This is an account of an international agency working in a rural area of Asia where infant mortality rates are very high—often associated with infantile diarrhoea. The development team decide that what is needed is to improve sanitation in the village and install a block latrine. Some years later they revisit the area and find that the latrine is unused and broken down. And that the health situation remains much the same. Somebody suggests that they should find out from the villagers what has gone on and what they think about it all. What they discover is that it is not as though the villagers are uncaring about the fate of their children but that sanitation is not at the top of their list of priorities. Their major preoccupation is that every year when the sugar cane is nearly ready the elephants appear and trample it all down so they cannot harvest it and obtain economic benefit from it. As a result of the discussions a new project is undertaken to protect the sugar from the elephants. When this has proved to be successful the credibility of the international group is enhanced, the villages are ready to talk about other concerns including infant welfare and sanitation.

I discovered this truth for myself in the Liverpool inner city area of Vauxhall in the early 1980s, an old Irish working class area of the city. The Eldon Street Community Association had come to organise themselves when the city council had threatened to demolish their houses as part of slum clearance. The Eldonians’ motto was “Professionals should be on tap not on top” and they had very clear priorities for their community. Decent housing, jobs, decent schooling for their children, and a safe community. With by far and away the worst health statistics in the city, poorly served by medical services, sky high smoking rates, and an appalling diet, these things took second place for their own clear understanding of what needed to be achieved first. Twenty years later with their priorities largely met this community is heavily engaged in more conventional health promotion and health improvement initiatives.