Comment
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DOI:10.1016/S0140-6736(09)61795-5.
2 Kolber AJ. A matter of priority: transplanting organs preferentially to
registered donors. Rutgers Law J 2003; 55: 671–740.
3 Steinberg D. An “opting in“ paradigm for kidney transplantation.
Am J Bioethics 2004; 4: 4–14.
4 Veatch RM. Bonus allocation points for those willing to donate organs.
Am J Bioethics 2004; 4: 1–3.
5 Epstein RA. Altruism and valuable consideration in organ transplantation. In:
Satel S, ed. When altruism is not enough: the case for compensating kidney
donors. Washington, DC: American Enterprise Institute Press, 2008: 79–95.
6 Bramstedt KA. Is it ethical to prioritize patients for organ allocation according
to their values about organ donation? Prog Transplant 2006; 16: 170–74.
7 Trotter G. Preferred allocation for registered organ donors. Transplant Rev
2008; 22: 158–62.
What would Jim Grant say now?
See Obituary page 1248 Jim Grant was a global advocate for children and an
American foreign-aid expert. He was born in 1922 in
Beijing, China, and died in 1995 in Mount Kisco, NY,
USA. What would he say now about the child survival
and development revolution he championed in the
early 1980s? First at the US Agency for International
Development and then at the Overseas Development
Council, he nurtured the “Green Revolution as a
means of assuring self-reliance and empowering small
farmers”.1 Because of his leadership as Executive Director
of UNICEF from 1980 to 1995, he is credited with saving
“more lives than were destroyed by Hitler, Mao and
Stalin combined”.2
I recall his excitement, in the autumn of 1973, as he
learned about the infant mortality reductions achieved
when village health-workers in Narangwal, India,
delivered an integrated package of health, nutrition, and
family-planning services.3 He said, “Carl, we can start to
talk about a child survival revolution!”4 In the 1980s,
UNICEF’s initiatives about GOBI (growth monitoring, oral
rehydration therapy, breastfeeding, and immunisations)
and EPI (expanded programme on immunisations) led
the global shift away from comprehensive health care
to selective primary health care.5 Liberal funding for a
few simple interventions evolved into global vertical
programmes, greatly weakening the momentum for
Health for All started at the 1978 Alma-Ata International
Conference on Primary Health Care.6,7
But it was a privilege in those years, as Jim’s close
friend, to debate directions for this child survival and
development revolution. One night on a train from
Kunming to Xi’an, when I was UNICEF’s Representative
1236
Bos MA, Busschbach JJ, eds. Organ transplantation: ethical, legal and
psychosocial aspects. Towards a common European policy.
Lengerich, Germany: Pabst Science Publishers, 2008: 327–32.
9 Matesanz R, Dominguez-Gil B. Strategies to optimize deceased organ
donation. Transplant Rev 2007; 21: 177–88.
10 Delaney J, Hershenov DB. Why consent may not be needed for organ
procurement. Am J Bioethics 2009; 9: 3–10.
11 Kranenburg L, Schram A, Zuidema W, et al. Public survey of financial
incentives for kidney donation. Nephrol Dial Transplant 2008;
23: 1039–42.
12 Tabarrok A. Life-saving incentives: consequences, costs and solutions to
the organ shortage. Aug 3, 2009. http://www.econlib.org/library/
Columns/y2009/Tabarroklifesaving.html (accessed Aug 1, 2009).
in China, we argued so intensively that our wives moved
to another compartment. (It did not help for me to
quote his father, John B Grant, who pioneered the inte-
grated community-based approach for the Rockefeller
Foundation’s International Medical Board and others
from 1918 to 1962.8) Jim’s main argument was, “Since
we have simple interventions, let’s use them to pick the
low hanging fruit, and later we will make the child survival
and development revolution sustainable.” We eventually
agreed on the need to do both vertical and community-
based activities, but we never did agree on timing.
In a book about Jim’s successes,1 Jon Rohde’s chapter
describes the rights approach Jim might use if he were
here; he would challenge us to vigorously defend
children’s right to survival and development, focus on
communities, monitor disparities for excluded children,
and bring new transparency and public honesty to
our current efforts. A development expert long before
arriving at UNICEF, he felt “a simple, doable proposition”
generates political will,1 but he also believed in “people’s
organized participation”.9
For the past two decades, I helped to develop Future
Generations as a non-profit organisation and its
associated graduate school to teach and empower
communities.10 This work gave me a chance to
understand the process by which interventions operate
in three domains. First, technical, in which interventions
can be applied almost mechanically. Second, behavioural,
in which new patterns for change are learned. Third,
empowerment, in which groups of people, especially
women, develop a shared vision and commitment,
making the ultimate change process sustainable.
www.thelancet.com Vol 375 April 10, 2010

UNICEF
Jim Grant, 1922–95
In my experience, the third domain promotes the first
two. Finding the right balance is not well understood
or easily measured. However, I saw early success with
remote and marginalised populations. In Tibet/China’s
Qomolangma (Mount Everest) Nature Preserve,
community workers promote both health and protection
of fauna and flora.4 In India’s Arunachal Pradesh, a
broader approach to development includes health,
environment, and income generation.4 In Peru, local
community leaders from committees of Comités Locales
de Administracion de la Salud share management with
health professionals.11 And in Afghanistan, community
surveillance shows that women’s action groups can
reduce infant mortality by 46% and sustain it for 2 years
in the midst of conflict.
Jim and I both recognised that the hardest challenges
in health and development are always sustain-
ability and equity. Service-delivery programmes are
www.thelancet.com Vol 375 April 10, 2010
Comment
unsustainable when implemented as silos. Vertical
programmes might produce quick benefits, but
sustaining them depends on more than professionals,
money, and technical interventions.
Our greatest mistake has been to oversimplify
the Alma-Ata vision of primary health care. Real
social change occurs when officials and people with
relevant knowledge and resources come together with
communities in joint action around mutual priorities.
The interplay between comprehensive (horizontal)
and selective (vertical) approaches requires careful
blending.12 It is my conviction that, if Jim were here
now, he would champion this blending, adapted to the
local context with a focus on communities, to ignite
the next child survival and development revolution.
Carl E Taylor
nkureshy@usaid.gov
CET drafted this Comment in November, 2009, when asked to contribute his
ideas on integration and health-systems strengthening from his personal
experience. After his death on Feb 4, 2010, references were added, as per CET’s
instructions, by Nazo Kureshy, Henry Perry, Daniel Taylor, Betsy Taylor, and
Henry Taylor. The information and views presented in this article are those of
the author and do not necessarily represent the views or the positions of USAID
or the US Government.
1 Jolly R, ed. Jim Grant: UNICEF visionary. Florence, Italy: UNICEF Innocenti
Research Centre, 2001.
2 Kristof ND. Good news: Karlo will live. New York Times March 6, 2008.
http://www.nytimes.com/2008/03/06/opinion/06kristof.html (accessed
March 26, 2010).
3 Taylor CE, Parker RL. Integrating PHC services: evidence from Narangwal,
India. Health Policy Plan 1987; 2: 150–61.
4 Taylor-Ide D, Taylor CE. Just and lasting change: when communities own
their futures. Baltimore, MD: Johns Hopkins University Press, in association
with Future Generations, 2002: 130.
5 Wisner B. GOBI versus PHC? Some dangers of selective primary health care.
Soc Sci Med 1988; 26: 963–69.
6 WHO, UNICEF. Declaration of Alma-Ata: international conference on
primary health care. International Conference on Primary Health Care.
1978. http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf
(accessed March 20, 2010).
7 Lawn JE, Rohde J, Rifkin S, Were M, Paul VK, Chopra M. Alma-Ata 30 years
on: revolutionary, relevant, and time to revitalise. Lancet 2008;
372: 917–27.
8 Seipp C. Health care for the community: selected papers of
Dr. John B. Grant. Baltimore, MD: Johns Hopkins University Press, 1963:
169–70.
9 Grant JP. Children in dark times. UNICEF News 1981; December: 30–31.
10 Future Generations. http://www.future.org (accessed March 15, 2010).
11 Altobelli LC. Case study of CLAS in Peru: opportunity and empowerment
for health equity. Aug 26, 2008. http://www.future.org/sites/future.org/
files/Case%20Study%20-%20CLAS%20Peru.pdf (accessed March 15, 2010).
12 Taylor C, Jolly R. The straw men of primary health care. Soc Sci Med 1988;
26: 971–77.
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