-based health care. There has been a new recognition of the enhanced role of community selected health volunteers, including trained indigenous healers and health attendants, not only in effecting changes of attitudes and behaviour towards health but also in gathering information about the incidence and causes of ill health within a community.
Those concerned with paediatrics need to become vigorous advocates of child health services and of legislation which favours mothers and children. This requires persistent education, persuasion and, in political terms, lobbying of those in control of budgetary priorities and national policy. New skills in communication and teaching methods are required.
The complete paediatrician needs to know about
Vlll Preface
critical pathway analysis, discreet education and persuasive presentation as well as about the murmurs of mitral stenosis and the clinical picture of malaria.
Against this background the present edition sets out to achieve a difficult but essential blend. Each section attempts to find a balance between clinical and applied paediatrics; between curative and preventive medical care; between disease in the individual child and in the community; between maternal and child health, acknowledging that mother and child are biologically and psychologically an inseparable dyad throughout the reproductive life of the one and the prenatal, neonatal and early pre-school life of the other. A balance has to be struck between the assembly of information and instruction needed by the paediatrician in the reference centres of excellence and the study and practice of management at the level of primary care.
The book therefore aims to be a readable specialized reference source appropriate to the care of children in well-equipped hospitals. In addition, it describes explicitly the presentation and management of child- hood disease problems in a way relevant to the practice of primary and preventive health care of the children in their communities. Furthermore, the perspectives of this edition are intended not only for those dealing with the practice and problems of child health now but also for medical students who will be the practitioners and leaders of health care in the future. It is very important that we share our hopes and ideals with those to whom they will become realities. The present publication is therefore geared to the training of medical students as well as offering a resource for general practitioners,
primary health centre doctors, paediatricians and those responsible for the planning and administration of maternal and child health services in the developing world.
The sudden and unexpected death of Michael Parkin, as this edition has gone to press, is a grievous loss to us all. It has been a great privilege to have worked with him as a member of our team in editing and writing parts of this edition. In spite of his many commitments he joined us gladly and his contribution to its production has been substantial. Michael was dedicated to family life in the North East of England, where he was known and loved by many parents and children. Sheila, Michael's wife, shared his commit- ments to the well-being of children throughout the world. She would join us in the hope that this book will enable many to appreciate and share Michael's care for mothers and children and the ways in which he practised this care. In his wide travels he made it clear, as he writes in his introduction, that the principles and practice he learned and taught in Newcastle were rele- vant to all parts of the world. It was characteristic of Michael that he introduced the section on growth and development with a verse from the Bible. Weare grate- ful that he was able to complete this task.
Paget Stanfield Michael Chan Martin Brueton Tony Waterston 1991
Acknowledgements
The editors acknowledge with thanks a number of colleagues and publishing houses who have contributed figures, tables and photographs which have helped to illustrate the text. The origins of these contributions are acknowledged individually as they appear in the book and we sincerely hope that no omissions have occurred.
It has been a privilege to work with such a ready, willing and patient team of contributors whose experience and knowledge are broadening and deepening the care of mothers and children throughout the world.
The editors would also like to thank Paul Price and the editorial staff at Edward Arnold for all their support, encouragement and advice.
In all, we hope readers of this book will benefit as much from its study as we have from its production.
Contents
Foreword Preface
Acknowledgements Contributors
111 V Vll X111
Section 1 Maternal and Child Health Tony Waterston
11 Introduction
Torry Waterston and Paget Stanfield 3
2 Cultural aspects of common childhood diseasesValerian Kimati 14
3 Primary health care
FJ Bennett 26
4 Delivering the services 38
Hospital and clinic
WEK Loening 38
Case studies in primary health care 56
Zimbabwe: the children's supplementary feeding programme
David Sanders 56
Brazil: oral rehydration therapy
MA de Souza 60
China: primary health careVictor W Sidel and Ruth Sidel 62
Bangladesh: primary health care in the rural communityZafrullah Chowdhury 65
Management in primary health care
John P Ranken 70
Immunization
Paget Stanfield 78
Maternal health
Kusum P Shah 88
Working with traditional midwives
Gill Tremlett 94
Breast-feeding: protection, support and promotionMichael C Latham 95
5 Community diagnosis
Michel Pechevis
1036 The doctor as teacher
Tony Waterston 114
7 Parents and children in hospital
Janet Goodall 120 Section 2 Maternal, Prenatal, Perinatal and Neonatal Care
Michael Chan 129
1 Introduction
Michael Chan
2 Maternal HealthMaternal care
Olive Frost
131 136 136
xii Contents
Maternallactation
Dorothy A. Jackson) MW Woolridge)
Stella Imong andJD Baum 153
3 Prenatal health
Michael Chan 158
Prenatal infections
Michael Chan 163
4 Perinatal health 175
Obstetric problems and perinatal mortality
David Goodall
175Perinatal infections
Michael Chan 180
5 Neonatal health 186
Neonatal care
Michael Chan 186
Feeding the neonate
Indira Narayanan 195
Low-birth-weight infants
Michael Chan 208
Neonatal jaundice
Michael Chan 221
Convulsions in the newborn
Michael Chan 228
Bleeding in the newborn
Michael Chan 229
Neonatal infections
Michael Chan 233
6 Organization of perinatal care
SK Bhargava) S RamJi and
I Bhargava
241Section 3 Growth and Dev.elopment Michael Parkin
and Paget Stanfield
2511 Introduction
Michael Parkin 253
2 Physical growth 254
Growth in childhood
AS Paynter and Michael Parkin 254
Making growth monitoring more effectiveGill Tremlett 270
Short stature
Michael Parkin 275
3 Puberty and its disorders
Michael Parkin 281
4 Development 286
Child development
P Morrell 286
Disability in childhood
P Zinkin 311
5 Nutrition 324
Nutritional need of healthy infants
RG Whitehead and AA Paul 324
Protein-energy malnutrition
V Reddy 335
Prevention of protein-energy malnutrition
MGM Rowland 358
Specific vitamin deficienciesV Reddy with WH Lamb 367
Mineral and trace element nutritional disordersPeter J Aggett
379Nutrition rehabilitation
MA Church 387
6 Behaviour 391
Emotional development
AD Nikapota and HG Egdell 391
Mental health problemsHG Egdell and AD Nikapota with
K Minde and S Musisi 398
Delinquency
K Minde and
SMusisi 419
7 Deprivation 422
Social deprivation
SN Chaudhuri
422Child abuse and neglect within the family
Nigel Speight 426
8 Genetics of tropical diseasesJ Burn and AJ Clarke 430
Section 4 Infectious Diseases Paget Stanfield 1 Introduction
Paget Stanfield2 Infections and the immune system
Badrul Alam Chowdhury and Ranjit Kumar Chandra3 Diarrhoeal diseases
William AM Cutting4 Common childhood infections
Nimrod Bwibo5 Tuberculosis
DH Shennan and MA Kibel6 Leprosy
M Elizabeth DuncanForeword
SG Browne7 Bacterial, spirochaetal, chlamydial and rickettsial infections
David Mabey8 Viral infections
Patrick Goubau) Jan Desmyter and Roger Eeckels9 Mycotic infections RJ
Hay10 Helminthiasis
John VinceDracunculiasis
H Taelman11 Schistosomiasis
HA Wilkins12 Malaria
Tan Chongsuphajaisiddhi13 Other vector-borne parasitic infections
Trypanosomiasis
H TaelmanLeishmaniasis
Phillipe LepageFilariasis
H TaelmanFilariasis in children in Asia
JW MakSection 5 Diseases of the Systems Martin Brueton 1 History-taking and examination
Wong Hock Boon2 Diseases of the respiratory system
JK G Webb3 Diseases of the gastro-intestinal tract
Martin Brueton4 Diseases of the central nervous system
Suresh Rao Aroor5 Cardiovascular diseases
F Jaiyesimi6 Disorders of the kidney and urinary tract
Yap Hui Kim7 Endocrine and metabolic disorders
Wong Hock Boon8 Haematological disorders C
Chintu9 Immunological disorders
Badrul Alam Chowdhury and RanJit Kumar Chandra10 Diseases of the skin
AN Okoro11 Neoplastic diseases
CLM Olweny12 Paediatric surgery
SD Adeyemi13 Diseases of the ear, nose and throat
Christopher Holborow14 Orthopaedic disorders
RL Huckstep15 Diseases of the eye
DD Murray McGavin16 Accidents and poisoning
Nimrod BwiboSnake bites
Martin BruetonArthropod-produced diseases
A MillerContents XlII
445 447 449 455 496 519 553 553 577 600 624 633 649 650 657 675 675 682 686 691
697
699
706
725
741
762
784
806
822
839
847
873
888
902
910
926
940
954
957
xiv Contents
Section 6 Practical Aids Tony Waterston 1 Introduction
Tony Waterston2 The appropriate use of drugs
Nigel Speight3 Appropriate use of the laboratory
Andrew Hughes4 Appropriate technology for health
Katherine Elliott5 Child care in refugee situations
john Seaman6 Practical procedures
Cj Clements7 Appropriate imaging techniques
PES PalmerIndex
965
967
968
974
985
993
1001
1019
1025
Contributors
SD Adeyemi, MB BS(Lagos), FRCS(C), FMCS, FWACS, CSCPS.
Associate Professor and Consultant Paediatric Surgeon, Department of Surgery, College of Medi- cine, and Lagos University Teaching Hospital, Lagos, Nigeria.
Peter J Aggett, MSc, MB ChB, FRCP, DCH(Eng.).
Senior Lecturer In Child Health and Nutrition, Department of Child Health, University of Aberdeen, UK.
Suresh Rao Aroor, MB BS, DCH, MD, DM.
Associate Professor of Paediatric Neurology, National Institute of Mental Health and Neuro- sciences, Bangalore, India.
JD Baum, MA, MSc, MD, FRCP.
Professor of Child Health, Department of Child Health, University of Bristol, Royal Hospital for Sick Children, Bristol, UK.
FJ Bennett, MB ChB, DPH, FFCM.
Formerly Director, Department of Community Health, African Medical and Research Foundation, Nairobi, Kenya.
I Bhargava, MB BS, MS, DSc, FlAP, FAMS.
Formerly Deputy Director General, Ministry of Health and Family Welfare, Government of India, New Delhi, India.
SK Bhargava, MB BS, DCH, MD, FlAP.
Consultant Paediatrician, Gouri Hospital, New Delhi and formerly Professor and Head of Depart- ment of Paediatrics, Safdarjung Hospital, New Delhi, India.
SG Browne, MD, FRCP, FRCS, FKC, CMG, OBE.
Formerly International Consultant in Leprosy;
Director of the Leprosy Study Centre, and Medical Consultant to the Leprosy Mission, London, UK.
Martin Brueton, MD, MSc, FRCP, DCH.
Reader in Child Health, Department of Child Health, Westminster Children's Hospital, London, UK.
J Burn, B Med Sci(Hon), MB, FRCP.
Consultant Clinical Geneticist and Clinical Lecturer, Department of Human Genetics, U niver- sity of Newcastle upon Tyne, UK.
Nimrod Bwibo, MB ChB, MPH, FAAP, MRCP.
Deputy Vice-Chancellor and Professor of Paediatrics, College of Health Sciences, University of Nairobi, Kenyatta National Hospital, Kenya.
Michael Chan, MD, FRCP, FRACP.
Senior Lecturer, Department of Tropical Paediatrics and International Child Health and Honorary Consultant Paediatrician, Liverpool School of Tropical Medicine, UK.
Ranjit Kumar Chandra, MD, FRCP(C), PhD, DSc(Hon), DPhil(Hon).
Professor of Paediatric Research and Medicine, Director of Immunology, Memorial University of Newfoundland, Newfoundland, Canada.
SN Chaudhuri, MB BS(Rgn), MD(AIIMS).
Director, Child In Need Institute, Vill. Daulatpur, PO Pailan, Via-Joka, 24 Parganas South, 743512, West Bengal, India.
XVI Contributors
C Chintu, MD, LMCC, FRCP(C), DABP.
Professor of Paediatrics and Child Health, Consul- tant Haematologist and Oncologist, University Teaching Hospital, Lusaka, Zambia.
Tan Chongsuphajaisiddhi, MD, PhD, DTM & H.
Dean, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
Badrul Alam Chowdhury, MD, PhD.
Resident, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA.
Zafrullah Chowdhury, MB BS.
Projects Coordinator, Gonoshasthaya Kendra (Peoples' Health Centre), PO Nayarhat; via Dhamrai, Dhaka, Bangladesh.
MA Church, MB B Chir, FFCM, DTPH.
Medical Advisor, Scottish Health Education Group, Health Education Centre, Edinburgh, UK.
AJ Clarke, BSc, MD, MRCP.
Senior Lecturer in Medical Genetics, University Hospital of Wales, Cardiff, UK.
CJ Clements, MSc, MB BS, MFPHM(NZ), MCCM, DCH, Dip Obst.
Medical Officer, Expanded Programme on Immunization, WHO, Geneva, Switzerland.
Research Worker, Department of Bacteriology, Edinburgh University Medical School, Edinburgh, UK.
Roger EeckeIs, MD, Dip Trop Med.
Professor of Paediatrics, University of Leuven, Belgium.
HG Egdell, MB ChB, FRCP, FRC Psych, DPM.
Clinical Lecturer, Department of Psychiatry, University of Liverpool, UK.
Katherine Elliott, MRCS, LRCP, FFCM.
Formerly Director of Appropriate Health Resources and Technology Action Group (AHRTAG), 1 London Bridge Street, London SEl 9SG, UK.
Olive Frost, MB ChB, MSc, MFCM, FRCOG.
Consultant in Public Health Medicine, Clinical Lecturer, Department of Paediatrics and Child Health, University of Liverpool and Honorary Senior Lecturer, Department of Tropical Paediatrics, Liverpool School of Tropical Medicine, UK.
David Goodall, MB BS, MRCS, LRCP, MRCOG.
Consultant in Gynaecology and Obstetrics, Queens Park Hospital, Blackburn and Honorary Senior Lecturer, Department of Tropical Paediatrics, Liverpool School of Tropical Medicine, UK.
William AM Cutting, MB ChB, FRCPE, DCH, Janet Goodall, FRCPEd, DCH, DObst RCOG.
DObst RCOG. Formerly Consultant Paediatrician, City General
Senior Lecturer and Honorary Consultant Hospital, Stoke on Trent, UK.
Paediatrician, Department of Child Life and Health, University of Edinburgh, UK.
Jan Desmyter, PhD, MD, Dip Trop Med.
Professor of Microbiology and Epidemiology, University Hospital and Rega Institute for Medical Research, University of Leuven, Belgium.
MA de Souza, PhD.
Professor of Community Medicine, Department of Community Health, Federal University of Ceara, Brazil.
M Elizabeth Duncan, MD(Hons), FRCSE, FRCOG.
Patrick Goubau, MD, Dip Trop Med.
Senior Registrar, Department of Virology, U niver- sity Hospital, Leuven and Lecturer, Institute of Tropical Medicine, Antwerp, Belgium.
RJ Hay, DM, FRCP, MRCPath.
Professor of Cutaneous Medicine, Department of Dermatology , United Medical and Dental Schools of Guy's and St Thomas' Hospitals, University of London, UK.
Christopher Holborow, OBE, TD, MD, FRCS, FRCSEd.
Consultant ENT Surgeon, Westminster Hospital, Consultant to the WHO, Ethiopia and Associate London, UK.
RL Huckstep, CMG, FTS, MA, MD(Cantab.), Hon.MD(NSW), FRCS, FRCSE, FRACS.
Professor and Head, Department of Traumatic and Orthopaedic Surgery and Chairman of the School of Surgery, University of New South Wales, Prince of Wales Hospital, Sydney, Australia.
Andrew Hughes, MA, BM BCh, MRCP, MRCPath.
Consultant Haematologist, Harold Wood Hospital, Romford, UK.
Stella Imong, MD, MRCP.
Clinical Lecturer in Paediatrics, Department of Child Health, University of Leicester, UK.
Contributors XVll
WEK Loening, MB ChB, FCP(Paed.).
Professor of Maternal and Child Health, Depart- ment of Paediatrics and Child Health, University of Natal, Durban, South Africa.
David Mabey, MA, BM BCh, MRCP, MSc.
Senior Lecturer, Department of Clinical Sciences, London School of Hygiene and Tropical Medicine and Honorary Consultant Physician, Hospital for Tropical Diseases, London, UK.
JW Mak, MB BS, MD, MPH, MRCPath, DAP &
E.
Head, Malaria and Filariasis Research Division, Institute for Medical Research, Kuala Lumpur, Malaysia.
Dorothy A Jackson, D Phil. DD Murray McGavin, MD, FRCSEd, FCOphth, Research Fellow in Child Health, Department of
Child Health, University of Bristol, Royal Hospital for Sick Children, Bristol, UK.
F Jaiyesimi, MB BS(Ibadan), FRCP(Lond.), DCH, FMCPaed, FWACP.
Professor of Paediatrics, University of Ibadan and Consultant Paediatrician and Paediatric Cardio- logist, University College Hospital, Ibadan, Nigeria.
MA Kibel, FRCP(Edin), DCH(Lond.).
Professor of Child Health, Department of Paediatrics and Child Health, University of Cape Town, South Africa.
Valerian P Kimati, MB ChB, FRCPE, FRCP(Glasg.), MRCPI, DCH.
Chief of Health, UNICEF, Lagos, Nigeria.
WH Lamb, MB BS, MD, MRCP.
Consultant Paediatrician, Bishop Auckland General Hospital, Durham, UK.
Michael C Latham, OBE, MB, FFCM, MPH, DTM&H.
Professor of International Nutrition and Director, Program of International Nutrition, Cornell University, New York, USA.
DCH.
Associate Senior Lecturer, Department of Preventa- tive Ophthalmology, Institute of Ophthalmology, London, UK.
A Miller, PhD, MS, BS.
Formerly Associate Professor of Medical Entomo- logy, School of Public Health and Tropical Medi- cine, Tulane University, New Orleans, Louisiana, USA.
K Minde, MD, FRCP(C).
Chairman of the Division of Child Psychiatry, McGill University, Director of Psychiatry, Montreal Children's Hospital and Professor of Psychiatry and Pediatrics, McGill University, Montreal, Canada.
P Morrell, MB ChB, MRCP.
Consultant Paediatrician, South Cleveland Hospital, Cleveland, UK.
S Musisi, MB ChB, FRCP(C).
Consultant Psychiatrist, York Central Hospital, Ontario, Canada.
Indira Narayanan, MD, MNAMS.
Formerly Head of Department of Neonatology and Senior Consultant in Paediatrics, Shri Mool Chand Kharaiti Ram Hospital, New Delhi, India.
Philippe Lepage, MD.
Head, Department of Paediatrics, Hospitalier de Kigali, Kigali, Rwanda.
AD Nikapota, MB BS(Ceylon), DPM(Lon), MRC Centre Psych(UK).
Consultant Child and Adolescent Psychiatrist,
XVlll Contributors
Brixton Child Guidance Unit and Senior Lecturer, Institute of Psychiatry, London, UK.
AN Okoro, MB ChB, MRCP, FRCP.
Consultant Dermatologist, University of Nigeria Teaching Hospital, Enugu, Nigeria.
eLM Olweny, MB ChB, MMed, MD, FRACP.
Professor, University of Manitoba, and Co- Director, WHO Collaborating Centre for Quality of Life in Cancer Care, St. Boniface General Hospital, Manitoba, Canada.
PES Palmer, MD, FRCP, FRCR.
Emeritus Professor of Radiology, University of California, Sacramento, California, USA.
Michael Parkin, MD, FRCP.
Formerly Professor of Clinical Paediatrics, Depart- ment of Child Health, Royal Victoria Infirmary, Newcastle upon Tyne, UK.
AA Paul BSc.
Scientist, MRC Dunn Nutrition Unit, University of Cambridge, UK.
AS Paynter, MB BS(Madras), MRCP, DCH.
Consultant Paediatrician, Community Child Health, West Cumberland Hospital, Cumbria, UK.
Michel Pechevis, MD.
Consultant Paediatrician and Head, Training Department, Centre Internationale de L'Enfance, Paris, France.
S Ramji, MB BS, MD.
Associate Professor, Department of Paediatrics, Maulana Azad Medical College, New Delhi, India.
John P Ranken, BA, MIPM, LHA.
Senior Lecturer, Tropical Child Health Unit, Insti- tute of Child Health, University of London, UK.
V Reddy, MD, DCH, FlAP.
Director, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India.
MGM Rowland, MB BS, FRCP(UK), MCFM, DCH, DTM&H.
Consultant Epidemiologist, East Anglian Regional Health Authority, Cambridge, UK.
David Sanders, MB ChB, MRCP, DCH, DTPH.
Associate Professor and Consultant Paediatrician, Department of Community Medicine, University of Zimbabwe, Harare, Zimbabwe.
John Seaman, MB BS, DCH.
Senior Overseas Medical Officer, Save The Children Fund, London, UK.
Kusum P Shah, BSc, MD, DGO.
Formerly Associate Professor of Obstetrics and Gynaecology, Grant Medical College, Bombay, India.
DH Shennan, MD, DPH, DCH, DTCD.
Tuberculosis Officer, Department of Health, Ciskei, South Africa.
Ruth Sidel, PhD.
Professor of Sociology, Hunter College, City University of New York, USA.
Victor W Sidel, MD.
Professor of Social Medicine, Montifiore Centre, Albert Einstein College of Medicine, New York, USA.
Nigel Speight, MB BChir, DCH, FRCP.
Consultant Paediatrician, Dryburn Hospital, Durham, UK.
Paget Stanfield, MD, FRCP, FRCPS, DCH.
Director, Department of Community Health, African Medical and Research Foundation, Nairobi, Kenya.
H Taelman, MD, Dip Trop Med.
Head, Department of Internal Medicine, Centre Hospitalier de Kigali, Kigali, Rwanda.
Gill Tremlett, B Nurse, MSc.
Nurse, midwife and health visitor, London, UK.
John Vince, MD, FRCP.
Specialist Medical Officer in Paediatrics, Port Moresby Hospital and Honorary Lecturer in Child Health, University of Papua New Guinea.
Tony Waterston, MD, MRCP, DCH, DRCOG.
Consultant Paediatrician, Community Child Health, Newcastle General Hospital, Newcastle upon Tyne, UK.
J
KG Webb, OBE, MA, BM BCh, FRCP.Emeritus Professor, University of Newcastle upon Tyne, UK.
RG Whitehead, MA, PhD, FI BioI, Hon. MRCP.
Director, MRC Dunn Nutrition Unit, University of Cambridge, UK.
HA Wilkins, MA, MB BChir, DTM&H, DObst RCOG.
Director, Medical Research Council Laboratories, Fajara, The Gambia.
Contributors XIX
Wong Hock Boon, MB BS, FRCP(Lond.), FRCP(Ed), FRACP, FRCP, DCH, PJG, PPA.
Senior Fellow and Emeritus Professor, Department of Paediatrics, National University of Singapore, Singapore.
MW Woolridge, PhD.
Research Fellow in Child Health, Department of Child Health, University of Bristol, Royal Hospital for Sick Children, Bristol, UK.
Yap Hui Kim, MB BS, MMed(Paed.).
Associate Professor and Head, Department of Paediatrics, Division of Paediatric Nephrology, Immunology and Urology, National University Hospital, Singapore.
P Zinkin, MB ChB, FRCP, DCH.
Senior Lecturer, Department of International Child Health, Institute of Child Health, London, UK.
SECTION I
Maternal and Child Health
Tony Waterston
CHAPTER 1
Introduction
Tony Waterston and Paget Stanfield
The world situation
Causes of high mortality and morbidity Socio-economic background
Effect of development on the environment Health service delivery
There must be very few doctors working with children in the closing years of the twentieth century who do not accept two cardinal statements about child health: first, that children cannot be considered apart from their family and society; and second, that doctors treating sick children in hospital have a wider responsibility for those outside who fail to reach their wards. It has taken time for these messages to penetrate into medical education, and to a wider public, through the efforts of prescient thinkers in developing and developed coun- tries. The concepts of integrated health care, of health promotion, of a group approach in addition to indi- vidual care, and of the political content of health are now widely accepted and have been well-publicized both by the
vy
orld Health Organization and by UNICEF in its annual reports on The State of the World's Children.It might with logic be asked, why have a section on mother and child health in a textbook on children's diseases? To answer this question, we need first to define health. Many doctors find the World Health Organization definition (a sense of complete physical, mental and social well-being) tendentious and illusory;
such a state is unlikely to be achieved in most parts of the world, even if it is the ideal, and progress towards such a state is impossible to measure. However, measurement of health is essential if we are to use the more positive term health promotion in addition to the rather negative 'disease prevention'. Indices are now available to measure health. 1 This section is entitled 'maternal and child health' because the health of the
Primary health care
The role of traditional medicine
Women and children in primary health care Children's rights
The role of doctors in primary health care References
mother is intimately bound up with that of the child, and because similar approaches are needed in the delivery of paediatric and obstetric care. But perhaps in the future, family health will become the more correct term. Its use would not only encourage the inclusion of fathers, but also of grandparents, uncles and aunts.
Fathers are essential to families and the recent spate of publications on fatherhood2,3 is a sign of the times. The fact that in many families, the father is absent or contri- butes little to child care does not negate this - there is a trend towards more paternal involvement and we hope that paediatricians will encourage this. Children need fathers too.
However, the above concepts have tended to suffer from excessive rhetoric and require illumination by detailed examples; they also require the application of a scientific approach. Health workers should not assume that public participation in health is an easy aim to achieve, nor that prevention in the community can succeed without special skills and long effort. In this section of the book we hope to provide the evidence for the effectiveness of the Primary Health Care approach (further defined on p. 26ff.) by giving the reader access to the basic sciences of preventive medicine: epidemio- logy, anthropology, psychology and sociology among others. A good grasp of politics is also needed but perhaps, like medicine, politics is more of an art than a science. The political content of medicine has long been recognized: it was Virchow who stated in the nineteenth century, 'Politics is nothing more than medicine on a grand scale' .
4 Introduction
The world situation
Globally, the annual death toll of mothers and children is still appalling and despite improved delivery of health care there is little light on the horizon because of the overall socio-economic depression affecting most developing countries. Experience in Western Europe has shown that health inputs alone contribute little to mortality reduction - improved nutrition and hygiene are more important factors. However, health measures which are appropriately targeted and which are inte- grated with initiatives from other sectors are effective, as some very poor countries have shown (see Fig.
1.1.1).
Improved care has barely touched the 'gap' area between the last antenatal visit and the first postnatal contact. Upwards of 80 per cent of women in develop- ing countries deliver at home, attended by older female family members or traditional midwives. Both mother and child pass this perilous time hidden and effectively out of reach from any health facility. The recent unveil- ing of the magnitude of neonatal tetanus mortality by dint of retrospective surveys has emphasized the high and, for the most part, unrecorded maternal and peri- natal mortality and morbidity rates in these countries.
Figures 1.1.2-1.1.7 illustrate the problems. In most developing countries children make up 50 per cent of the population and this proportion is not decreasing.
The world figures for death rates and causes of death at different ages are shown, as well as comparisons from high, middle and low-mortality countries. It is important to remember that there are differences within, as well as between, developing countries and this is illustrated by an example from Asia (Fig. 1.1.6).
Such disparities are the result of the 'dual economy'
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300 250 200 150 100 50
High mortality
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which exists in many low-resource countries and which is further discussed below.
It is now well-known that the most common causes of death in these countries are malnutrition, infectious diseases and (for mothers and children) childbirth. It should be remembered, however, that child morbidity and disability also form an increasing burden, parti- cularly in situations where medical services prevent child deaths but do not combat their causes. Some of these conditions (for which accurate figures are rarely available) are outlined in Table 1.1.1. The burden these conditions present to the community is enor- mous, yet they are highly amenable to prevention. If preventable, why not prevented?
Causes of high mortality and morbidity
The multiple origins of child and maternal deaths are now well understood. Detailed analysis of causes will be found under the various disease sections but we will examine more closely here two of the fundamen- tal factors: the socio-economic background, and the structure of medical services.
Socio-economic background
Most of the diseases of developing countries are poverty-associated rather than purely tropical diseases and the spectrum is very similar to that seen in Europe in the nineteenth century, as shown in Table 1.1.2.
There remains a close association between economic status and child deaths as illustrated by Fig. 1.1.8 comparing economic development and infant mor- tality. Poverty contributes to child deaths for
Middle and low mortality
140
....
120
. . , ...
.... ... ...a. 100
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.~ .... 1 ...
en
80(ij ~ ~I Philippines
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8 40
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Fig. 1.1.1 Mortality reduction among children under five in some developing countries. (Reproduced from State of the World's Children 1990, by permission of the Oxford University Press.)
Key
World population 4432 million
Annual births 121 million
1131 Million (25.5%)
18 Million (15%)
Annual infant deaths (0 - 11 months)
10.7 million
Annual child deaths (1 - 4 years)
4.5 million
Causes of high mortality and morbidity 5 0.3 Million
(3%)
0.1 Million (2%)
D
Developing world's share 'WIi:i:Mit::1 Developed countries shareFig. 1.1.2 The developing world's share of population, births and deaths (1983).
(Reproduced from State of the World's Children 1984, by permission of the Oxford Univer- sity Press.)
Table 1.1.1 Causes of child morbidity and disability
Disease Disability
Recurrent diarrhoea Malnutrition
Measles
Whooping cough
Polio Tuberculosis
Malaria
Helminth infections;
hookworm; ascaris Bilharzia
Trachoma; vitamin deficiencies Neonatal jaundice;
birth asphyxia Accidents
Malnutrition; time off school Mental and physical stunting;
infections; blindness Malnutrition; blindness; cancrum
oris
Mental retardation; respiratory impairment
Paralysis and deformity Respiratory impairment; chronic
bone disease; mental retardation;
deafness Anaemia
Anaemia; mental and physical stunting
Liver disease; renal disease Blindness
Deafness, cerebral palsy
Physical handicap
various reasons, some of which are listed in Table 1.1.3. It is always worth asking the fundamental question 'Why?' when a child is admitted to hospital with a problem. Werner has shown the value of this approach well (see Fig. 1.1.9).
'Development' has a harmful effect on particular sectors of the population within low resource countries as a result of the so-called 'dual economy'. This phenomenon is also recognized within industrialized countries for the same reasons. In the very high- mortality countries this disparity is less noticeable, since the population is almost entirely rural and depen- dent on subsistence. Urbanization is occurring less rapidly in these countries and everyone remains poor.
However, in the medium-mortality countries poverty is more and more an urban phenomenon. The rural population suffers relative poverty but, except when affected by drought or war, are able to live at sub- sistence level. It is the drift to the cities, the result of national and international development, which leads to the dual economy whereby a relatively well-off elite is dependent for its servicing on the poverty-stricken masses living in the slums and shanty towns. Table 1.1.4 illustrates the degree of urbanization in develop- ing countries. To some extent, urbanization is encouraged by patterns of agricultural development which favour capital-intensive cash crops such as
6 Introduction
The United Kingdom
Age
1
90Tanzania
I I I I I I I I I I I I I I I
8 6 4 2 0 0 2 4 6 8 10 12 14 16 18 Percentage of the population
Fig. 1.1.3 Population age structure in developed and developing countries.
tobacco, cotton, tea and coffee and, more recently, exotic fruit and vegetables intended for the luxury markets of the richer countries. For those moving to the cities, the only work to be found in the informal sector is in ministering to the needs of, or robbing, the well-
off - which includes food marketing, personal services and petty crime. The environment in which such families are forced to rear their children in the peri- urban and inner-city ghettos is appalling, with inade- quate housing, poor sewage and water supplies, limited health services and an absolute dependence on the cash sector for food and resources. It is hardly surprising that in these circumstances there is a shift to bottle-feeding (copying the habits of the well-off), weaning diets are inadequate, malnutrition and diarrhoea are rife, and families break up as the mother and often older children are forced to work - yet no appropriate child -care facilities are available. It is the exception for urban 'development' funds to trickle down to the inhabitants of the inner-city or periurban slums.4
This picture of gloom is hardly lightened when we look at the overall relationship between spending on health and on other sectors of the economy. World Bank figures show that the 43 countries with the highest infant mortality rates (over 100 deaths per 1000 livebirths) are currently spending three times as much on defence as on health. Yet at the same time, aid from industrialized countries has fallen from 0.51 per cent of their combined GNP in 1960 to 0.37 per cent in 1982.
During this period (see Fig. 1.1.10) arms spending has increased world-wide and we now have a situation where the more developed countries spend 20 times as much on the military as on development assistance, while developing countries spend twice as much on arms as on the health of their children. In a significant number of countries, war (either internally or externally mediated) is a major cause of death of children.
These grim statistics illustrate the interdependence of health and development and show that political factors lie at the root of the major health problems affecting mothers and children. Only a redistribution of national resources, both within countries and between rich and poor countries will begin to affect the balance in
Table 1.1.2 Death rates (per million) in 1848/54 and 1971 in England and Wales
Conditions attributable to micro-organisms (communicable) Airborne diseases
Water- and food-borne diseases Other conditions
Total
Conditions not attributable to micro-organisms All diseases
1848/54
7259 3562 2144 12965 8891 21 856
1971
619 35 60 714 4070 5384 Reproduced with permission from Sanders, D. The Strugglejor Health, 1985, Macmillan.
Percentage of reduction attributable to each category
40 21 13 74 26 100
Causes
of
high mortality and morbidity 7Annual number of infant deaths in thousands India (27.6)
China (9.3) Bangladesh (5.0) Nigeria (4.7) Indonesia (4.4) Pakistan (4.3) Brazil (2.9) Ethiopia (2.1) Vietnam (2.0) Turkey (1.8) Iran (1.7) Egypt(1.6) Afghanistan (1.4) Mexico (1.4) Zaire(1.3) Burma(1.3) South Africa (1.0) Algeria (1.0) Sudan (1.0) Philippines (0.9)
More developed regions 3%
Africa 24%
Note: Figures in parentheses are the percentages of the world total
East Asia 10% * Latin America 8%
Percentage of total infant deaths (1975 - 1980) Note: * East Asia excludes Japan
Fig. 1.1.4 Countries with the greatest number of infant deaths (1975-1980). (Reproduced from State of the World's Children 1984, with permission from the Oxford University Press.)
Table 1.1.3 Poverty and child death Underlying factor
Poor land; urbanization and migrant labour; low income;
low parental education
Cause of death Malnutrition
Overcrowding; lack of Infectious diseases water/latrines; lack of
appropriate health services
Maternal malnutrition; lack of Maternal/neonatal deaths health services; low parental
education
Table 1.1.4 Proportion of urban population and projected increase in 109 developing countries (1980-2000)
1980 2000
Proportion urban No. (%) No. (%)
population (%) countries countries
0-25 41 (37) 19 (17)
26-50 38 (35) 32 (29)
51-75 22 (20) 42 (38)
Over 75 8 (7) 16 (15)
Reproduced from Ebrahim GJ, Social and Community Paediatrics in Developing Countries, 1985, Macmillan.
favour of the disadvantaged. The countries which have attempted this have achieved a measure of success, as outlined below.
Effect of development on the environment 'Development' affects health not only through urban- ization but by its effect on the land. Population pressure and the lack of national energy policies leads to a shrinking of forested land as trees are cut down for firewood. This not only makes the women's tasks heavy (for who collects wood but the women ?) but also causes soil erosion and makes the land less productive. Land policies which encourage the production of cash crops by commercial farmers cause malnutrition in at least three ways: less food is grown for local consumption;
small farmers stop producing and become labourers, so entering the cash sector (but farm workers are often very poorly paid); and the land requires expe~sive
fertilizer to grow crops to international standards, with consequent diversion of scarce foreign exchange. There are many complex interrelationships between agri- culture and health which merit deeper study by thoughtful paediatricians.
a
Introduction 50004000
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Key:
1;~imMNI All causes
c=J
Immaturity ~ Nutritional deficienciesFig. 1.1.5 Mortality in children under five years of age from all causes and from nutritional deficiency and immaturity. (Repro- duced with permission from Sanders, D. The Struggle for Health, 1985. Macmillan.)
-s
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0: IMR (infant deaths per 1000 livebirths) Fig.1.1.6 Income and infant mortality, New Delhi (1969-74).
(Reproduced from State of the World's Children 1984, with per- mission from the Oxford University Press.)
Landowner Owner worker Agricultural labourer
Deaths per 1000 livebirths 43
Fig. 1.1.7 Occupation of household head and child death rate Matlab, Bangladesh (1 974-7). (Reproduced from State of th~
World's Children 1984, with permission from the Oxford Uni- versity Press.)
Health service delivery
Any discussion on methods of prevention must take into account the past role of the health services in its effect (or lack of it) on the pattern of disease in children.
Writers such as Cicely Williams, Morley, Illich and McKeown have analysed the over emphasis of these services on disease, on the curative approach and on high-technology medicine practised in large hospitals, to the detriment of health, prevention and community- based medicine. Two memorable statistics tell us that the cost of one bed in a major teaching hospital in Africa would pay for the upkeep of a rural health centre, while 250 such centres could be built for the same price as that large hospital. The historical evolution of curative care for the individual has made this situation inevitable.
Doctors are trained to treat sick people, ill people desperately want help, and the well-off are better at finding help than the poor. Criticisms of this situa- tion are less helpful than attempted solutions, and it is essential to remember that adequate curative services provided appropriately at primary, secondary and sometimes tertiary level are a necessary part of any primary health care programme.
Key:
Cci
%
~.~
Causes of high mortality and morbidity
9
12820
MM~mM Per capita GNP 1981 ($) f:~t}d IMR (infant deaths per 1000 livebirths) * figures for 1980.
Fig.1.1.8 Economic development and infant mortality. (Reproduced from State of the World's Children 1984, with permission from the Oxford University Press.)
A further constraint in the health sector in addition to the maldistribution of services is the professional attitude of many medical personnel which again Werner illustrates well (Fig. 1.1.11).
Health workers in the past were taught not to disclose information to patients as this might cause anxiety and confusion and would not be understood. Sanders considers5 that doctors deliberately withheld health knowledge in order to retain their control over the health care system. Whatever the reason, the fact is that doctors have tended to play little part in effective health education or promotion. Since they set an example and teach many of the other cadres in the service, this defi- ciency is soon replicated throughout the system; hence the importance of improving training as a way of improving the system (see pp. 114-28).
A third factor in the health services which more positively contributes to ill health is iatrogenesis, or medically-induced sickness. Two areas where this is particularly obvious are bottle-feeding and the misuse of potent drugs. The reasons for harm are not positive intent but the increasing technological orientation of
the system, as well as the intervention of the commercial sector in health. Doctors have been passive partners in this process, perhaps failing to recognize its side-effects.
Thus, the swing to artificial feeding is influenced by hospital practices (e.g. separation of mother and baby after birth) and by commercial promotion of breast- milk substitutes (see p. 100). Drug misuse is accelerated by opportunist sales tactics, by excessive medical prescribing, by a demand for injections (at first doctor.;.
induced), and by the lack of government controls over the sale of potent drugs on the open market. A single example illustrates the tragedies which may result from the unrestricted commercial sale of drugs in poor countries:
As the boat drew into the shore we heard a strange sound from the bank. A woman was crying. We found her with a dead baby in her arms and a collection of medicine bottles beside her. She had spent all her money on these expensive drugs.
She could not understand why they had not saved her baby.
This Bangladeshi woman had never been told what was obvious to the doctor who found her. The baby had become severely dehydrated from diarrhoea. Her death could have
10 Introduction
0: What caused Luis's illness? 0: BUT WHY did he refuse?
A: Tetanus - the tetanus bacterium. A: Because he did not trust her. Because he thought it 0: BUT WHY did the tetanus bacteria attack Luis and not would be dangerous for the children.
someone else? Q: WHY did he think that way? Was he right?
A: Because he got a thorn in his foot. A: (Again a whole discussion.)
0: BUT WHY did that happen? Q: BUT not all children who get tetanus die. WHY did Luis die while others live?
A: Because he was barefoot.
A: Perhaps it was God's will.
Q: BUT WHY was he barefoot? Q: BUT WHY Luis?
A: Because he was not wearing sandals. A: Because he was not adequately treated.
0: BUT WHY not? Q: WHY NOT?
A: Because they broke and his father was too poor to buy A: Because the midwife tried first to treat him with a tea.
him new ones.
Q: WHY ELSE?
0: BUT WHY is his father so poor? A: Because the doctor in San Ignacio could not treat him. He A: Because he is a sharecropper. wanted to send Luis to Mazatlan for treatment.
Q: BUT WHY does that make him poor? Q: BUT WHY?
A: Because he has to give half his harvest to the landholder. A: Because he did not have the right medicine.
0: BUT WHY? Q: WHY NOT?
A: (A long discussion can follow, depending on conditions in A: Because it is too expensive.
your particular area.) Q: BUT WHY is this life-saving medicine so expensive?
A: (A whole discussion can follow. Depending on the group, 0: Let us go back for a minute. What is another reason why this might include comments on the power and high
the tetanus bacteria attacked Luis and not someone profits of international drug companies, etc.) else?
A: Because he was not vaccinated. Q: BUT WHY did Luis's parents not take him to Mazatlan?
A: They did not have enough money.
Q: BUT WHY was he not vaccinated?
Q: WHY NOT?
A: Because his village was not well covered by the
A: Because the landholder charged them so much to drive vaccination team from the larger town.
them to San Ignacio.
0: BUT WHY was the village not covered?
Q: WHY did he do that? (A whole discussion on exploitation A: Because the villagers did not cooperate enough with the and greed can follow.)
team when it did come to vaccinate.
A: Because they were so poor.
0: What is another reason? 0: BUT WHY are they so poor? (This question will keep A: The doctor refused to let the midwife give vaccinations. coming up.)
Fig. 1.1.9 A group discussion is presented with a story about the death of a boy called Luis. To help the group recognize the complex chain of causes that led to Luis's death they play the game 'But why ... ?'. Everyone tries to point out different causes. Each time an answer is given, the question 'But why ... ?' is asked. This way, everyone keeps looking for still other causes. If the group examines only one area of causes, but others exist, the discussion leader may need to go back to earlier questions, and rephrase them so that the group explores in new directions. The question game might develop as shown above. (Reproduced from Werner D, Bower B, Helping Health Workers Learn, 1982.)
been prevented with a simple home-made solution of water, salt and sugar. No amount of medicine could have kept her alive. (Melrose D. Bitter Pills. Oxford, Oxfam, 1984.)
It is because some doctors are too closely associated with such tactics, that they are sometimes seen more as a part of the problem of under-development, than as a part of its solution.
Primary health care
It is heartening to see from UNICEF figures
(Fig. 1.1.1) that some countries are succeeding in improving their children's health, and these examples should be proclaimed by paediatricians everywhere.
There is no reason now for any country to fail to show progress on the child health front - even though major improvements will depend on reforms in international trade, aid and finance. Within poor countries WHO and UNICEF have shown unquestionably that primary health care can improve the lot of the poor but a strong commitment to its implementation is essential, as well as an understanding of its radical nature. Governments practising primary health care need to have close contact with their people; it would be hard indeed for a
500
400
200
100
o----:-=-:::-:::
Key:
_ Military expenditures ~ Foreign economic aid Fig. 1.1.10 Military and aid expenditures, industrialized nations (1960-82). (Reproduced from State of the World's Children 1986, with permission from the Oxford University Press.)
Listen carefully!
Primary health care 11
country which neglects human rights and which gives its people no political or economic power to practise true primary health care.
Primary health care depends on:
• health workers at grass-roots level;
• integration of prevention with cure;
• recognition in secondary/tertiary care of the priority of primary health care;
• integration of health with other sectors of the economy;
• involvement of people in their own care, including planning.
There is an increasing recognition that health care at primary level is a synthesis between health care delivery and community-based health care (which people generate for themselves). Such programmes require considerable skill and experience and are better organized locally (,horizontal') than through national or international directives (,vertical'). The community is encouraged to identify and select some of its own members for a short training in health care. Training will include 'awareness developing' or 'conscientization' as described by Paulo Freire in Brazil6 and further discussed by Werner.7 Shaffer8
I will tell you what to do
Fig. 1.1.11 Attitude of medical personnel. (Adapted from Werner op. cit.) This teacher assumes ignorance among those being taught and gives advice which is inappropriate for the moment and impractical. Health education to parents should relate to their imme- diate needs and build on their con- siderable knowledge of children, child care and the constraints under which they live.
