110. The primary health care of 2013 and beyond or Health for All : The vision whose time has come again.

World Nutrition Volume 4, November 2013, Journal of the World Public Health Nutrition Association

Claudio Schuftan, Maria Hamlin-Zuniga with an invited case study by David Werner

WHO/UNICEF Alma Ata Conference (1978), Alma Ata, the capital of Kazakhstan, now called Almaty. Site of the 1978 WHO/UNICEF conference ‘Health for All by the Year 2000’

Halfdan Mahler and Margaret Chan [Photos are missing. Available from schuftan@gmail.com]

David Werner

Editor’s note:
World Nutrition thought that its readership would welcome an update of what is happening in the areas of primary health care given the key role that the same should, once and for all, take up in the post 2015 development agenda and particularly in the area of public health nutrition. The authors here introduce what is their understanding of how primary health care should be seen in 2013, 35 years after the historic Alma Ata Declaration. (pictured above) (wiki) (See Box 1) Under the leadership of Dr Halfdan Mahler (Wiki), then Director General of the World Health Organization, (pictured above) Alma Ata launched primary health care as the main focus global health should take –nutrition very much included. We know now that history was not kind to the Alma Ata Declaration in that primary health care was never comprehensively applied to reach the Alma Ata goal of “Health for All by the Year 2000”. During the preparation of this article, the authors thought they needed a good case study that gave readers a historical perspective of the last 35 years with some mention of issues dear to public health nutrition. We are fortunate to have David Werner (pictured above) (wiki) of “Where There Is No Doctor” (wiki) and “The Village Health Worker: Lackey or Liberator” (wiki) fame share with us his views on the evolution of health, along processes of liberation, in Latinamerica. His riveting review puts primary health care in the context where it most probably should be in the post 2015 agenda. His review vividly chronicles the victories and defeats encountered along the rocky road to Health and Nutrition for All.

Box 1: The 1978 Conference on Primary Health Care was held in Alma Ata, USSR. Out of that conference, attended by government representatives, health providers and development workers from around the world, came a revolutionary document, The Declaration of Alma Ata, which asserts that health is a fundamental human right and that responsibility for assuring this human right through the provision of primary health care lies not only with people themselves, but with the governments which represent them. The Declaration notes that attaining the highest possible level of health ‘is a worldwide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector’. (1) However, shortly after the conference, doubt began to be expressed about whether there were the resources and commitment to achieve the Declaration’s goals. In 1979, Walsh and Warren proposed a programme of ‘selective’ primary health care’ that would focus on a smaller, more attainable set of mostly technical objectives. (2) From this was born, much later, the idea of the UNICEF-sponsored Child Survival Revolution (wiki) that would focus on four basic health interventions designed to save the lives of millions of children each year. (3) Its promises never fully delivered. The second-best approach chosen for ‘Health For All by the year 2000’ simply fell short.

What Alma Ata painstakingly established was primary health care as a concept encompassing a technical package, plus an unmistakable call for democratization and decentralization of the health sector’s infrastructure and supra-structure leading to increased coverage of services delivered equitably and at low cost through a network of community health workers and with community participation. The totality of these elements was meant to establish a whole new philosophy of participation leading to a greater control by the people over their own health. Of course, this can only be achieved by reshuffling all priorities in health through deliberate planning guided by the principles of this new philosophy.

The revolution that was called-for at the time was hailed as having a new potential to drive primary health care to the far reaches in every country and for people to care for their own health needs, as well as turning into a social movement that would permeate people’s lives. Optimists thought this was a breakthrough of an altogether different order. (4)

2013 and beyond:

Sadly, the last thirty years have seen increasing privatisation and commercialisation of health systems across the world. The new market economy in health has undermined health services run by the public sector and has negatively affected the ethical standards of health workers; it has also eroded the trust between communities and their health care providers. The result has been increasing inequalities and growing gaps in access to health care and related services such as, importantly, nutrition. As we prepared this paper, we focused our concerns around how social inequalities are having an impact on health and on nutrition. This is what this paper thus addresses. We ultimately explore what it would take to literally reduce millions of maternal and child deaths every year.
The failures and successes of the way current health and nutrition services are being provided to poor mothers and children show how ‘magic bullet’ mostly technological solutions have only brought about some survival, but without asking: survival at what cost and for what type of a future for those that survive? The ultimate aim for mothers and children is not only for them to survive, but to be healthy in the fullest sense of wellbeing; and that is what we must all move towards.

A sorry diagnosis?

An appalling waste of human life, represented by the annual maternal and under five years child mortality figures, is still today’s reality. Most of these deaths are occurring in the ‘Majority World’ due, in great part, to the appalling neglect of primary health care, especially since we know that it can provide effective, sustainable interventions. But while it is clear that the rate of maternal and child deaths is a reliable indicator of a nation’s poverty, it also says something fundamental about social inequalities among and within nations.

The question we want to pose here is: Do poor mothers really have choices? Choices like lighter workloads and more food during pregnancy, long-term commitment to breast-feeding, adequately feeding a child during periods of illness, using home-based oral rehydration therapy for diarrhoea, weighing the child periodically, vaccinating him/her, as well as choices about child spacing? These really non-available choices are all intimately linked to the poverty of most populations. It is thus clear to us that some additional empowerment is badly needed for meaningful choices to become realistic options. This begs yet another question: Is the main primary health care problem one of scarcity of resources or of scarcity of democracy in decision-making processes where power plays a key role in determining where health budgets go? We think we know the answer. Do you?

Primary health care means more than the mere extension of basic health services; much more.
Given the above diagnosis, the struggle for comprehensive primary health care really becomes a port of entry to fight for structural changes in society as a whole. Therefore, we contend that those colleagues that primarily apply technological approaches and call for greater ‘professionalisation’ in the delivery of services, in reality, serve interests other than those of the most affected people. Too many of these colleagues keep dreaming that the maladies of society can be reversed…if only we all do our technical work better and more efficiently.

What we argue is that too many actors in primary health care still poorly understand the web of underlying and root causes of preventable ill-health and malnutrition. This leads them to apply what really are pat-solutions. The interventions we see them introducing simply do not simultaneously emphasise needed actions to address the root causes. Inequality and poverty cannot just be accepted as inalterable facts as such pat-solutions do.

It is the persistent and universal correlation of high levels of preventable ill-health and malnutrition with income distribution disparities that leads many analysts today to, beyond any doubt, assert that the alleviation of dire poverty is actually a precondition to health and nutrition improvements. The argument goes on to say that minimising the inequalities in society will do more to reduce high levels of ill-health and mortality rates than all preventive measures put together –strictly nutrition intervention included.

This is the reason why, above all, a primary health care policy for 2013 and beyond calls for renewed commitments, which, while affirming the fundamental calls made in Alma Ata thirty five years ago, also takes into account the new realities in the world of 2013. The comprehensive approach called for by the Alma Ata Declaration remains as relevant today as it was 35 years ago. But it was never really fully implemented to reflect its true spirit. Why? Because the basic intent of the Declaration was to highlight the need for a New International Economic Order (wiki) to ultimately solve the pervasive inequalities in health and in nutrition; this aim remained indefinitely relegated.

A renewed commitment to primary health care in 2013 must thus vie to address the obstacles that have blocked its comprehensive implementation so far and must, furthermore, decisively commit to incorporate into it the new challenges that have emerged since 1978.
Bottom line here: It is poverty rather than any microbe, parasite or worm that is the key vector of preventable ill-health, preventable malnutrition and preventable deaths.

What does it mean to commit to promote the still unshaken core principles of the Alma Ata Declaration?

To start with, primary health care and public health nutrition are to be embedded in the social and political processes in each specific context where they are applied. For that, primary health care must:

-be neither limited to just providing primary level of care and prevention, i.e., providing a ‘basic package’ of care and of health and nutrition surveillance for those who are poor; instead it must include comprehensive public health and public health nutrition interventions, as well as a working referral system to secondary and tertiary (higher) levels of care;
-be financed through public sources, so as to ensure universal and equitable access;
-address the socio-economic injustice underlying a system of health care that does not provide equitable access to health care and to nutritional services according to need;
-resolutely address the social, political, economic and environmental determinants of preventable ill-health, malnutrition and deaths and not just be limited to providing health care services;
-address the issues of global water shortages; of global warming and related natural disasters, as well as the changing patterns of disease associated with these;
-raise the concern about the current unfair international economic order and the militarization the latter has brought about since these greatly affect health and nutritional wellbeing.
-empower communities, especially, the most disadvantaged, so that they can act as protagonists and claim holders in actively demanding improvements of their health, their nutrition and their livelihoods;
-use technology in a manner that is sensitive to local needs and contexts;
-combine traditional and modern medicine to maximize benefits to patients; and
-embed policies and interventions in the human rights framework, i.e., recognising and supporting the role of beneficiaries as claim holders with an undisputed right to hold to account duty bearers in bringing about needed changes in the provision of health care and nutrition services.

Primary Health Care remains the best tool to achieve ‘Health For All’.

All the above challenges must be incorporated in a renewed vision for primary health care. In this context, we strongly believe that:
-Neoliberal globalisation presents us with new threats to health and to nutrition such as, among other, (i) an increase in trade in unhealthy food and other commodities, (ii) international free trade agreements that are not ‘free’ since they promote the penetration of transnational corporations into the health, food and nutrition sector, (iii) patent rights that are being used against the urgent health needs of poor people (e.g., for medicines), and (iv) unfair rules in the international price fixation and trade of agricultural products that devastate the livelihood, the food sovereignty (Note 1), the nutritional status and the health of members of poor households. All these threats seriously undermine the ability of poor countries to adequately support primary health care and nutrition services. Global inequalities also result in poor countries being left with too few resources to sustain funding for these services thereby becoming reliant on external sources of funding. (As someone in the Society for International Development once said: ‘Money has rained on jungles, plains and deserts for 40 years; in the end only poverty has grown’). We posit here that the negative aspects of globalisation are the major obstacle to Health For All.
-Selective, vertical health care and nutrition programmes remain dominant, not only fragmenting, but also drawing away scarce human and financial resources from wider primary health care services; these programmes also treat mothers, children and patients as passive recipients of care or services and totally ignore the ever-present social, economic and political determination of what is good health and good nutrition. While there may be a need for focused programmes, the same need to be integrated into a comprehensive primary health care approach as here described.
-The planning and execution of primary health care and nutrition activities must be genuinely community-driven and community-centred.
-Both in light of the looming health and nutrition humanpower crisis, and as a core primary health care principle, there must be a renewal of the role of community health workers to not only extend health, sanitation and nutrition services coverage at the local level, but also to give them a concrete role as social mobilisers in the right to health-based empowerment of communities, particularly to address the social determinants of health. The training of health and nutrition workers, not only in clinical and preventive skills, but also in skills that make them effective agents of social change is, in our view, a must.
-Significant investments in primary health care do bring about important changes –as the example of Brasil has demonstrated. Similar initiatives will have to be actively pursued by countries across the globe. (5)
-For a good primary health care policy to succeed and to make a real difference in access and in equality, it must have sufficient resources specifically allocated to it. We all must lobby states to invest more in public health, particularly in primary health care and public health nutrition. At the same time, WHO should lead this effort: WHO simply cannot consider itself as just a technical agency.
-The role and influence of Big Pharma, of Big Food, of Big Beverages and of international financial institutions or IFIs in shaping the prevailing policy setting and thus the political economy of health and nutrition have to be stopped. For that, the influence of global public private partnerships (PPPs) (and of big philanthropies like the Bill and Melinda Gates Foundation) in shaping policy also has to be drastically curtailed. The current PPPs in which WHO is currently engaged-in must also be reconsidered as a matter of priority. (See box 2)

Box 2: Global PPPs are seen by the Establishment as a way to bring new financial resources to address global health, food and nutrition challenges. However, in reality, they have further reinforced selective vertical programmes by focusing on non-sustainable, technocratic solutions to single issues, and are not addressing the social determinants of ill-health and malnutrition or the many burning needs of national health and nutrition systems to deliver such services. PPPs need to be seriously questioned since they have proven to be unable to promote integrated, sector-wide approaches with an explicit commitment to strengthening local health and nutrition systems and, mostly, to respond to locally felt needs. They have also been unable to build new alliances with people’s civil society organisations and social movements that are struggling for more participatory decision-making in all social matters. Existing global PPPs must also be audited, in order to expose the conflicts of interest of their corporate members. Furthermore, the basic flaws and rules that such PPPs continue to apply must be exposed, among other making them not to build upon existing public systems and not to embed the actions they fund in a genuine primary health care structure.
We further strongly believe that:

-In most countries, there is a profound need to strengthen the public health sector, as well as the ‘public ethic’ of service provision and providers. Moreover, the private medical sector needs to be regulated as a matter of priority. (It must be emphasised here that, with the exception of NGOs, the private sector is a non-actor in public health nutrition. You have never heard of a nutrition surveillance programme in the private sector, have you?).
-Primary health care in 2013 and beyond must also address the critical problems of the global health workers’ labour market and must ensure an adequate human resources supply for health and nutrition in all countries –including compensating poor countries for the losses suffered by their health systems as a consequence of migration (brain drain) of health humanpower.
-There also is an urgent need to change the training curricula of our young upcoming professionals so as to give comprehensive primary health care and public health nutrition a more central role in their learning.
-Intellectual property rights issues (wiki) are increasingly used against the interests of poor countries and poor people. The development of technology for the treatment of diseases is oligopolistic and ignores the research needs directed at the diseases of poverty. Meanwhile, many useful technologies already available in 1978 are still unavailable to millions of people. Intellectual property rules cannot be allowed to continue to make new life-saving medications unavailable and unaffordable to the people who need them the most. Primary health care requires universal access to essential medicines, with most of them made available as generic drugs. Patents in the field of medicines need to be sternly confronted, because they are primarily market-oriented. Drugs must be available to all who need them either free or at affordable costs.
-It is true that the institutions currently involved in primary health care will need to change their focus. But, we want to insist, it is not a time to blame; it is a time to move forward.

If we are to succeed, sentences starting with “The Government should” are out! People have to stop just complaining –they must now actively demand and become the protagonists of change!

Three and a half decades have passed since Alma Ata and the situation is, in many respects, worse than what it was in 1978. Our ability to support human health and nutrition is now at greater risk from an unjust and unsustainable process of development; inequalities have increased between and within countries. Access to food, education, water, shelter, sanitation and employment (all among the social determinants) are still grossly inadequate for many; war, financial crises, violence and conflict abound; the challenges of globalisation, poverty, gender inequality and social exclusion continue; both communicable and non-communicable disease epidemics challenge health and nutrition systems already stretched to the limit. What the latter leaves us with in public health nutrition is the challenge of having to deal with the double burden of under- and over-nutrition.

Today, we must look at WHO to provide not only the technical, but also the moral and political leadership in this entire process. It has to reclaim its legitimate position as the global leader in promoting policies that lead to a world with healthy and well nourished populations. Specifically, we expect WHO to actively support member countries to adopt policies that promote primary health care as an integral part of their national policies. This support is not just to be given in the area of health systems development, but also in promoting policies that more resolutely address the issues related to the social determination of health. WHO must also take the lead in promoting alternate models of research that promote the development of health products and nutrition processes that address the critical needs of people in developing countries more so than the needs of Big Pharma, Big Food and Big Beverages.
 The People’s Health Movement (PHM) has rightfully said that, while the primary health care of 2013 and beyond reiterates the core principles of Alma Ata, it must, in addition, address these new challenges at local, national, regional and global level. PHM is committed to put the health of marginalised groups at the centre of its commitment to ‘Health for All – Now’ –a commitment already espoused by PHM in the year 2000 as the core principle of its People’s Charter for Health (www.phmovement.org).

Notes:
1. Wikipedia defines food sovereignty as: ‘a term coined by members of Via Campesina in 1996 (wiki), that asserts the right of people to define their own food systems. Advocates of food sovereignty put the individuals who produce, distribute and consume food at the center of decisions on food systems and policies, rather than the corporations and market institutions they believe have come to dominate the global food system.
References
1. World Health Organization/United Nations Children’s Fund. Alma-Ata 1978 Primary Health Care,
Geneva, 1978
2. in Friedman, G. Oral Rehydration Therapy and the Children’s Revolution, working paper on the
Future of Health and Health Care. Institute for Food and Development Policy. October 24, 1984.
3. UNICEF. The State of the World’s Children 1984, Oxford University Press. Oxford. 1983. p 1.
4. Questioning the solution -The politics of primary health care and child survival with an in-depth
critique of oral rehydration therapy. D. Werner and D. Sanders et al. Healthwrights Paperback,
1997, 207 pp.
5. http://www.who.int/bulletin/volumes/86/4/08-030408.pdf

CASE STUDY:
People’s struggle for health and liberation in Latin America: A historical perspective. (1)
David Werner
[Photos are not included. Available from schuftan@gmail.com]

I. Introduction
A. The struggle for health is a struggle for social justice

What can we learn from the hey-days of the Community Based Primary Health Care in Latin America during the last half of the 20th Century? I would suggest we can learn a lot … including things that can help ground us in our current strategies of organized action for the needed changes in health.
As an aging activist from those challenging times, I would like to share with you some stories and lessons about the role that village health promoters and their grassroots networks played in the pursuit of health and social justice in those days.

The period from the 1960s to the 1990s was an exciting if difficult time, one of brave popular action for equal rights and the common good. Grassroots actions in many countries were countered by the ruling classes (or powers that be) with fierce repression including torture, disappearances, and other violations of human rights and of international law. But for all the suffering and setbacks, this was a time when some very positive, deep-seated changes also took place. A number of heavy-handed dictatorships and repressive regimes were ousted and the foundation was laid for the more recent dramatic shifts toward representative government and “Power by the People” that have been emerging in the 21st Century.

What we should remember is the key role that Community Based Health Care played — and can still play — in this liberating, bottom-up Struggle for Health for All. The People’s Health Movement in Latin America, as an outgrowth of this popular struggle of the previous century, can indeed be informed and inspired by its early history.

B. The politicization of Primary Health Care in Latin America

Beginning in the late 1950s, in various parts of Latin America, small nongovernment health programmes began to crop up in the poorest, most underserved rural areas and urban slums.
The combination of social injustice, poverty-related ills, and minimal public services at this time led to the spontaneous generation of numerous small, non-government community health programmes. Many of these projects were started by concerned outsiders — priests, nuns, doctors, nurses, social workers — committed to serving the poor.

As the community-based, primary care programmes evolved and became more participatory, the ‘promotores’ and villagers began to discuss and analyse the underlying causes of the health-related problems. Then they began to organise to overcome their common problems, at least at the local level. Out of these collective efforts grew informal organisations: of mothers, landless farmers, day labourers, share-croppers, even street children and youth, all seeking a greater voice in the decisions that affected their health and their lives. In this way, many informal community-based programmes evolved from a focus on curative care, to preventive measures, and finally to socio-political action.

As such, community initiatives began to mobilise people to address the root causes of ill health and malnutrition. In doing so, they were often seen as threats by the local power structure: landlords, public authorities, loan sharks, medical professionals, and others whose routine exploitation of the poor contributed to hunger and poor health. As a result, many of the non-governmental programmes that were first welcomed as inoffensive charities were eventually blacklisted by the local authorities and, in time, by national governments. Increasingly harsh rules and obstacles were imposed for such grassroots initiatives, and, in some countries, health workers or participating midwives were arrested — or worse. In response, many persecuted health workers went underground and joined resistance movements. With their valuable health and organisational skills, some become leaders in the growing liberation struggles against tyrannical rule.

In this way, grassroots Community Based Health Care in Latin America came to play a key role in the mobilisation of marginalised people in the struggles that contributed to the emerging process of genuine democratisation in Latin America … and beyond.

Let me give you a few examples with which I am more familiar with.

II. Local and national origins
A. Guatemala

Dr Carrol Behrhorst

Helping Health Workers Learn

In Guatemala, one of the earliest and most influential Community Based Health Care programmes was started in the highlands of Chimaltenango by a visionary physician, Dr Carroll Behrhorst, (picture above) (wiki) to serve marginalised and cruelly exploited indigenous communities. This was one of the first programmes to train local ‘promotores de salud’. As the promotores began to help the villagers to analyse the underlying determinants of health and take collective action to improve their situation, the military government began to view the community programmes and its workers as subversive. Some promotores were murdered or disappeared. And in the years of the “Scorched Earth” pacification programme, entire villages were burned to the ground. One such village was San Martín, where I took the cover-photo for Helping Health Workers Learn, which shows a promotora teaching a group of mothers. (see picture above)

B. Chile

Salvador Allende

Military junta, Chile 1973

Milton Friedman

In Chile — after the democratically-elected president of Salvador Allende (picture)(wiki)was overthrown by the US-supported military coup forty years ago in 1973 — the autocratic (General Augusto) Pinochet junta (photo of the junta) implemented the neoliberal “free market” policies imposed by Milton Friedman’s “Chicago Boys”. (picture) (wiki) The junta privatized government industries and public services, including health. During the dictatorship of General Pinochet, ‘Donde No Hay Doctor’ (Where there is no Doctor) was banned by the military. However, the publisher of the Chilean edition, Editorial Cuatro Vientos, took the government to court. Amazingly the court sided with the publisher and lifted the ban.

During this time of violent repression and vast unmet needs, a radical community health programme called EPES (Educación Popular en Salud) was born in the impoverished sectors of Santiago and the city of Concepcion. As part of its health education, EPES promoted the “concientización” (awareness-raising) and mobilisation of people around the root causes of poor health. This “empoderamiento popular” (community empowerment) played a critical role in the groundswell of resistance that eventually led to the ouster of the repressive dictator in 1988.

C. El Salvador
[Need photo of El Salvador and of Mexico?] MARIA

Similarly, in El Salvador in the 1970s and ’80s, in impoverished areas, a number of community based health programmes had arisen out of the enormous unmet needs. Widespread unrest was on the rise. As measures of social control became more oppressive, complete with death squads, community health programmes and workers increasingly aligned themselves with the Frente Farabundo Marti para la Liberación Nacional (FMLN). (wiki) As elsewhere, the promotores played a key role in mobilising the groundswell of resistance to the US-supported military dictatorship.

D. Mexico

My own involvement with the struggle for health and justice began in Piaxtla, a villager-run health programme in Mexico’s Sierra Madre Occidental. It is from my experience with Piaxtla –which I helped start back in 1965– that the books Donde No Hay Doctor and Aprendiendo a Promover la Salud (Learning how to promote health) were born — and years later, Cuestionando la Solution: las políticas de atención primaria en salud y la sobrevivencia infantil. (Questioning the Solution: The Politics of Primary Health Care and Child Survival). Like many grassroots health programmes in Latin America, Piaxtla evolved through 3 stages, from an initial focus on curative care, then to preventive measures, and finally to socio-political action.

The Mexican Constitution –which grew out of the Revolution of 1910– provided for a more equitable distribution of land, but a half a century later the best farmland was still illegally held by large landowners. These landlords sharecropped small parcels to landless farmers at such exploitive rates that hardship, hunger and malnutrition were inevitable. A survey we took in the mid-1960s showed that one third of the children died before the age of five years, mostly from diseases related to under-nutrition.

As the programme evolved, the promotores brought their fellow villagers together to analyse the root causes of poor health, and explore solutions. People began to organise and demand their constitutional land rights. It was a long battle, with both formal demands and direct confrontations. Several health workers were killed in the process. But in the end, the campesinos succeeded in invading and reclaiming over 50% of the illegally large parcels of land which they distributed to the landless farmers.

The health and nutrition results were impressive. In a little more than a decade, child mortality dropped to under 20% what it had been. Maternal mortality fell to less than half. And the population as a whole appeared happier, healthier and more self-determined.

E. Nicaragua

Anastasio Somoza

During the brutal, US supported, Somoza family (pictured above)(wiki) dynasty that ruled Nicaragua from 1936 to 1979, the poor majority lived in deplorable conditions. Many of the community health initiatives that emerged to respond to the many unmet needs were assisted by foreign nongovernmental organisations or by charitable religious groups that had no political agendas. But the pervasive “diseases of poverty” they encountered were so clearly the result of an unjust social order that many community health workers began to facilitate organised action at the local level. Thus the promotores de salud gradually became agents of change –and were thus soon branded as subversives.

As the informal network of community based programmes expanded, Somoza’s brutal National Guard, as well as paramilitary groups, increasingly targeted grassroots health workers –along with union leaders and community organisers– for harassment, detention and disappearances. This led many to go underground and join the growing Sandinista resistance (wiki). As collective punishment, the government cut off water, food, and other basic supplies and services. In response, the grassroots communities that supported the Sandinistas set up Civil Defence Committees that acted as ad-hoc local governments. In these “liberated” communities, an effort was made not only to distribute food, water, and other essential supplies, but also basic health services. Local health volunteers, known as brigadistas de salud were recruited and trained. In this way, the grassroots network of community-run health initiatives played a vital role in the broad-based awakening and mobilisation that eventually led to the overthrow of the oppressive Somoza dynasty in July of 1979.

III. Other highlights

A. Solidarity building between programmes and nations

A process of networking and solidarity-building, within countries and between countries, has been one of the most important, strategic outcomes of what became known as the Community Based Health Care Movement –of which the People’s health Movement (wiki) has been its more recent and far-reaching accomplishment.

The network grew stage by stage in an organic, bottom-up way. In the early 1960s, no serious networking existed. For example, in the first years of Project Piaxtla we were totally ignorant that any similar programmes existed. We were in an isolated mountain area without electricity, and with only mule-trails connecting the villages. When I first wrote Donde No Hay Doctor in the early ’70s, we never imagined it would ever be used beyond the wilds of the Sierra Madre. But somehow news of the handbook began to spread to other grassroots health programmes I’d never heard of, in Mexico and then to other countries. Little by little, different programmes began to communicate, share ideas, and eventually exchange visits.

As the resistance to organised repression became more militant, health workers increasingly found themselves in sympathy with the guerrilla uprisings for social justice and self-determination. Some worked directly with them. Among the best known on the medical front was the North American doctor, Charlie Clements (photo) (wiki) whose experiences are recorded in his book, Witness to War. (wiki) In like manner, a young Mexican doctor, Carlos Miyazaki, spent three years in El Salvador during the ’80s, volunteering in the embattled and liberated villages. There, he trained over 300 health promoters –and provided each with a copy of Donde No Hay Doctor.

PROJIMO, a programme that was dedicated to meeting the needs of disabled children, grew out of Piaxtla. During the late ’80s and early ’90s, Projimo arranged secretly to bring severely disabled guerrilla fighters from Guatemala to their programme where they were provided free rehabilitation services and assistive devices.

B. A study trip to learn about other programmes

Largely through the informal distribution of Donde No Hay Doctor, in the 1970s, Project Piaxtla in Mexico made contact with an assortment of community health programmes in Latin America. In 1975, a group of us from Piaxtla took a study trip through Mexico, Central America, and the northern part of South America to visit and exchange ideas with the various programmes. The trip –and the publications that grew out of it, such as Helping Health Workers Learn– became a catalyst for the early networking process.

We visited nearly 40 rural health projects in nine counties. In general, we arrived at the conclusion that these programmes existed on a continuum –from programmes that were community supportive to those that were community oppressive. Community supportive programmes encouraged responsibility, initiative, decision-making and self-reliance. Those that were community oppressive were fundamentally authoritarian, paternalistic and encouraged dependency, servility and unquestioning acceptance of outside regulations and decisions. Interestingly, it was often the non-governmental programmes that usually operated on a shoestring budget, that were more community supportive.

As we went from programme to programme, we gave special attention to the roles that were assigned to the local village health (and nutrition) worker. We found that, if the village health workers were taught a respectable range of skills, and if they were encouraged to think, learn, and take initiative, they made a major contribution to their community and won the people’s confidence and love. This is as valid today as it was then.
However, in countries where potential change agents were feared, village health workers were often taught a pathetically limited range of skills. They were not trained to think, but to follow a list of very specific instructions or ‘norms’. Such health workers had a predictable limited impact on health and nutrition and even less on the growth of the community.

C. Networking: from national to regional

Through these study visits and exchanges networks began to form. The early associations were within a single country. In Mexico it was PRODUSSEP. In Guatemala, ASECSA. In Nicaragua, CISAS and PROSALUD.

Soon, national associations began to arrange international gatherings of community health programmes. In them, it became painfully clear that an overriding determinant of health and nutrition –even in the smallest, most isolated villages–was the top-heavy global economic system, controlled by a very small, but incredibly powerful, ruling class. People in a remote village –or even a small country– can work collectively to improve local conditions affecting their health and nutrition. But as our interconnected global crises –political, economic, and environmental– become more all-encompassing, the need for a united worldwide popular front has become even greater.

It was the common concern about social injustice as the mega-determinants of health and malnutrition that spurred the national associations in Mesoamerica to join forces. In 1975, a ground breaking meeting was organized in Emaus, Guatemala. This gave birth to The Regional Committee for the Promotion of Community Health or CRPSC in Spanish covering Mexico, Central America, and the Caribbean.

D. Reaching out to other parts of the world

Over time, the Regional Committee for Community Health Promotion gradually expanded to include more countries of the Caribbean and representatives from programmes in South America. They also began to have exchanges with like-minded programmes and networks in other parts of the world.

For example, in 1980, one of the lead village health workers of Piaxtla in Mexico, had a chance to visit India for an international health conference titled, “Let the Village Hear.” Martín (his name), as one of only a few actual villagers present at the conference, stressed the need for more villagers to have a chance to speak up rather than to just be talked about. The conference closed with an official decision to change its theme from “Let the Village Hear” to “Let the Village Be Heard.”

The following year, in August 1981, a group of health workers from programmes in Guatemala, Honduras, and Mexico travelled to the Philippines where they exchanged ideas with health workers in the countrywide network of community based health care programmes there.

Ferdinand Marcos

In the Philippines, the despotic US-supported president Ferdinando Marcos government (picture)(wiki) was overthrown in 1986 in the massive, largely non-violent, popular uprising called the “Revolution of Flowers”. (wiki) The Community Based Health Care Movement, whose health workers reached nearly every town and village, had played a strong underground role in mobilising and preparing the people for this revolution.

E. Partial reversals
As already indicated, the country in Central America where the liberation struggle appeared most successful –at least for a while– was Nicaragua, where in 1979 the Sandinistas overthrew the Somoza dynasty. The Nicaraguan victory had ‘threatened’ to demonstrate that an alternative model to the one advocated by the global elites could work well and provide far superior health, nutrition, welfare and educational opportunities to the people. Although Nicaragua is only a small country, such a demonstration was deemed to have far reaching consequences. This could not be tolerated by the global elites; it had to be undermined at all costs. So, the United States, under Ronald Reagan, initiated economic embargoes and a programme of counter-revolutionary terrorism carried out by what became known as the Contras.

The overall influence of the Catholic church also played its part in rolling back some of the gains we saw in Nicaragua and elsewhere, though the facts here are complex. The Church became divided between the traditionalists who stood up for the top-heavy status quo, and the backers of the Theology of Liberation, (wiki) which followed the teachings of Christ by siding with the oppressed.

In Nicaragua, the institutionalized terrorism perpetrated by the United States, the embargo and other more sophisticated strategies of social control took their toll. In 1990, the Sandinistas were voted out, and the conservative UNO Coalition party, propped up by the CIA, took power.

Similar scenarios played themselves out elsewhere. In the Philippines after Marcos, and in South Africa after liberation from apartheid rule, people’s hope for radical change was high. But within a few years, reversals took place that moved back to the top-down model of the delivery of health care which brought back the polarized social order of before. Even for a revolutionary as visionary as Nelson Mandela, (photo)(wiki) the overarching power of the globalized plutocracy was just too much.

In 1990, an international meeting organized by a group of community health pioneers in various parts of the world, was scheduled to take place. The Symposium on Health in Societies in Transition, as it was called, was initially to focus on positive transitions toward more equitable, health-promoting governance. However, in view of some of the current negative transitions, the decision was made to focus on strategies to preserve whatever gains had been made before the tides turned and things regressed in an unhealthy direction.
For all these troubling reversals, this Managua symposium broke new ground. There was penetrating analysis of the similar problems people from diverse locations were experiencing, and solid proposals for local and international action were made. During the closure, the group agreed that the exchange that had begun needed to continue and expand. To this end, they formed a new intercontinental coalition, called the “International People’s Health Council” (IPHC).

During the 1990s, the IPHC arranged periodic international gatherings, held in South Africa, Palestine, Europe, and Australia. Conjointly it facilitated short courses on topics such as Health Education for Change, Child-to-Child activities, grassroots organisation, and other action-oriented topics.

Towards the end of the 20th Century, key players in the IPHC and the Regional Committee, together with other national and international health networks, began to plan of a turn-of-the-century global conference, named the People’s Health Assembly. The same was held at Gonashasthaya Kendra in Bangladesh in December, 2000. (picture) www.phmovement.org The “PHA”, as it was branded, was attended by over 1400 health workers and activists from more than 70 countries. Out of this ground breaking Assembly emerged the ongoing People’s Health Movement (PHM) (wiki) which has held subsequent assemblies in South Africa and in Ecuador.

[Insert photo of People’s Health Assembly 1?]MARIA

Currently –with thousands of members, a diversity of national and regional programmes, numerous watchdog groups, and a foot in the door of the World Health Assembly (link to the WHO Watch here)– PHM now adds a sobering “voice of the people” to the discussions of the world’s top planners and decision-makers in health-related concerns. A regional arm of PHM is the Movimiento por la Salud de los Pueblo-America Latina (MPS-LA).

F. Need for evolution as part of revolutionising the health and nutrition agenda

What can we learn from the fact that so many struggles for liberation, after the best they could overcoming oppressive regimes, gradually slipped back to the old pecking order, with a new batch of tyrants rising to the top? The key lesson, perhaps, is that revolution without evolution doesn’t change much –or at least not for long. If we are looking for radical change of governance, we have first to build a radical change in the way ordinary people see themselves in relation to other people and the natural world. For this reason, if we are to advance towards a healthier, kinder, more sustainable social order, we need to start with our children –and specifically, with how they learn.

IV. Health Education for Change

Paulo Freire

This historical sketch of the Struggle for Health in Latin America would not be complete without focusing on the methodologies of a liberating health education that evolved as part of the movement. Here, I can only touch on some of the highlights.

The most well-known proponent of Education for Change in the last century was the Brazilian adult-literacy facilitator, Pablo Freire. (picture) (wiki) Freire’s classic book, Pedagogy of the Oppressed, (wiki) revolutionized the methodology of information sharing and “concientización” (awareness raising) in community-action movements worldwide. Freire described two of kinds of education. First, is the ‘banking’ approach where an all-knowing authority deposits ideas into his or her pupils’ empty heads. The second is the ‘liberating’ approach where the facilitator pulls ideas out of the heads of the learners, and helps them build on their own observations and experience. In Freire’s ‘learning for change’ model, people collectively assess the situations in which they live and develop strategies for change.

A. Community diagnosis

Community Diagnosis

Different programmes have used different methods to help people analyse their health- and nutrition-related needs and to explore solutions. To engage groups of farm workers, mothers, or schoolchildren in a situational analysis, many promotores begin with a community diagnosis. The group identifies their common health- and nutrition-related problems, which they label according to Frequency, Severity, Contagion, and Duration. Next, they look at which problems contribute to others, and how. Finally they discuss which problems they should try to attack first, and try to develop a plan of action. Because the activity is so visual and hands-on, nearly everybody gets involved. It is an eye-opening, action-oriented learning experience … and lots of fun. (photo above)

B. Storytelling, the ‘But Why?’ game and the ‘chain of causes’

One widely used method to help people learn about interrelated causes of different health and nutrition problems uses storytelling, followed by a “But Why?” game, and the creation of a ‘chain of causes’. First, a true story is told, perhaps about the recent death of a child. Into the story is built a whole series of causes, one leading to the next. After the story is told, the learning group retells it, and each time a cause is stated, everyone asks, “But why?” thus progressively getting from the more immediate to the more structural causes. Physical, biological, cultural, economic, political and environmental causes pop up spontaneously from the community, are all examined, and appropriate problem solving procedures are proposed. The game aims at what we would today say is ultimately exploring the social determinants (or more properly, the social determination) of preventable ill-health and malnutrition.

C. Discovery Based Learning

The ‘chain of causes’ is one of the many methods we health and nutrition educators use. We call it “Discovery Based Learning”, an approach pioneered in the community based programmes in Latin America, and elsewhere. Such methods are in tune with Freire’s Education for Liberation, because people critically analyse the interlinking determinants of ill-health and malnutrition and then embark on a reasoned plan of action.

D. Child-to-Child

David Morley

Child to Child

Speaking of Education for Change, I would like to draw your attention to what, for me, has been one of the most exciting developments to emerge out of the people-centred struggle for health. I speak of the Child-to-Child initiative. The Child-to-Child concept grew out of an international gathering of health educators in 1979, convened by David Morley, (picture) (wiki) a paediatrician with long experience in rural Africa, and a leading pioneer in primary health care. The idea for Child-to-Child emerged from the fact that in very poor families older siblings, especially girls, are often kept out of school, because they are needed to care for their younger siblings while their mothers are working. A variety of Child-to-Child ‘activity sheets’ were developed to help children learn preventive, and curative skills regarding the health of younger siblings. Early activities addressed topics such as diarrhoea, lowering fever, getting enough to eat and to drink, cleanliness, prevention of accidents, and so on.

As it was developed in Africa, Child to Child was an effective, but in many ways conventional, teaching tool. Health workers and educators in Latin America helped to transform it into a liberating learning experience which encourages children make their own observations, draw their own conclusions, and take collective action to solve problems in their own homes and communities.
Since its modest start, the concept of Child-to-Child expanded in a number of ways. It is now practiced in more than 70 countries. And the range of activities has grown to include such diverse activities as tree planting, recycling garbage as fertilizer, and caring for the elderly.

Latin America has made its big contribution to Child-to-Child by helping to transform it from an useful but fairly orthodox teaching tool to a liberating learning experience. The transformative potential of Child-to-Child should not be underestimated, either for children or for schools. Child-to-Child, in its more liberating form, encourages children make their own observations, draw their own conclusions, and take collective action to solve problems in their own homes and communities. Thus Child-to-Child, when practiced in the schools, can help make schooling more relevant to their lives.
Actually, the children begin by doing their own community diagnosis. This helps the kids look at the larger picture of sickness and health in their village and to visualize how the various health problems are linked together. Often, based on their findings, the children choose which health problem about which they want to learn first, and about which they want to explore possible solutions.

E. Using children’s ‘participatory epidemiology’ to combat malnutrition

Measuring arm circumference

In the chain of causes leading to death from diarrhoea in children living in poverty, malnutrition is often the most pernicious link. In Latin America, the Child-to-Child activity titled “Helping children who are too thin” takes a discovery-based, learning-by-doing approach. This technique actively engages the children in the entire problem solving process, from measuring the severity of the problem to planning and implementing solutions. (photo above)

Clearly, the health and nutrition needs of infants in impoverished, marginalized families will not be resolved by groups of schoolchildren. To do away with hunger, the underlying social determinants of malnutrition (cultural, economic, and political) must also be collectively addressed. The long-term transformative potential of the Child-to-Child approach to education should thus not be underestimated. Its influence both on the children involved and on the school system can be far-reaching.

V. Conclusion — Where do we go from here?

A. The Challenge

Today, in the second decade of the 21st Century, we live in a different and more endangered world than in the past. The current economic system that is centred in the United States and dominated by multinational banks and corporations has placed the collective health and nutrition and the survival of humanity in graver danger than ever before. This system now threatens the well-being and the very existence of our species, because of the Pandora’s Box of problems that it has created, including the growing gap between rich and poor; the threat of never ending wars, both conventional and nuclear; the threat of genetically engineered crops; add to this the turning of our environment into a carcinogenic pool by nuclear and chemical waste that we cannot dispose of, and the global warming ever-lurking crisis.

The enormity and the interaction of these crises leads to a ‘pandemic despair’ and to violence. Yet the world’s top politicians –bought off or intimidated by the multinational banks and corporations- have no interest in taking the radical steps that are needed.

On the other hand, some hopeful things are happening as well. Inspired by Latin America, we see a growing number of populations who, after enduring centuries of colonial and then neocolonial oppression, have begun to rise up en masse and say, “Ya basta”! (Enough is Enough!).

The push needs to come from below. It is time for the world’s people –like the people in a growing number of Latin American countries– to stand up and cry, “Ya basta”! But for such a global groundswell of solidarity to come about, a groundswell of organised action is needed. The People’s Health Movement, at regional and global level, is already playing a critical role in this process.

But many of us are getting older. We have struggled, sacrificed and learned. We have done some things well. We have also made mistakes. Now, we must look to young people to learn from both our successes and our failures, and to carry the struggle forward –young people who believe in and embody the essential goodness of humanity.

B. Sumak Kausay — and the dream of Health for All

For too long, the dominant concepts of development and progress have been tethered to the capitalist paradigm of unlimited growth through the exploitation of people and the unbridled extraction of resources from the environment. But this acquisitive approach to development –as if the Earth belonged to us, rather than us to it– is now returning like a boomerang.

Ultimately, what our common struggle comes down to, in Latin America and worldwide, in the not-too-distant future, is Health for All or Health for No One.

I would like to reemphasize that today when we speak of Health for All in our endangered planet, “All” does not mean only us hairless apes. It means Health for ALL, in the most inclusive sense. We humans are one small part of an astounding planet where everything is interwoven as a vibrant living whole. On this beautiful planet, we are a thread in the web of life, a participant in the ecological balance of all biologic and non-biologic things, a part of Earth, Air, Fire, and Water, of Warm and of Cold, of Yin and of Yang of which the mysterious cosmos is composed. Unless and until we learn to live in balance and compassion with one another, and with our critically-endangered ecosystem –local and global– health for any of us will remain a short-lived dream.

This larger vision of unity and empathy for all is the essence of the ancient Ecuadorian concept of Sumak Kausay or “Buen Vivir” (good living). It is heartening that Ecuador, with its long history of indigenous wisdom, built into its new 2008 Constitution that affirms of the rights of nature as part of holistic living, is a large but humble step forward toward the vision we share for the Health and Rights of ALL.

Notes:
1. Adapted from “Encuentro Pluricultural para la Salud y Bien Vivir” (Multicultural Encounter for Health and Living Well), presented at the first international assembly of The People’s Health Movement–Latin America, Cuenca, Ecuador, October 7-12, 2013.

References
Werner, David, Where There Is No Doctor, 1974, Macmillan Press, London; Hesperian Health Guides, Berkeley, California, http://hesperian.org/books-and-resources/

Werner, David. Helping Health Workers Learn, 1982. Hesperian Health Guides, Berkeley, California,

Werner, David “The Village Health Worker: Lackey or Liberator” 1977; World Health Forum. 1981. http://whqlibdoc.who.int/whf/1981/vol2-no1/WHF_1981_2%281%29_%28p46-68%29.pdf
Or see: https://healthwrights.org/content/articles/lackey_or_liberator.htm

Werner, David, Sanders, David. Questioning the Solution: The Politics of Primary Health Care and Child Survival. HealthWrights. Palo Alto, California, 1997. https://healthwrights.org/index.php?option=com_content&view=article&id=208:ques-solu&catid=85

Freire, Paulo, Pedagogy of the Oppressed, 1968. Barnes and Noble

Werner, D., Zuniga, M, et al. Health Care in Societies in Transition, 1993, International People’s Health Council, Hesperian Foundation, Berkeley, California

CISAS – Centro de Información y Servicios de Asesoria en Salud (Centro de Información y Servicios de Asesoría en Salud); http://www.cisas.org.ni/

HealthWrights website: www.healthwrights.org

Politics of Health website: www.politicsofhealth.org

HAIN. Report on The Philippine/Latin American CBHC Exchange, [find details]

Werner, David B. “Good News – and not so good news – from Bangladesh” Newsletter from the Sierra Madre # 70, Dec., 2012, http://healthwrights.org/index.php?option=com_content&view=article&id=241

Wikipedia. “Rights to Nature” (Sumak Kausay or Buen Vivir = “Good Life” in Kichwa) http://en.wikipedia.org/wiki/Rights_of_Nature#Ecuador_Development

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