This month we review a study finding out how primary health care programmes can be made to reach the people who need them; and two books showing why people still go hungry though farmers grow more food every year. Editor: Anuradha Vittachi

Global health

Practising Health for All
by David Morley, Jon Rohde, and Glen Williams

OUP (pbk) £3.50/$6.00 (inc. p. & p.)

If health for all could be achieved through the implementation of health technologies alone, it would be a relatively straightforward process - since effective and affordable technologies are available. The major obstacles to the implementation of primary health care are not technical but political and organisational.

Few authors have attempted to look at how attempts to implement primary health care around the world have battled on in spite of political problems, how these problems have been overcome in some places, and also at the value of primary health care initiatives that can only exist at a local level because of political obstacles at the national level.

Through well-illustrated case studies, Practising Health for All considers the lessons to be learnt from national primary health care programmes such as those in China and Cuba. It also looks at countries where a national strategy has been implemented but where, nevertheless, small pilot projects have carried on despite political obstacles. In some places the influence of these small projects has spread far beyond their starting point.

Not all the examples given are success stories. The authors question what the criteria should be for evaluating the success of primary health care programmes. Should we consider their medical effectiveness, or their social impact, or the extent to which they are implemented throughout a country?

The first two are suggested as valid criteria. But these are still very difficult to assess. There is still no internationally accepted set of quantifiable indicators of community health status. Assessment of social impact is even more difficult. In some countries, as in the example given in the book from the Dominican Republic, it is based on observing the changes in the health, social status and responsibilities of women in society.

China, Cuba and, more recently, the People’s Democratic Republic of North Yemen are often considered the only countries where primary health care has been truly successful because it has been adopted as part of a national political commitment. However, various examples in the book, especially from South East Asia and Latin America, describe small primary health care initiatives within a state or a district that have had considerable impact on the community despite an unfavourable national political climate.

Health is a function of the political process. It therefore reflects the best and the worst of that process in each country. The establishment of health as a universal right is obviously dependent on the development of more equitable societies. Nevertheless, it would be shortsighted to undervalue the efforts in many countries without a national commitment to primary health care to implement small scale projects. As Emmanuel de Kadt (of the Institute of Development Studies, UK) comments: ‘the seeds of change may need to be sown in unfavourable circumstances and the results may surprise even the most sceptical observer’. The roots of future equitable societies may lie in some of the seemingly isolated primary health care initiatives struggling to develop in repressive political climates.

Denise Ayres

Denise Ayres is Executive Editor of ‘Diarrhoea
Dialogue’, published by the Appropriate Health
Resources & Technologies Action Group (AHRTAG).

SPECIAL OFFER: Currency restrictions make it difficult to market this book in many developing countries. But if you will pay for two copies forfriends who live in the Third World, you will receive a free copy from Teaching Aids at Low Cost, P.O. Box 49, St Albans, Herts, U.K.

Hard-bitten

More Than We Can Chew:
the crazy world of food and farming
by Charlie Clutterbuck and Tim Lang

Pluto Press (pbk) £2.50

Food, Poverty & Power
by Anne Buchanan

Spokesman (pbk) £3.50

More Than We Can Chew describes,in the words of its subtitle, ‘the crazy world of food and farming’. The authors are of course right to inveigh against our present agricultural policies which are both ecologically and socially damaging. The blurb sets the scene enticingly:

More Than We Can Chew examines the power struggles and crazy contradictions of the modem world food economy and shows their impact on nutrition, food adulteration and factory conditions.

‘The harsh reality is that the world elite have convened to stalk the progress of the rural masses, not to seek ways to alleviate their sorry plight.’ The Lesotho Agriculture Minister, speaking at a world conference on agrarian reform, 1979.

Alas, the title and the blurb tum out to be the best parts of the book. The rest, while making many good points, does so in a superficial and stereotyped manner that will convince only the converted. ‘Food does affect our health,’ write the authors, adding that there are wide differences in life expectancy between the classes in Britain:

Only two paragraphs are devoted to how the Common Agricultural Policy actually works, while the crucial issue of subsidies from the taxpayer to the farming industry merely merits the odd mention now and again.

All this is a great pity. The authors have one of the most vital international topics of our times in their sights but they miss their aim completely. They have simply bitten off more than they can chew.

Much more serious in tone and convincing in treatment is a thoughtful study, Food, Poverty and Power, which uses a wide range of sources to document many of the political and social causes of hunger. There are short, succinct chapters on all the main aspects of poverty: colonialism, ‘dependent’ development, myths about hunger, and the Third World connection from the Green Revolution to trade, export cropping to aid. There is also a very useful annotated list of references. While the overall analysis will be familiar to readers of How the Other Half Dies or Food First, the clear writing, well-chosen quotations and drawings make this book a very good introduction to the issue.

Tony Jackson

Brave New World
...being the book that showed why science won’t save the world

'O BRAVE NEW WORLD, that has such people in’t!’ cries Miranda, the heroine of Shakespeare’s Tempest, ‘How beauteous mankind is!’

Poor girl - she’s not to know how wrong she is. She has lived all life on an island inhabited by spirits. The sight of a bunch of Milanese courtiers of doubtful morality is enough to make her gasp. But her father, Prospero, knows better.

For Prospero, insert Huxley. His black satire, Brave New World presents a vision of an ultra-modern scientifically-controlled utopia that strikes its unsophisticated heroine, Lenina, as wonderful; but Huxley shows the reader what a nightmare it really is. He lays the futuristic horrors on thick - rather too thick for my taste, but then I’m already a convert to his point of view. When the book was written, over 50 years ago, it had to break through a pervasive illusion that scientific ‘progress’ was going to solve humanity’s problems.

Huxley’s argument was that science isn’t neutral: it would always serve the interests of those in power. The powerless would remain weak; more comfortably so, perhaps, but robbed increasingly of their right to decide their own lives.

The novel is set some 600 years in the future. Society is tamed, stable. No-one goes hungry. There is no sickness or senility. Everyone wants security and has it.

The miracle has been achieved through technology. Babies are no longer born to mothers impregnated by fathers. ‘Father’ and ‘mother’ are the new dirty words. Babies are grown in bottles, treated with chemicals to determine what type of human being should emerge from them.

A handful of Alpha-plus humans are carefully nurtured to become future decision-makers; rather more Betas, to hold responsible but not crucial jobs; Epsilons, mindless manual workers, are grown in bulk. As children, bedded in institutional dormitories, they are brainwashed in their sleep (a soft voice breathes, hypnotically, ‘Oh, no, I don’t want to play with Delta children’ over and over) until they hold, unconsciously, the prejudices and aspirations that maintain the social heirarchy.

If, despite all this genetic engineering and social conditioning, anyone should still feel a nameless unease that this somehow isn’t the way human beings should behave, soma comes to the rescue: a tranquillising and mood-elevating drug to soothe the doubts away. It’s Huxley’s prediction of the Valium generation.

And this leads us to the heart of the book. It is so much more comfortable to remain unaware; to be unconscious of moral choices - like a baby blissful in the womb, letting someone else take all the responsibility. But it opens the door to totalitarianism. Those who are in positions of power make sure they hang on to it. And those who remain lulled and drugged are deprived not only of the discomfort but also of the delights of having freedom and responsibility.

Who actually runs the show, if almost everyone in this brave new world is a moral zombie? The Controller, who knows science is no more than ‘a cookery book’. Only those in power can change the recipes and, he notes with satisfaction, ‘I’m the head cook now.’ Only he has access to the forbidden books.   Shakespeare, for example - that remind one of change and crisis, passion and pain. He is clearly aware of the choices before him: he can offer society drugged ‘happiness’ or moral freedom. To choose the former guarantees his position as puppet-master. To choose the latter would be to cut the strings.

There is one other major characteT in the novel who is not a zombie. ‘The Savage’ stands for the individual determined to stay close to raw human feeling, and to experience its depths as well as its heights. He believes it is necessary to stay vulnerable to pain in order to be properly human; he isn’t squeamish about emotional intensity. He tries to live alone, making up his own morality as he goes along. But he is too heavily outnumbered: he dies, a messy and tragic suicide, victim of a crass ‘civilisation’.

The novel has, not surprisingly, been coopted at times by the political right as a way of attacking collectivism and upholding a narrow brand of individualism. The first half of the book does, indeed, tempt one to see it that way. But by the end, Huxley’s anarchist tendencies start to emerge. He isn’t for individualism at the expense of the good of all - he’s for the evolution of the individual so that he or she may play a better part in the greater good. He’s a fan of Kropotkin and of cooperatives. Brave New World shows the failure of the scientific route and of the individual alone. For Huxley’s vision of a utopia that works, you have to read Island, his last great novel. But that’s a story for another day.

Anuradha Vittachi

Brave New World
by Aldous Huxley (1932)

Panther (pbk) UK: £1.50! Aus: $5.95