In reality: A medical anthropologist's reservations about the viability of leprosy control within primary health care

Abstract

It seems that primary health care (PHC) is winning converts because it is economical, an inexpensive means towards achieving the goal of health care for everyone. It seems logical that participation of the community in identifying their own health priorities guarantees that PHC will succeed. Motivation is most keen when innovations accord with the needs as perceived by the community. Where previous attempts to improve health care have turned out to be disappointing, policy makers and high level administrators have usually had to bear the blame. Whatever their motives for promoting secondary and tertiary health facilities, prestige and profit included, it appears that no significant improvement of public health can be credited to these initiatives. Should PHC fail in the end, however, decision makers at the top will be able to displace responsibility from their shoulders on to local communities. To translate the attractive ideology of PHC into a functional system involves, as numerous examples suggest, severe headaches. The variety of cultures in the world should alert us to the implausibility that a single remedy for health problems is likely to apply in all settings. How seriously are we to take the principle of self-determination when it comes to identifying and proposing solutions to community health problems, and are community needs at all likely to conform to the perceptions of outside experts? WHO wants to emphasize preventive measures. What villagers desire instead is above all the elaboration of curative services. Despite health education and extensive discussion in cadre programmes e.g., in North Sulawesi, PHC appears to wake little response because prevention fails to interest people - people in good health. The health authorities of developing countries do not by and large accord leprosy control a high priority in their national activities. After all, other illnesses and problems are statistically far more important, and urgent, e.g. malaria, nutrition, birth control. However, village people were found so preoccupied by this disease that the attention they paid to it could be described objectively as out of proportion to the public health danger which leprosy presented. Thus, there is no consensus between community-perceived needs and the priorities of health planners and experts. The reality of the field situation as I have known it suggests, however, that for the present it would be premature and counterproductive to divert efforts or resources to this new approach. When and where a PHC project has managed to take root in a community and has, for some years, demonstrated that it is functioning effectively, the time will be ripe for an attempt to introduce leprosy control into the project.