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The Struggle for health: Problems and Solutions
Reflections from the South
This document in pdf format 132
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This booklet was printed in the month of January, 2003 in Editronic, S.A.
Telefax: 222-5461 Managua, Nicaragua. 2000 copies were printed.
Funding for this publication was provided by HIVOS of The Netherlands.
The Globalization and Health Project of IPHC is funded by NOVIB of The Netherlands.
Introduction
Maria Hamlin Zuniga
(International People’s Health Council)*
Mike Rowson
(Medact and Health Counts)**
The continuing relevance of Alma-Ata
The year 2003 marks the 25th anniversary
of one of the most important documents in international health, the Alma-Ata
declaration on Health for All. The
declaration set a deadline of the year 2000 for achieving a level of health that
would enable all of the world’s people to “lead a socially and economically
productive life.” The strategy to achieve the goal would be the implementation of primary
health care, with its emphasis on community participation, and tackling the
underlying causes of diseases, such as poverty, illiteracy, and poor sanitation. The
declaration was drafted by WHO and UNICEF and signed by over 130 health ministers
(including those from the developed countries) and called for a New
International Economic Order to benefit the developing world, and the diversion of
money spent on arms to investments in health. It seems slightly unbelievable
today that rich nations and international agencies could have put their names to
such a radical declaration. However, despite promises, very often the
Declaration was not put into effect: Health for All by the year 2000 was patently not
achieved.
But this does not mean we should throw away the Declaration. It has
continuing, and even heightened relevance for the world today. Alma-Ata was an
evidence based Declaration, which sprung from the lessons learnt in the many
community based projects working in health and from the performance of some of the high
achieving developing countries such as Costa Rica, Malaysia, Cuba, China
and Sri Lanka. The emphasis these countries placed on reducing social and
economic inequalities and providing broad based education, health, water and
social security services, showed that good health could be achieved in even very poor
countries, if the political will was in place. Although these problems are
challenging, experience shows that they cannot be ignored.
Challenges
Since Alma-Ata parts of the world have undergone a ‘health reversal’,
and many of the contributions to this booklet show the consequences. Health
systems have come under unprecedented stress, as Dr. Sanders shows in his analysis of
the situation in sub-Saharan Africa. New diseases (and old ones) have
flourished, and public health has deteriorated in many countries. Dr. Unnikrishnan
highlights the intolerable burden that health care costs place on the poor: it is a
pervers world in which the actual costs of health care can push people into
poverty, but in many places they routinely do so.
Globalisation and the expanding role of the market have also frequently
damaged health and health care. The new world of free trade in goods and capital
has led to greater instability in the global economy, with dire consequences for
health, as Dr. Monsalvo reveals in his analysis of the Argentinian situation.
Global trade agreements, as Dr. Sanders shows, have prioritized trade concerns over
public health. At a deeper level, the emphasis on introducing markets in health
care has had an unhelpfulinfluence on fundamental values such as co-operation and
solidarity, and affected the ability of countries o re-distribute income
from richer to poorer segments of society.
Alternatives
Dealing with these global problems, as well as those at the national and community level is a complex and tiring business for
health activists.
The experiences of the Council for Health and Development in the Philippines
show how positive health interventions can be set back by the actions of
governments and the military. However, even in dire situations bravery and tenacity
can win through. In Latin America, Dr. Monsalvo describes the efforts of health
professionals and others to envisage a new Argentina (and a new world!)
through practical health interventions and policy debate. Dr. Quizphe shows how
in Ecuador, health activists have composed their own ‘Health Charter’
with a list of demands to government. All such efforts bear testimony to the values
encapsulate in the Alma-Ata Declaration.
All over the world, people concerned with health are trying to focus the
attentions of governments and international agencies on the promises they signed up
to 25 years ago in Alma-Ata. Recently, the People’s Health Movement, with
which International People’s Health Council and Health Counts are closely
involved, has been formed to focus attention on these goals and to mobilize
activities. We hope that this booklet will be part of that process and that people
concerned with health will join us in the ongoing struggle for ‘Health for All’.
* IPHC is a worldwide coalition of people’s health initiatives and
socially progressive groups and movements committed to working for the health and
rights of disadvantaged people - and ultimately of all people. The vision
of the IPHC is to advance toward Health for All—viewing health in the broad
sense of physical, mental, social, economic, and environmental well-being.
The IPHC maintains that:Health for All can only be achieved through:
participatory democracy - decision-making power by the people,
equity - in terms of equal rights and everyone’s basic needs, and accountability
of government and industry, with strong input by ordinary people in the
decisions that effect their lives. The International People’s Health Council – IPHC - is one
of the
groups that helped to organize and coordinate the People’s Heath Assembly held in
Bangladesh in December of 2000.
If you want to learn more about the IPHC and the People’s Health
Movement as well as future plans for action, please contact:
IPHC Global Coordination
Apartado No. 6152, Managua, Nicaragua
Web site: www.iphcglobal.org
E-mail: info@iphcglobal.org
Fax: (505) 266-2225
** Medact is a UK-based organization of health professionals undertaking education, research and advocacy on the health
impacts of conflict,
poverty and environmental degradation. Medact is a member, with the Dutch NGO Wemos
and the Finnish NGO Solidar, of the Health Counts consortium which calls
for economic policies which respect equity and the right to health. website:
www.medact.org e-mail
mikerowson@medact.org
CRY MY BELOVED COUNTRY
By Dr. Unnikrishnan PV
| The picture below shows Endramaya (60), a migrant casual labourer
carrying on his back his wife, Lakhamma (50), her broken right leg in a plaster
cast. Lakhamma is also a migrant worker, and she was injured in an accident in
the outskirts of Bangalore two weeks earlier. The couple came to the city
from Raichur in the northern dry belt of Karnataka state, where a farm and market
crisis make local people migrate in search of work elsewhere in the country. State
capital Bangalore, one the best technology hubs in the world, “the Silicon
Plateau of India”, is a favourite destination for many migrants. |
 |
I was on my way to office when I spotted the couple. Endramaya had
already walked for over two hours along the two km stretch of Mahatma Gandhi Road
in the heart of the city, carrying Lakhamma on his shoulder, occasionally
resting on the roadside.
Endramaya made several attempts to get his wife medical treatment. His
first stop was the government Primary Health Centre (PHC). But the PHC did not
even have the basic facilities to take an X-ray or to put a plaster cast
on the patient’s leg. Endramaya then took his wife to several private
hospitals and clinics, but they would not treat her. He did not have enough money to pay.
After several days, once he was able to mobilise some money, Endramaya took Lakhamma to a private
clinic for treatment. Needless to say, the couple ended up spending most of the money they had. They
had just enough for the bus fare to Raichur. After treatment, they spent the
night on the pavement and it was raining. Around midnight, Endramaya started
walking towards the Central Bus Station located in the heart of
the city. He walked over 7 km, almost unnoticed in a City that is home to six
million people, thousands of them employees of top firms, including several
Fortune 500 companies. He tried several times for a free lift, waving at cars,
some of them latest models, four-wheel drives and auto rickshaws passing by. It
did not work. Perhaps after several days on a hospital trail and a sleepless
night he did not look quite presentable.
Endramaya would walk slowly, after every few yards letting his wife sit
on the kerb, so that he could stretch his hands and try to flag down some
vehicle. Moments later he would continue his journey.
It was morning peak hour. Several vehicles slowed down, those driving
them staring at the couple in disbelief, but they proceeded to catch their
deadlines as if nothing had happened. I was upset and angry. Running towards them, I
pulled my camera out of my backpack. I paused and started clicking. Then they
told me their story. I joined the duo, waving hands at vehicles. Two cars
stopped, their occupants willing to help. We all pooled in some money and helped the
couple get a taxi to the bus station.
That evening at the photo studio I was waiting for the prints to come. A
curious clerk at the cash counter asked me about the photograph. I was still
upset, so I talked a bit loud about it all. Overhearing our conversation, a gentleman
patted me from behind. “It is a good shot, but you should have used a
wide-angle lens,’’ the professional photographer said, leaving me speechless. As a medical
professional, I should have told him about the ‘rigor mortis’ of the
private sector health care and the numbness of citizens in general. As a humanitarian
professional, I should have told him that medical expense is the second largest
contributing factor for rural indebtedness in India after dowry, an
equally unacceptable social evil.
A leading national newspaper flashed my photograph of Endramaya’s
journey on the front page of their city edition the following morning. The
caption said how callous the city could be towards its “guests” like migrant
workers. They said it was “reality and not virtual,’’ probably referring to the
virtual reality shows at the city’s annual international IT fare that concluded the
previous day. It did not have space to discuss larger issues - mounting medical
expenses and an insensitive health policy that denies even basic facilities to the
poor. A day after the news report, I was giving a class on humanitarian action
at a leading medical college in the city. I waved the newspaper featuring
Endramaya’s journey on the front page. One of the senior students said: “It
is a
multiple fracture of tibia and fibula.” Quite a professional remark! By that evening I
had one more professional remark, from a photographer: “It is a very good
picture, but we missed the story.” Sad.
These professional reactions are the signs of our times. The present
health care system has become super-efficient, and it is going fast forward, at least
in terms of technology and innovation. But it has lost touch with social
realities, and it is losing its human element.
By the time you finish reading this note more than 15 people in India
will have died of tuberculosis (TB). Every minute one person dies in India because
of TB. Treating TB is no rocket science. A nutritious diet, sanitation and basic
public education can cut down TB toll. This year we have even seen reports of
“alleged starvation deaths” from two belts in India, a country that has a
surplus of food grains. In a country where a large percentage of women are anemic, this
sounds like a riddle.
Around the same time Endramaya was walking his way of the cross in Bangalore,
experts were discussing the proposed new Health Policy in New Delhi. The
last National Health Policy was announced in 1983. Compared with that, the new
policy draft looks like a sell out. “The new policy (draft) is more
eloquent where it is silent,” says a critique. It omits the very basic concept
of
comprehensive and universal health care. For example, one of the salient features of
the 1983 document was its commitment to the Alma Ata declaration. It said: “India
is committed to attaining the goal of ‘Health for all by the year 2000 AD’
through the universal provision of primary health care services.” The new
policy (draft) is silent about it.
The new policy is also silent about the role of village health workers,
the frontier guards of public health, who keep the pulse of this country ticking. The
new policy has just a few lines about the women’s health, without any
specific plans to improve their health - a betrayal of half the population. The policy
does not care about children. It does not even have a separate section for children’s health
in a country where 70 out of 1000 children die prematurely.
Endramaya’s desperate walk in one of the fastest growing cities in Asia
is symptomatic of the sickness of the health systems in a large part of the
developing world where they fail to cater to the needs of the poor. India’s
experience of dealing with the health needs of its majority, especially the poor, has
not been very impressive. In fact, the health care system has worsened in the last
decade, which has seen comparatively good economic growth.
Critics argue that neo-liberal policies related to trade and commerce, as
part of the World Bank - and IMF - imposed Structural Adjustment Programmes, have
left a long trail of ill health. The cost of medicine, including that of
essential drugs, has shot up. In the last 10 years, the price of drugs used even
for killer diseases like malaria and TB have been decontrolled to boost the health
of the pharmaceutical industry at the cost of human lives.
Public health investment in India is one of the lowest in the world and
it fell from 1.3 per cent of the GDP to 0.9 per cent during the 1990s. The new
policy recommends an increase to 2.0 per cent by the 2010. This still falls much
short of the 5.0 per cent benchmark demanded by the People’s Health Movement,
several health and social groups and the WHO long back.
The new draft policy projects that by 2010 public expenditure will be 33
per cent of the total health expenditure. But even 33 per cent will be lower
than the government expenditure of some of the most privatised health systems in
the world. At present India spends an average of around Rs.160 (less than US
$ 4) per person per annum on health care. That is roughly the price of three
hamburgers, going by the standards of the new economy. No wonder that Lakhamma had to
go from pillar to post before finding place in a private clinic.
In contrast to the cut in health care sector, the defence budget has shot
up. This is an insult to the people of India, where 200 million people (1/5th of
the total population) do not have access to safe drinking water and 600 million who
do not have access to basic sanitation. Moreover, India pays a huge amount
every year to the World Bank by way of debt servicing - much more than what the
country receives every year. “Our programmes are like medicine. Some of
the medicine has harmful side-effects, and there are real questions about
what the dosage ought to be,” says Michael Mussa, Chief Economist at the
International Monetary Fund. “The best that can be hoped for is that we are
prescribing more or less the right medicine in more or less the right dosage.”
The bitter pills prescribed by the World Bank have worsened health
problems in many countries. For example, Bank loans for agriculture, dams, mines and
power plants often cause health problems as a side effect of environmental devastation.
Bank-financed dams around the world have increased the incidence of
waterborne diseases like malaria and schistosomiasis because the stagnant pools of
water in dam reservoirs breed vectors such as mosquitoes and snails- an additional
burden on the already crippled health system. Further, structural
adjustment programmes have often meant drastic cuts of social safety measures. Often
poor people have ended up paying more for products and services, further
cutting their limited food budget.
As a health and humanitarian worker, my attitude should be positive. I
should explore the possibility of saving and rebuilding lives in disaster, war
and epidemic situations. This note may sound pessimistic. But it reflects the mood of
our times.
(Dr Unnikrishnan PV (unnikru@yahoo.com) works on health and humanitarian
issues (disasters, conflicts and wars) with a humanitarian agency in
India. He balances his work with community based humanitarian interventions and
policy research. He is closely associated with the People’s Health Movement
and the International People’s Health Council).
Globalisation, Health and Health Services in Sub-Saharan Africa1
by Dr. David Sanders
Professor and Director
School of Public Health
University of the Western Cape
Health is in a state of crisis in Sub-Saharan Africa (SSA). While at an
aggregate level health status has improved in SSA over the last fifty years, these
improvements have been slower in SSA than in other regions of the world.
For example, between 1981 and 1999 IMR has decreased in SSA from 126 to 107
as compared with 78 to 57 for the world as a whole. The respective percentages of
decline for this period are 15.1% and 26.9%. Furthermore, in 1999, seven
of the 48 SSA countries had a lower life expectancy (LE) than in 1970, while
eight countries have seen an increase in infant mortality rate (IMR) between
1981 and 1999. Life expectancy in 17 of 48 countries has declined between 1981 and
1999 (1)(2)(3). In addition, young
child malnutrition has worsened significantly over the past decade in SSA(4).
In the past two decades there has been an alarming resurgence and spread
of “old” communicable diseases once thought to be well controlled, for
example cholera, tuberculosis, malaria, yellow fever and trypanosomiasis, while
“new” epidemics, notably HIV/AIDS, threaten last century’s health gains(5).
To aggravate matters, a number of African countries are experiencing an “epidemiological transition”, with cardiovascular
diseases, cancers,
diabetes, other chronic conditions and trauma, replacing communicable diseases in
some social groups, but in others, co-existing with them(6).
Access to health services improved considerably during the period 1980
– 1990, but has worsened since then as shown by Expanded Programme on
Immunisation (EPI) coverage data. EPI coverage data for SSA in 1999 show declines in
coverage of all routinely administered antigens(7).
This occurred despite the intensive polio vaccination campaigns and the regular measles vaccination campaigns.
The above declines in health status and health sector performance are the
result of the combined impact of economic decline and adjustment, the HIV/AIDS
epidemic which now affects 28 million Africans, approximately 70% of the
total of HIV infected people globally(8),
and conflict and violence which involves 13 of 48 SSA countries.
The serious economic situation is summed up by the startling statistic
that 28 of 48 countries had an average per capita income of less than $1 per day in
1999 compared to 19 of 36 countries in 1981(9).
Furthermore, there is evidence that the income gap between rich and poor within countries has increased
dramatically over the past decade. In addition, most SSA countries still spend less
than an average of US$10 per person per year on health care, an amount that is
20-40% below even that required to cover the basic package of health services
advocated by the World Bank(10).
The above situation is the result of a number of factors, some historical
and others contemporary, the latter being ultimately linked to various
aspects and instruments of globalisation.
In Africa, amongst the most important components of the recent phase of globalisation have been Structural Adjustment
Programmes (SAPs), which
have had the effect of further integrating countries into the global economy
through the imposition of stringent debt repayments and liberalization of trade.
SAPs have also resulted in significant macro-economic policy changes and
public sector restructuring and reduced social provisioning, with negative effects on
education, health and social services for the poor. A recent review of available
studies on structural adjustment and health for a WHO commission states: ‘The
majority of studies in Africa, whether theoretical or empirical, are negative
towards structural adjustment and its effects on health outcomes’(11).
More recently, other instruments of globalisation have further undermined
the ability of developing country governments to provide health care for
their populations. For example, the development of agreements under the World
Trade Organisation (WTO), notably Trade-related Intellectual Property Rights
(TRIPS) and its interpretation by powerful corporate interests and governments,
have already threatened to circumscribe countries’ health policy options.
The best known case relates to the recent legal battle around the attempt by South
Africa to secure pharmaceuticals, especially for HIV/AIDS, at a reduced cost.
In
1997 Nelson Mandela signed into legislation a law aimed at lowering drug
prices through “parallel importing” – that is importing drugs from
countries where they are sold at lower prices – and “compulsory licensing”, which
would allow local companies to manufacture certain drugs, in exchange for royalties.
Both provisions are legal under the TRIPS agreement as all sides agreed that
HIV/AIDS is an emergency. This was confirmed during the WTO meeting in Doha
in 2001. The USA administration did not bring its case to the WTO but
instead, acting in concert with the multinational pharmaceutical corporations,
brought a number of pressures (e.g. threats of trade sanctions and legal action) to
bear on the South African Government to rescind the legislation. This followed
similar successful threats against Thailand and Bangladesh(12).
However, an uncompromising South African Government, together with a vigorous
campaign mounted by local and international AIDS activists and progressive health
NGOs, forced a climb-down by both the US Government and the multinational pharmaceutical companies(13).
Notwithstanding this important victory, the provisions of the WTO,
particularly TRIPS and the General Agreement on Trade in Services (GATS) hold many
threats for the health and health services of developing countries(14).
Accompanying neoliberal reforms of the macro-economy have been health
sector reforms (H.S.R.). Key components of HSR include decentralisation of management responsibility and/or provision of health care to local level,
improvement of national ministry of health’s functioning, broadening
health financing options through, for example, user fees, insurance schemes and
introduction of managed competition; and rationing of health care through
the identification of public health and clinical “packages”, comprising a
set of (often limited) interventions.
The combined effect of the above interventions together with the impact
of HIV/AIDS on the health workforce has resulted in a significant reduction in
public provision of social (including health) services in SSA, and there is
mounting evidence of a general decline in access to health services, affecting
particularly the poor. This is starkly illustrated by immunization coverage, a
sensitive marker of health service coverage, which has fallen during the 1990s.(15).
In recognition of the growing global health divide between North and
South, the crisis imposed by HIV/AIDS and the resurgence of TB and malaria, as well
as the inability of both for governments and increasingly cash-strapped
multilateral (UN) agencies to invest in health services, a number of Joint Public -
Private Initiatives (JPPIs) have been recently launched. The best-known of these
in health are GAVI (Global Alliance for Vaccines and Immunisation) and the GFATM
(Global Fund Against Aids, Tuberculosis and Malaria).
The first disbursements of the GFATM have still to be made, but those for
GAVI, made for 2000/2001, totaled USD 150 million from initial commitments
totaling USD 1.03 billion. Of this initial disbursement 90% was allocated for the
introduction of new vaccines and single use injection materials, while
only 10% went to strengthen immunization services. Anita Hardon has commented: “The
emphasis on the introduction of new and under-used vaccines in GAVI
reflects a more general shift away from equity towards technological innovation and
disease eradication in global health programmes. This appears to indicate a fundamental
move in vaccine policy from the values of the Post-Alma Ata (PHC) era.” (16).
Further, it is emblematic of the current emphasis of health policy and
the influence of the private sector partners, that, notwithstanding the clear inability
of health systems – particularly in Africa – to sustain “delivery” of
robust, effective and tested technologies, such as the standard six vaccines, that the focus is
on the pursuit of new technologies, rather than the resuscitation of delivery
systems. Without a shift in currently dominant neoliberal thinking and a
consequent change in macroeconomic policy and its reflection within the health sector, the
future for Africa’s health is bleak.
References
1 UNICEF. State of the World’s Children. 1984.
Oxford: Oxford University Press, 1983.
2 UNICEF. State of the World’s Children. 1994.
Oxford: Oxford University Press, 1993.
3 UNICEF. The State of the World’s Children.
2001. Oxford: Oxford University Press, 2000.
4 ACC/SCN, Nutrition Throughout the Life Cycle, 4th Report on the World Nutrition Situation, Geneva, 2000
5 Sanders D, Primary Health Care 21: “Everybody’s
Business”, Commissioned Directional Paper for an International Meeting to celebrate 20 years
after Alma-Ata, Almaty, Kazakhstan, 27-28 November 1998, Jointly organised by WHO
Headquarters, Geneva, Switzerland and the WHO Regional Office for Europe, Copenhagen, Denmark, WHO
EIP/OSD/00.7,
6 Frenk J, Bobadilla JL, Sepulveda J, Lopez
Cervantes M. Health Transition in Middle-income Countries: New Challenges for Health Care. Health Pol
Planning 1989; 4: 29-39.
7 UNICEF. State of the World’s Children, Reports
1984, 1994, 2001 op.cit
8 Collins J, Rau B. AIDS in the Context of
Development. Programme on Social Policy and Development, Paper number 4. Geneva: UNRISD, 2000.
9 UNICEF. The State of the World’s Children.
2001. Oxford: Oxford University Press, 2000.
10 Simms C, Rowson M, Peattie S. The Bitterest Pill
of All. The collapse of Africa’s health systems. London: Medact/Save the Children Briefing
report, 2001.
11 Breman A, Shelton C. Structural adjustment and
health: A literature review of the debate, its role players and the presented empirical evidence. WHO
Commission on Macroeconomics and Health Working Paper WG 6:6. Geneva: WHO, 2001.
12 Bond P. Globalisation, pharmaceutical pricing,
and South African health policy: Managing confrontation with U.S. firms and politicians. Int J Health
Services 1999; 29: 765-92
13 Hong E. Globalisation and the impact on health:
A third world view. Third World Network, 2000. Available at http://www.twnside.org.sg/health.htm
14 See http://www.preamble.org
15 UNICEF. State of the World’s Children, Reports
1984, 1994, 2001 op.cit
16 Hardon A. 2001 Immunisation for All? HAI Europe,
2001: 6(1).
TAKE TIME GIRLS
By Fortunate Kahari
Mwanza Secondary school
Zimbabwe
Let me take this opportunity
To warn you my fellow sisters, teenage girls.
Before attempting to do anything
Think of the four Ps first
That is Purpose, Plan, Perseverance and Price
Nowadays, there is AIDS.
Do not rush to be parents
Those boyfriends lovers of your are liars
They tell you that they have cars
Where as they are fathers
They tell you that you are as sweet as sugar
But imagine girls can you be put into tea
They tell you that your eyes are stars
But do you really know what exactly a star is like
They can even tell you that you are a rose of Sharon.
But why did not they plant you in their gardens.
Take time to know the one you desire in life
Do not rush
And you girls are sometimes foolish
When you hear that, you think that they genuinely love you
But no they are only after your bodies
They are only there to vacate you
You agree to the proposal and have sex with them
After that, they spit you like unsweet bubble gum.
Take time to know what you are doing
Do not rush
Some young girls are involved in such activities
Just because they are blessed at a young age.
Some even, wear cloth that attracts boys
But I tell you; you do not need to show off your body to catch a boy’s
eyes.
Their eyes dance every time a boy whistles.
Girls are stopped in streets like commuters.
Girls why not wait like a boutique;
These are not like flea markets
For many people enter in a flea market and a few in a boutique.
Wait until the right time comes and the right one takes you.
Some of you girls have vanished and come are regretting.
Ignore those silly boys and concentrate with school first, lastly boys
Story of a community health worker from the Philippines:
Developing Self Reliance in Health
Nang Vicky’s story
Nang Vicky Undangan is a peasant woman from a mountain village in Surigao
del Sur, which is home to landless farmers in this northwest province of
Mindanao in the Philippines.
When the Community Based Health Program (CBHP) of Tandag reached
Nang
Vicky’s community in Camam-onan, San Isidro, she was among those chosen by her community members to be trained as a community health worker (CHW).
With the existence of CBHP Tandag, the training and developing of
CHWs in Surigao del Sur has been a community effort. Normally, one per 10-15
families is chosen to be trained as a CHW.
Aside from training CHWs, the health program undertakes community
organizing and health services delivery, which includes assisting referral patients
and conducting medical missions. The trained CHWs are deeply involved in such
activities not only in their communities, but also in nearby communities
as needed. Attending health skills training was never simple for any CHW. This would
mean leaving their children at home, foregoing a day’s work in the farm
and finding extra food to bring and extra money for transportation.
When the CHWs of San Isidro had a 6-day training on Anatomy, Parasitism
and Tuberculosis, Nang Vicky resolved to attend the training at any
cost. Only at that time, the challenge was even harder for her. For three weeks, her
husband then had been suffering from a kidney infection with occasional bouts of
vomiting and fever. The situation made her think twice. She presented her problem
to her family groups, which had offered to look after her husband and children
while she was training.
The importance of community health services
Nang Vicky finished the scheduled training and
went on to serve her community as a health worker. She belongs to the over 3,000 CHWs of the 57 CBHP
members of the Council for Health and Development (CHD). The CBHPs
directly serve marginalized sectors in Philippine society, namely, the peasants,
farmers, fisher folk, workers and indigenous peoples in 2,000 villages spread out
in 67 provinces in the Philippines. (The country is comprised of 75 provinces).
Most CHWs like Nang Vicky now recall common experiences of carrying sick members of their communities in hammocks down the mountain trails for a
day or two to reach help. Most of them suffered from tuberculosis, malaria or
diarrhea. The children were malnourished. People died as they were being brought to
the nearest doctor. These deaths happened because health services were
inaccessible and unaffordable.
They are one in saying that “We have learned so much since that time”.
As products of CBHP training programs, the CHWs have been trained in basic
health skills such as prevention and treatment of common diseases, first aid,
use of herbal medicine, dental hygiene and tooth extraction. And from the basic
line of prevention, the knowledge and skills of the CHWs were raised to a higher
level. They were given trainings on basic anatomy and physiology, history-taking
and physical examination, acupuncture and acupressure. The trained CHWs multiplied themselves by training new
CHWs.
In undertaking such trainings, Nang Vicky, as well as many of her
co-community health workers, are able to find new directions in life after being
introduced to the CBHPs. With limited education and seemingly no hope in the
communities to be employed decently, many of them regain their confidence because
they realize that they can acquire skills that can be of productive use.
Military threats
Many communities of CBHP Tandag were never before visited by
government health care providers. When the whole province was put under massive
military operations against insurgency, soldiers were everywhere in the province—the
town hall, the plaza, the market place and in the fields. People were
driven away from homes and from their sources of livelihood. Women and children alike
were caught in the crossfire.
The CBHP communities, including San Isidro where Nang Vicky lives,
became the subject of undue suspicion from the military and were subjected to
tactical interrogations. The CHWs were also favorite targets for intimidation and
harassment, just like leaders of people’s organizations. The intense
military harassment demoralized many CBHP communities, forcing the program to
cease its operations.
A decade after, CBHP-Tandag was back on its feet again, working
closely with the diocese of the catholic church. Because of the CBHP’s long and
effective history, there was much work that needed to be done. Memories of the
turbulent period were still poignantly vivid for the communities. However, the
tremendous help the communities have gained from the CBHP outweighed the fear they
had for themselves.
Although, Nang Vicky and the other CHWs of San Isidro like Nang
Dolor were met with malicious suspicions and even threats from the military, they
were never afraid to let the military know that they were CHWs. In the case of
Nang
Dolor, her regular visitors during those days were not her family groups
asking medical help, but the military looking for subversive documents like her
training manuals in acupuncture, herbal medicines and the likes. Thus, before any
military personnel could rummage through her belongings, she would hide her
training manuals at the back of her house.
After a painstaking period of recovery, CBHP Tandag continues to
operate in 33 villages from different municipalities, making people aware of their
capacity to help alleviate their situation by working together as one community. And
the likes of Nang Vicky, Nang Dolor and the rest of the CHWs
have once again proven their worth as many times before in contributing their
share in
developing self reliance for an alternative health care system that CBHPs promote.
The story of Nang Vicky and CBHP Tandag that she worked
with is only reflective of what is now 29 years experience of CBHPs in the
Philippines. Evolving from the first mobile-paramedic training health team in the
1970s to actually laying the foundation for an alternative health care system,
CBHPs continue to survive and thrive because they are rooted in a very strong
and solid foundation—the people of the community who struggle unceasingly to
defend their lives and rights, and to develop their own appropriate health
programs. —
[Council for Health and Development, 04 November 2002, Quezon City, Philippines].
Argentina 2002
Endemic Injustice and Silent
Proposals from Daily Life
By Dr. Julio Monsalvo
Argentine doctor and activist of the peoples Health Movement
“Microbes are insignificant as a cause of disease compared to the
illnesses that cause poverty, the social despair, anguish and misfortune of peoples.”
Ramón Carrillo (first Minister of Public Health of the Argentine Nation,
1945-52)
The growth of hunger
Angela lives in a poor neighborhood in one of Argentina’s large cities.
She is 39 years old, mother of four children. In the “Health Center,” a young
doctor, Alejandra, diagnoses that Angela has anemia. The cause is quite clear.
She lacks access to adequate nutrition. Angela is one of nine women over age 35 who
have been diagnosed with anemia this week, all due to the same cause. A simple
test shows that Angela barely has 8 grams of hemoglobin, as well as low levels
of red cells.
In this Health Center, as in most Argentine hospitals, medications with
iron supplements have not been supplied for quite some time. This is happening
throughout the country, anemia is being detected in all age groups due to
a lack of access to food. Numbers are growing of malnourished and anemic
children (particularly under age 5), anemic pregnant women, anemic children with
low birth weight, and malnourished elderly people. In one province alone,
official 2001 data showed 71 deaths from malnutrition, of which 44 were children
under age 5 (62%) and 21 people over age 50 (30%).
But our young doctor does not become discouraged. She researches what
local plants may be a source of iron and discovers “nettle” (Urticara urens
L.) She prepares a nettle tincture in the Health Center and gives Angela this
natural treatment for three weeks. The test results improve and Angela feels much
better. This encourages Alejandra and other health workers to treat the other
women with nettle tincture. The results were successful and the word of the
solution spreads. It’s an uphill struggle, but also heroic and hopeful. Bit by
bit, spread from mouth to mouth, people begin to talk about this possible treatment.
An abundance of food
Argentina annually produces, according to official data, 68 million tons
of food. With a population of 35 million, there would be an abundance of food if
this were deemed a social good and the production of food was aimed at feeding
people instead of increasing the profits of a few corporations. Each
person would have 2 tons of food per year, five and a half kilograms per day.
Even
part of that food would take care of the country’s needs, and the system could keep
exporting the rest. Instead, over half of the population is living in poverty or
outright indigence.
In addition, there are concerns about food quality. Argentina is one of
the countries with a large area dedicated to growing genetically modified foods. The
use of agrochemicals not only contaminates food sources and soil, but also leads
to poisoning and deaths. Animals are subjected to cruelty, fed unnaturally
to be fattened quicker, in order to produce “increased economic benefits.”
The industry uses an abundance of chemicals for coloring, as preservatives, and “authorized”
flavoring. On top of the injustice that the great majority is denied the
right to feed themselves, we now have food insecurity in a country that has lost
its food sovereignty among its many other losses.
Another Argentina, another world
Alejandra, the young doctor in our story, is one of thousands of health
workers in this country who silently struggle every day to provide humanitarian
answers to pain and misery. At the same time proposals are being made to build a
different Argentina!
For many years in cities there has been a food production for consumption program called “Prohuerta.” The State provides
seeds for vegetables
and fruit and farm animals, in addition to training for organic-style production
(no agrochemicals or chemical fertilizers are used). Between large cities and
smaller communities, up to 400,000 family, school and community garden plots have
been registered. These produce about 80,000 tons of food per year for 2.5
million people. It is estimated that the country has 7.5 million indigent people.
Instead of supporting and broadening this program, the budget allocated for it
has been reduced by 7%. Other State and NGO programs also help people feed
themselves. However, these efforts are not encouraged or supported by the State.
Here and there, throughout the country, small groups of women and men
farmers produce events with incredible political and transformational voltage:
fairs to exchange seeds from local production and establishing local markets with
organic products. There are many examples of healthy food production systems,
social and economic organizations based on respect for all forms of life, which
translates into healthy relations with the ecosystem that have a positive impact on
health. A change in paradigm and in consumption patterns is urgently needed to
roll back the endemic social injustice and immediately bring an end to all
cruelty and the denial of access to foods and healthy foods.
Over 50 years ago Ramón Carrillo pointed out that social injustice was
the cause of illness. Today in Argentina those social injustices have deepened and
spread, and have become ecological injustices in the form of soil deterioration,
the disappearance of forests, contamination of rivers and the air. For many
years in this country, women farmers, professionals and students committed to
health and life have been proving that it is possible to create another
Argentina, and another world as well.
Mandate to the new Government
Health for all:
Essence of a good Government
Dr. Arturo Quizhpe Peralta
Dean of the Medical School of the University of Cuenca-Ecuador
Coordinator of the International Peoples Health Council, IPHC-South
America
“Equity, ecologically sustainable development and peace, are the
central focus of our vision of a better world. A world in which a healthy life
for all becomes a reality; a world that respects, appreciates and celebrates all
life and diversity; a world that allows the flourishing of talents and
abilities to enrich all of us; a world in which the voices of the people guide the
decisions that affect our lives. More than enough resources are available to
achieve this vision.” (1)
A sick society
The neoliberal development model in effect is not sustainable; its
failure has been extensively proven in countries like Argentina. It cannot even be
considered as a model of development, as it is designed to perpetuate
underdevelopment and strengthen dependency. We survive in a sick society in which humans
have been sacrificed for the market, where nature is profaned and attacked by
the greedy interests of large transnational corporations, where the abuse of
power, corruption, intolerance, segregation and injustice rule.
We cannot go on with more deceit and white lies. Health is intimately
connected to development, and development in turn, produces health. One cannot
speak of health policies for the majority if this does not go hand in hand with an
integral reform of the State aimed at the well being of the majority. As Dr.
Roses, the new Director of PAHO, has stated: health programs are a reflection of a
country’s ethical decisions, they reflect the value given to life and human
development in general, and even more specifically, the value of the life of each human
being, of women and children, of the disabled and elderly.
Poverty must be eradicated
In Ecuador and the other countries of Latin America, poverty constitutes
the main cause of illness and death, and therefore its roots are found in the
economic and social policies imposed upon us.
Poverty arises from the inequitable distribution of wealth, the society’s organizational structure, the unequal trade between
nations, the
exaggerated power of transnational corporations, and the policies they impose to
increase their profits.
As stated in the People’s Charter for Health: “economic globalization
and privatization have deeply disrupted communities, families and cultures.
Public institutions have been undermined and weakened; many of their
responsibilities have been transferred to the private sectors, to corporations or other
national and international institutions that rarely take on responsibility before the
people.” Poverty must be eradicated, not lessened. Attempting to lessen poverty
means treating the symptoms instead of the disease. Fighting poverty means redistributing wealth, working for more just rules of trade, generating
employment, allocating resources, responsibility and power to the people. All the countries in the region have included health in
their
constitutions as a right of all people. However, expenditures on health have been determined
and subjected to economic calculations, the decisions of transnational
corporations, and market interests, sacrificing the life of millions of men, women,
children, and elders.
Human development indicators reflect a degrading reality for human
beings: 80% of Ecuadorian homes are poor; 20% are indigent, with no access to
education, social security, or basic sanitary infrastructure; maternal mortality
(160 to 300 for 100,000 live births) and infant mortality (39 out of 1000) are high
and result from preventable causes, the persistence of illnesses associated with
poverty such as dengue fever, malaria, yellow fever, tuberculosis, and others.
A variety of organizations and groups from towns in Ecuador working in
this area and committed to the struggle for the respect and full effectiveness
of this primordial human right, appropriate as our own the points of the People’s
Charter for Health and set forth the following:
Basic Principles for a Program of Health for all
- Guarantee the universal access to high quality integrated Primary
Health Care, according to the needs of the population, not their ability to pay.
- Elimination of cost-effectiveness criteria as a defining factor for
the implementation of health care programs and the abolition of cost recovery
projects because they generate inequity and obstacles to access to
services.
- Stop privatization of public health and social security services,
ensuring the effective regulation of the private medical sector including medical
charities and NGOs.
- Increase public investment to at least 70% of the national
expenditure on health.
- Emphasize the promotion of health, primarily in community
organization and participation.
- Strengthen and legally support social participation, intersectoral
work, and a multidisciplinary approach to health problems.
- Promote health programs aimed at women, the eradication of domestic
violence and fulfillment of the Law of Free Maternity.
- Establish promotion and prevention programs for the health of young
people, particularly related to sexual and reproductive rights.
- Adopt measures to ensure occupational health and safety that include
oversight of working conditions, particularly for high-risk sectors (for example:
assembly plants, flower growing companies, the informal sector and others).
- Regulation of the use of technologies, production and issue of
medications, to assure they are subordinate to the needs of the population.
- That research on health – including genetic research and the
development of reproductive medicines and technologies – be oriented towards people
and public health and respect universal ethical principles.
- To defend harmony with the environment and the protection of
ecosystems.
- Invest more, invest better and begin to pay the social debt, giving
priority to health and education, reducing military expenditures and payment on the
foreign debt.
- Submit economic policies to assessment regarding their health,
equity, gender and environmental impact and include regulatory measures to follow-up on
their fulfillment.
Health is a fundamental human right, and this is why we tell, beg, and demand that the new government make a
serious commitment to Health for All.
Cuenca, November 2002
(1) People’s Charter for Health. IPHC. December 2000.
1 * This Policy Brief draws heavily upon: Sanders
D., D. Dovlo, W. Meeus, U. Lehmann, “Public Health in Africa” in Global Public Health, R.
Beaglehole (ed.), O.U.P. (forthcoming)
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