Journal Issue

Bank Group activity: The role of health in development

International Monetary Fund. External Relations Dept.
Published Date:
June 1975
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Equating health with wealth

Poverty continues to be a major cause of ill health around the world according to a study by the World Bank on health issues.

The 83-page Health: Sector Policy Paper, released recently notes that health conditions in developing countries have improved considerably in recent decades. Nevertheless, it states that “international differences in health levels remain substantial: within nations, differences in the health of the rich and the poor are no less wide.”

The study adds that from available evidence it appears that health conditions among the poor in different countries are basically similar.

“The poor suffer from a core of fecally-related and air-borne diseases. Malnutrition increases the susceptibility to many of these diseases and compounds their severity,” according to the study.

The Bank policy paper notes that health policies are inefficient and inequitable in many developing countries, and concludes that governments need to curtail their expenditures on hospitals and highly trained personnel, and devote more resources to the staffing of low-level health services in areas with little or no facilities.

The paper advises that “reforms in the service offered to the poorer people should concentrate on improving health at the community level. The objectives should include changes in living habits and attitudes, as well as household and community activities to improve water supply and sanitation.”

The World Bank has, in the past, initiated project lending in a number of areas that directly affect health, such as water and sewerage, population planning, education, rural development, irrigation and drainage, and urbanization.

For the future, the Bank has decided that it will continue “to strengthen its awareness of the health consequences of the projects it supports, and of opportunities for improving health that are available under present patterns of lending.”

In other words, while the health benefits of projects are expected to increase, the patterns of lending will remain basically unchanged.

Battling Bilharzia in the Sudan

“The effects of bilharzia are not unknown. The kinds of sanitary regulation needed to lessen the risks of infection are at least as important, in terms of human welfare, as the stresses of concrete in the dam or the safe transmission of high voltages of electricity. It is just as inconvenient to be killed by a sanitary failure as to be drowned by an engineering one. The only clear advantage is that the drowning may be quicker.”

Only One Earth, by Barbara Ward and René Dubos, page 161.

Dr. El Sunni Amin, senior public health inspector in charge of bilharzia control, was in his office at Wad Medani, the Sudan, looking through the microscope at the schistosomes. “It’s probably the most prevalent occupational disease in the world,” he said.

Among the schistosomes he was examining were the species Schistosoma haematobium, and Schistosoma mansoni. Both infect a quarter of a billion people around the world with a chronic disease called bilharzia, or schistosomiasis. Though most people do not die of the disease, the productive lives of a great majority are greatly reduced.

Bank Group projects with schistosomiasis control components
CountryNature of projectDate
EgyptWater drainage1973
MalawiRural development1972
PhilippinesRural development1975

Schistosome cercariae (larvae at tadpole stage) are picked up by humans who wash or bathe in infected waters. The cercariae penetrate the skin, mature into adult worms, and lay eggs in small veins associated with the bladder or intestine. Most of the eggs then exit from the body in either the urine or feces. Some worms lodge in the liver and other organs, causing tissue damage; still others remain on the bladder and intestine walls and give rise to calcification and cancer.

When the eggs are excreted into the water, they change into larvae, and are harbored by host snails, where the life cycle of the schistosome is repeated. Without the snail—Bulinas truncatas and Biomphalaria glabrata are the two most common varieties in Africa—there would be no schistosomiasis.

Wad Medani is located in the middle of the Gezira, a large, flat plain lying between the Blue and White Nile rivers south of the country’s capital of Khartoum. On this plain is the world’s largest farm, the Gezira Scheme: more than 2 million acres, tended by about 100,000 tenant farmers and their families. Six thousand acres of cotton are cultivated each year, on the Gezira, and the cotton is picked by a half million migrant workers who come from all parts of Africa to earn a cash income.

World Bank loans approved during third quarter of fiscal 1975(ended March 31, 1975)

($ millions)
Brazil (2)Highways, railways285.0
Colombia (3)DFC, water supply, telecommunications47.5
Egypt (2)Industry, railways77.0
Ivory Coast (3)Cotton, sewerage, education supplement42.2
KoreaUrbanization, DFCs, education197.5
Romania (2)Agricultural credit, irrigation100.0
Sierra LeoneHighways supplement2.3
Total loans during third quarter of fiscal 19751,211.0
Total loans during first three quarters of fiscal 19752,420.85

With a $7.5 million IDA credit

With a $7.5 million IDA credit

IDA credits during third quarter of fiscal 1975(ended March 31, 1975)

($ millions)
Bangladesh (3)Industry, population, imports73.0
GhanaOil palm13.6
India (3)Industrial imports (2), agriculture245.0
MalawiRural development8.5
Mali (2)Livestock, rice irrigation supplement15.9
Western SamoaHighways4.4
Yemen, P. D, R.Fisheries supplement1.6
Total credits during the third quarter of fiscal 1975416.5
Total credits during first three quarters of fiscal 1975971.55

With a $7.5 million Bank loan

With a $7.5 million Bank loan

Cotton, the source of wealth of the Gezira Scheme, can be raised because of the Scheme’s extensive irrigation network. Children swim in the canals; women wash the family clothes in the canals; men work in fields by the canals, and bathe and cool off in its waters. The same snail-infested waters account for the fact that the men, women, and children of the Gezira Scheme—in some villages as many as 80 per cent of them—are infected with bilharzia.

Most of the Gezira villages are within 300 meters of the irrigation canals. Dr. M.H. Satti, who works at the National Health Laboratory in Khartoum, says that villages should be located at least a kilometer from the water.

“It might not be much of an advantage for the men who have to work in the fields,” he says, “but it would help the small children who stay at home.”

Little was known about schistosomiasis when the Gezira Scheme was first begun in 1911.

Later irrigation projects in the Sudan—in Managil (adjacent to Gezira and for which a $19.5 million Bank loan was approved in 1961), and in nearby Rahad (for which IDA extended a $42 million credit in 1973)—have included protective health services in the blueprints from the beginning. Villages are furnished with safe, assured supplies of water for drinking, bathing, and laundering while the villages themselves have been located away from canals. Schools have been built so children may not spend their idle time at snail-infested canal banks, where schistosomiasis lurks. Workers in the fields, however, must be protected in other ways.

Until five years ago, the only method of controlling the snail population in the developing world was to apply copper sulphate to the water. The chemical had a kill radius of only 100 meters. Moreover, it had a relatively low poisonous effect on snails, and was not “host specific”—meaning that it proved toxic for other, possibly useful organisms in the water, as well as the snails, which carried schistosomiasis.

Today, petroleum-based chemicals are proving their worth—but at a great cost. Before the dramatic increases in prices for petroleum products, the Sudan had begun a snail eradication campaign in the Gezira using a molluscicide developed by the Shell Oil Company. The cost for controlling snails in the Gezira is $1.50 an acre yearly (for a minimum of from three to five years) or about $9 million to $15 million.

In spite of the new molluscicides, however, public health officials in the Sudan realize that schistosomiasis will never be eradicated in the country. “If we reduce the incidence of the disease to 15 per cent of the population living in irrigated areas, we will have done a good job,” said one official.

Until that can be done, the Sudan and other countries throughout the developing world will experience productivity losses from workers infected with the schistosome worms.

Peter C. Muncie

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