Nationalism, international public health assistance, and epidemiologic transitions.

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 " (http://www.usaid.gov). 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 health 2 and Omran's epidemiologic transition theory 3 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 disease...to 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 oV 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 coVee 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 …