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This article is published as a tribute to Professor Thomas McKeown, the eminent epidemiologist, who died in 1988 aged 75. In it the author urges that the spread of services comprising primary health care be arranged in strict order of priority. Since improvements in nutrition have a particularly profound effect on health they should be the primary aim of developing countries.
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The early impact of the expanded programme on immunization (EPI) in reducing morbidity from diphtheria was evaluated in the province of Yogyakarta, Java, Indonesia. Since 1980, coverage of two doses of diphtheria-tetanus-pertussis (DTP) immunization has been greater than 60% in Yogyakarta. The morbidity rate for diphtheria for children aged 0-4 years decreased from 4.3 per 100 000 population in 1978-79 to 1.7 per 100 000 in 1981-82, a reduction of 60%. In contrast, the morbidity rate for children aged 5-9 years remained relatively constant over the 5-year period. The EPI programme has therefore had a demonstrable effect on 0-4-year-olds in Yogyakarta.
In the Kingston Project malnourished children referred from public health clinics to a metabolic ward were treated at home using community health aides within the existing health service. We have previously provided anthropometric results showing significantly greater gains in weight and length for groups given a high energy supplement (3.31 MJ daily) for 3 months during treatment, and greatest gains for a group treated with metronidazole at the beginning of supplementation [Heikens et al., Eur. J. Clin. Nutr. 43, 145-160 (1989); 47, 160-173 (1993)]. We now present findings on morbidity and relate these to the separate interventions and to growth velocities. Although referral was solely on nutritional criteria, 65% of the sample were found to have additional illnesses at enrollment. During the study period (6 months) upper respiratory tract infections (URTI) were the commonest illness in all groups; there were significantly more gastroenteric infections in the group given the supplement, but not the antibiotic, treatment; the children who received only the standard health service care were ill more often and for longer periods than children in the other groups. Diarrhoea, fever and dysentery prevalences were all found to relate significantly to weight velocity, and although prevalences differed between treatment groups, the detrimental effect on velocity was similar whichever the group.
The potential for using community health workers (CHW) for administering timely and effective treatment for presumptive malaria attacks was evaluated in the Katana health zone in Zaire. In each of the 12 villages of an intervention area (area A) with 13000 inhabitants, a CHW was trained in the use of a simple fever management algorithm. The CHWs performed their services under the supervision of the nurse in charge of the area's health centre (HC). Malaria morbidity and mortality trends were monitored during 2 years in area A and in an ecologically comparable control area (area B), where malaria treatment continued to be available at the HC only. Health care behaviour changed dramatically in the intervention area, and by the end of the observation period 65% of malaria episodes were treated at the community level. Malaria morbidity declined 50% in area A but remained stable in the control area. Parasitological indices showed similar trends. Malaria-specific mortality rates remained, however, at essentially the same levels in both areas. The non-comprehensiveness of the CHWs' care and their ambiguous position in the health care system created problems that compromise the sustainability of the intervention.