Global initiatives to control specific diseases, such as polio or worm diseases, in low income countries not only do good. Sometimes they pull people and resources away from basic health care. Then the remedy may be worse than the disease. In an article in the open-access journal PLoS Neglected Tropical Diseases, researchers from the Antwerp Institute of Tropical Medicine (ITM) caution the international aid community for complacency.
Basically it is a matter of balance between curative and preventive medicine – or as the Greeks would have put it, between Hygeia and Panacea, the two daughters of Asklepios, god of Medicine. Prevention can be achieved by periodical campaigns, but care for the sick and injured should be available on a daily basis. Permanent access to health care is unfortunately not yet guaranteed everywhere in developing countries; if in such a context (in itself valuable) mass campaigns have to be implemented with absolute priority, the daily provision of basic health care may well suffer.
Over the last decades an increasing number of health problems have been identified as 'priority diseases'. For a typical West-African country, these may include: river blindness, Guinea worm, tuberculosis, vitamin A deficiency, bilharzia, intestinal worm diseases, trachoma, polio and other vaccine-preventable child illnesses, malaria, HIV. In most cases, each problem is addressed by a separate control programme – although now there is an integrated preventive programme tackling five neglected diseases at the same time, with four drugs (and 28 extra forms that have to be filled in by the health workers, on top of their normal duties).
Hardly any research has been done into the local consequences. In sixteen health centres in two rural regions in Mali, the ITM scientists determined the time spent by nurses on 'campaign-related work against neglected diseases'. Over a year, the campaigns claimed about one third of the time of the health workers; a quarter of the year they were absent from the health centre (and thus unavailable for their patients) for campaign work. In return for this they received a bonus of about one tenth of their annual pay, which is quite motivational for health centre staff who are often underpaid.
During these campaigns the rural health centres were often closed, out of sheer necessity, as the nurses involved were the only ones in the centre qualified to offer curative consultations. Scheduled vaccinations had to be postponed. Children only received the campaign drug; other obvious illnesses they presented with were often disregarded.
Only the strongest health centres (2 out of 16), with more, experienced, and highly motivated staff members, could more or less integrate the campaigns into their main duties. In all other cases, targeted disease campaigns – sometimes against diseases with no clear local priority – were at the expense of basic health care. The ITM researchers conclude that Hygeia and Panacea should sit together and talk.
Journal
PLoS Neglected Tropical Diseases