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Nationalism, international public health assistance, and epidemiologic transitions
  1. Department of Epidemiology (CB 7400), University of North Carolina School of Public Health, Chapel Hill, NC 27599–7400, USA (cpoole{at}

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    The United States Agency for International Development (USAID) describes itself as “an independent federal agency that conducts foreign assistance and humanitarian aid to advance the political and economic interests of the United States” ( The explicit nationalism in this mission statement raises a problem that stretches far beyond any particular ideology: How should the public health community respond when any nation A exerts an active interest in the public health of any nation B to further the economic and political interests of nation A?

    For Dr Avilés, the answer is that when nation A is the United States and nation B is El Salvador, the response should be condemnation.1 He concludes from his case study of Ayalde's report on Salvadoran public health2 and Omran's epidemiologic transition theory3 4 that both extol a harmful, Eurocentric colonialism; fail to consider the social, political and economic determinants of public health; and ignore health disparities.

    In his critique of epidemiologic transition theory, Dr Avilés disregards the fact that the causal response of “patterns of health and social and economic changes” is the theory's primary subject matter (page 3).4 He also overlooks the emphasis Omran placed from the start on examining transition disparities by socioeconomic measures such as gender and race: “The epidemiologic transition among the nonwhite population of the U.S. was slower than that among the whites. Whites have always been better off than nonwhites with regard to housing, education, living standards, social and economic levels, nutrition, access to medical care, and other cultural and demographic characteristics”.(page 33)4

    In his critique of Ayalde's report, Dr Avilés overlooks much of that report's content. It goes to great lengths to attribute the current state of Salvadoran public health to widespread poverty. It links many public health problems, especially those of the rural poor, to the economic conditions of large scale coffee production. It draws dire public health implications from the fact that one fifth of the Salvadoran population lives in the United States. And it places great emphasis on the severe and acute public health needs of the thousands of Salvadoran refugees from the armed conflicts, some still in camps, and the thousands more internally displaced persons. (Specific points and page numbers available upon request.)2

    Dr Avilés imputes to epidemiologic transition theory a determinism it does not possess. This theory does not assert that any nation must undergo any specific transition. It merely provides general descriptions (models) of commonalities shared by populations after they are observed to undergo transitions that are similar in certain ways. Omran described three general transition models. In two of them, changing social, economic and political conditions are theonly major determinants of changing public health. In the third, targeted public health interventions have major effects early on; then social, economic and political changes become the dominant forces, as in the other two models. Omran noted that the particularistic conditions of the populations that fit this third model, to a greater or lesser degree, are so heterogeneous as to indicate “...the utility of developing submodels, particularly with regard to the varying responses of fertility and socioeconomic conditions to national development programs” (page 536).2

    Consequently, Ayalde does not merely apply to El Salvador epidemiologic transition theory as Omran first described it. Instead, given the country's “ambiguous” place among the models and stages (page 10),2 Ayalde follows Omran's advice and considers the particulars of the Salvadoran situation. Ayalde finds that much depends on the health measure, the data source, and the population subgroup examined. For example, he notes that one source lists “external causes” (homicide, suicide, accidents, etc) as the country's leading cause of death (page 10).2 Dr Avilés repeats this information uncritically to score a debating point. If one reads Ayalde's report itself, however, one finds that it quite appropriately questions the validity of the original information source for not even including diarrhoea or acute respiratory infections as causes of death. One also finds Ayalde citing an alternative source that lists diarrhoea as the leading cause of death among Salvadoran children (page 10).2

    The element of epidemiologic transition theory to which Dr Avilés takes the strongest exception is that some aspects of public health, under some circumstances, can respond favourably to interventions that are not structural changes of social, political and economic conditions. He calls “futile and hopeless any technical intervention in the health sector that ignores the social and political context of the country.” He flatly asserts his “belief that better public health cannot be achieved without improving the social, economic, and political situation” and complains that epidemiological transition theory considers this belief “ ‘unscientific.’ ”

    By contrast, the theory treats Dr Avilés' belief as an empirically testable, scientific hypothesis. Ayalde's relevant observations are that vector control in El Salvador greatly reduced malaria incidence (pages 27–29)2; that poliomyelitis, whooping cough, measles and neonatal tetanus incidence declined dramatically in response to immunisation programmes (pages 32–33)2; that improvements in potable water supplies, sewage treatment and solid waste disposal would produce major reductions in the incidence of acute diarrhoea, cholera and other diseases (pages 33–34, 40–41, 46–47)2; and that effective iodine fortification would greatly reduce goitre prevalence from its current level of one quarter of the Salvadoran population (page 38).2 Each of these measures improves public health. Some preferentially improve the health of the poor. None restructures social, political or economic conditions. Together, they refute Dr Avilés' hypothesis.

    Dr Avilés accurately discerns a favourable view of economic development in Omran's exposition of epidemiologic transition theory and in Ayalde's report. But not all economic development is exploitative development that hurts developing nation B and benefits the economic and political interests of developed nation A. It is hard to interpret Omran's analysis of epidemiologic transitions in Japan,3 4 for example, as propaganda for a Eurocentric ideology of neocolonialism. Unfortunately, Dr Avilés does not describe the economic future he envisions for El Salvador. Is it a return to the subsistence agriculture of the mid-1800s? Or is it merely a different kind of economic development that somehow would avoid all interaction with the United States and the former colonial powers of Europe?

    The answers to these questions would be interesting. But I fear that if Dr Avilés' proposal for ideological cleansing of public health discourse were to become fashionable, the views at greatest risk of eradication would not be those held by USAID or other institutions of the most powerful government on earth. More probably, the disappeared views would be minority views such as those of Dr Avilés, which no less deserve exposure to the antiseptic light of day.