Book Review

At the Edge of Development: Health crises in a transitional society

N Engl J Med 1996; 335:1539-1540November 14, 1996

Article

At the Edge of Development: Health crises in a transitional society
Edited by Richard L. Guerrant, M. Auxiliadoro de Souza, and Marilyn K. Nations. 449 pp. Durham, N.C., Carolina Academic Press, 1996. $65. ISBN: 0-89089-788-3

A large segment of the world population still suffers from poor sanitary conditions, inadequate access to health care, and an unsteady supply of food. In spite of our understanding of the causes of many of these problems, integrating that knowledge with the sociocultural, economic, and political components of a successful and sustainable intervention continues to be extremely difficult. In fact, it seems that as science and technology advance, so does the gap between our knowledge and our ability to translate it into effective change. This book is a good example of the type of approach needed to fill that gap.

This book stems from the experience over 15 years of a multidisciplinary team of physicians, nutritionists, anthropologists, parasitologists, epidemiologists, and public health specialists in providing primary health care to populations in northeastern Brazil, one of the most impoverished regions of the country. (As pointed out by the authors, Brazil has earned a bronze medal for social inequity, having the third-worst income distribution in the world.) The authorship of the chapters largely reflects the composition of that multidisciplinary team, thus providing a degree of consistency frequently absent from multiauthored books.

The book is divided into three parts: “The Social and Cultural Context of Disease,” “Reviews of Major Endemic Tropical Diseases to Brazil's Northeast,” and “Local and Institutional Behaviors Relevant to Endemic Tropical Diseases.” The first section deals with the complex interplay of health, development, and demographic transition. Using data from the region, it provides a concise and well-documented review of socioeconomic development and disease, the role of traditional medicine, the impact of migration to the cities on the health of the rural poor, and the patterns of childhood diseases over the past several decades. The second section reviews the major tropical diseases that affect northeastern Brazil and discusses the role of oral rehydration, expanded immunization programs, and the interactions between malnutrition and infectious diseases. The last section is perhaps the most challenging and valuable of the book: an effort to address the constraints on program implementation as well as to identify opportunities for alternative approaches to health care.

Always drawing from their experience in Brazil's Northeast, the authors provide an insightful critique of the current trends in primary health care delivery and offer ways to integrate traditional medicine and the sociocultural and political context into health interventions. The authors argue that major threats to our survival, such as population overgrowth, can be reduced by improving the health of poor populations (indeed, there is plenty of evidence that it is good health, not bad health, that reduces population growth). The important role of the health care professional in generating the political will that is essential for programs to succeed is also discussed.

This book is a must for any health care professional planning to work in developing areas of the world. It offers well-documented insights into the roots of many of the difficulties that health care providers in poor regions must face. As stated by the authors, “the growing health problems of the new urban poor in Brazil's Northeast illustrate those throughout the developing world. . . . [T]hese experiences . . . hold key lessons about what is urgently needed to address these problems.” The book offers an excellent review of many of those lessons.

Benjamin Caballero, M.D., Ph.D.
Johns Hopkins University, Baltimore, MD 21205